Blog

We reviewed the data elements collected by Partners Healthcare for transfers from SNF to ED. While not all elements are applicable all the time, together they provide a comprehensive snapshot that helps the ED to quickly assess the needs of the patient.

Based on these data elements, we can try to map them to existing C-CDA sections and work on building the content for the initial transaction.

Volunteers to take up this task, as well as visualizing the workflow transitions, are welcome!

Reviewed the ONC Tech Forum - it was a worthwhile experience. We got several questions on SDoH and 360X.

New 360X logo has been put on the Wiki.

Reviewed updated steps for SNF to Acute care transfers from the August 24 call. Open questions about transfer/referral identifiers:

• Transfer to ED is an identifiable event in the SNF system, so the system will assign the required referral ID.
• When the patient is discharged from ED back to SNF, the identifier is used to close the loop.
• If the patient is admitted to the hospital (post-ED), then the discharge is to follow the 360XL steps of request/accept/confirm/transfer
  • if the patient is not going to the originating SNF, then a new referral id will be created. At some point a notification to the originating SNF may have been sent with the originating referral id
  • if the patient is going back to the originating SNF, ideally, we want to use the originating referral ID.
    • Is this possible? It is not clear the ED/Hospital systems would have the original transfer information at this point. Something to check.

Reviewed the data elements for initial transfer to ED from Partners Healthcare.

• Data is thorough, and extremely useful
• Many SNF system have the data is some form
• We will call for volunteers to find matches to C-CDA sections and entries.

Review of ONC Tech Forum information and signup.

Update on outstanding work on existing specifications

• AUT HL7 segment information was recorded (thanks Chuck!)
• 360XL has been submitted to IHE for public comment

Update on the discussions with the Ohio Health Information Partnership (OHIP)

• They are very excited about 360X becoming available form vendors
• They have a very strong statewide foodbank network (Ohio Association of Foodbanks)
• They want to see how using 360X can help with social care referrals
• Challenges:
  • Clinical information is not meant to be sent with the request
  • Support for 360X for initiating clinical referrals does not easily transfer to extra-clinical referrals (different users, different workflows)
  • If we add social care referrals to 360X, it will likely be years before implementations are available to users, and OHIP is looking for quick turnaround.
• We will continue discussions next time

Transfers from LTPAC facilities to Acute care facilities. We answered some of the questions of the steps, and updated as follows:

1. Referral to ED
   1. This is a notification, not a request. We will need to be careful to describe edge cases where ED cannot take the patient (re-routing, etc.)
   2. Starting set of the data needed from SNF to ED from Partners Healthcare
2. Discharge from ED back to SNF
   1. Notification, with a summary of what happened in the ED - close the loop outcome
3. Transfer to Hospital admission
   1. Notification from ED/Hospital to SNF
   2. Response from SNF to Hospital with additional information
   3. Can we keep the referral ID? Should we call it something else?
4. Determination whether the patient will be discharged to the same SNF
   1. Can be due to timing - whether the patient bed can stay on hold for time necessary to be at the hospital - possibly a notification from SNF to hospital
   2. Patient may decide to look for a different facility - notification form hospital to SNF
5. Patient Discharge - close the loop. Whether they go to the same SNF or another, follow the 360XL process of request, select, transfer
   1. Which identifier? Use two?

We need a diagram for this, any volunteers?

There are some existing transactions: https://pathway-interact.com/ - we will review in two weeks.

Discussions about the ONC Tech forum booth, exhibit materials, and time slots.

• Sheila will send out a doodle poll for volunteers to sign up.

Discussions about existing work that needs to be completed:

• Chuck will fill out the missing HL7 segment information
• Vassil will submit 360XL for IHE PCC public forum

ONC Tech forum - 360X will have a booth in the "virtual exhibition hall". We may be able to have a live booth presence, there were several  volunteers to be present during the the event. We will discuss setup and other details on 7/17 call.

