crossbeamHEALTH

The infrastructure layer for specialty care collaboration.

Specialty judgment at the threshold of every referral: the hallway curbside consult, rebuilt as infrastructure.

Concept draft for clinician feedback   |   July 2026   |   US market   |   Confidential draft, not an offering

DRAFT

"Crossbeam Health" is a draft working name. Nothing in this deck is an offer of products, services, or securities. Photo: AI-generated illustration.
The strain

Demand is compounding while the workforce shrinks.

Specialty care is now a structural bottleneck: more referrals every year, longer queues, fewer specialists per patient.

31 days
Waits keep climbing
average specialist wait across 15 major metros (2025), up 19% since 2022 and 48% since 20042, 5
291 days
The worst case
the longest reported wait for a dermatology appointment (Portland, OR); OB/GYN averages 42 days nationally2
40,400
The shortage ahead
upper-bound AAMC-projected US shortage of primary care physicians by 2036, plus 10,100 to 19,900 surgeons17
+34.1%
Demand accelerates
projected growth of the 65-and-older population, 2021 to 2036: the heaviest users of specialty care17
HRSA projects thoracic surgery at 69%, ophthalmology at 70%, and nephrology at 79% of the physicians needed by 2035