Discussion on the top next proposed project for 360X - transfers from LTAC facilities to Acute care facilities

• Main points for SNF to acute transfer:
  • initial transfer is most commonly to the ED - referral for consultation
  • ED transfers have very specific, targeted information requirements from the SNF
  • In many cases patient is then transferred back to SNF - loop is closed 
  • In other cases patient is moved form ED to Hospital admission
  • Hospital admissions have different information requirements to be obtained from the SNF, mainly to inform inpatient nursing staff how the patient needs to be managed
  • Discharge from hospital admission can be to same SNF or to a different one
• Steps to consider
  1. Referral to ED
     1. Is this a request that can be denied, or is it more like a notification to the ED (expect this patient)?
     2. Need to describe the data needed from SNF to ED
  2. Discharge from ED back to SNF
     1. Notification, with a summary of what happened in the ED - close the loop outcome
  3. Transfer to Hospital admission
     1. Notification from ED/Hospital to SNF
     2. Response from SNF to Hospital with additional information
     3. Can we keep the referral ID? Should we call it something else?
  4. Determination whether the patient will be discharged to the same SNF
     1. Can be due to timing - whether the patient bed can stay on hold for time necessary to be at the hospital - possibly a notification from SNF to hospital
     2. Patient may decide to look for a different facility - notification form hospital to SNF
  5. Patient Discharge - close the loop
     1. to same SNF - folow steps from 360XL for an already selected facility
     2. to a different SNF - use the full 360XL process - request, select, transfer 

We will continue discussions during the 7/24 call.

No call today, most everyone had the day off for Independence Day.

Survey was sent to the mailing list, received some responses:

• needed to add newer participants to mailing list
• more responses were sent during call

Looking at the responses, and considering the e-mail from Terry O'Malley, the LTC to acute care was the front-runner for our next use case.

We had more discussions on the various options, and next step.

In addition, the ONC Tech Forum will take place virtually on August 10-11. They will have an "exhibit area", and we are expecting that the 360X project will have presence there. Details will be coming over the next few meetings. Based on that, our focus for the general meetings should be on getting our documentation in the best shape possible for August 10.

Discussion focused on what use cases to consider:

• Current workload - based on following, we may take one new use case, and possibly a second.
  • finish publication of 360XL
  • Improve documentation
    • Insurance and prior authorization description - update IG and finish change proposals
    • Use of Argonaut FHIR scheduling - update IG
• Possible new use cases:
  • LTC facility outbound transfer - to acute, to another LTC faciltiy, to home care
  • eConsult - a consult based on documentation only, no patient visit (in person or tele-)
  • Referrals related to Social Determinants of Health (SDH)
• Additional discussion:
  • Patient involvement - this needs to be better documented (add to current workload)
  • Payer interactions - this needs to be better documented
    • prior authorizations (already in workload)
    • in/out of network (add to current workload)
• Followup - create a survey of the following use case options and send to mailing list
  
  • LTC to Acute
  • LTC to LTC
  • eConsults
  • SDH referrals

Discussions on the relevance of 360X and the COVID-19 pandemic, and future development of the specification:

• Nursing homes/LTC faciltities are hot-spots, what can be done to help care givers?
  • LTC to acute referrals/transfers
  • Acute to nursing home re-admits (Note that the re-admit may not be to the same facility that originated the referral)
• Extra-clinical services, can we extend 360X there?
  • different context for content, C-CDA has too much information, most of it not useful for the referral recipient.
  • BSeR has initial work in that area, as well as the Gravity Project

It seems that looking at LTC to acute referrals is a logical next step.

Discussion to continue next week, June 19th. 

No call today, due to a demo for the VA/DoD

The call was repurposed for demo testing for the Direct Trust Summit testing.

Note: Next Saturday, June 5th, we are having a demo for the VA, and the call is cancelled.

Review of IHE profile proposal for long term care (SNF) transfers - 360XL

A discussion to consider transforming 360X as a "base standard" with different higher layers to include PCP to specialist referrals, acute to SNF referrals, etc. This may be done in a different way, for example in the "XDM and XDR for Direct" specification to be balloted and published by Direct Trust Standards, where fundamental requirements for XDM are specified to be used by other implementation guides like 360X.

Note: the IHE Profile proposal was approved for public comment on the subsequent IHE PCC call. When the public comment period is open, the participants will be notified to provide more feedback.

Short call, work continues on preparing the 360XL (long term to SNF referrals) IHE proposal for public comment.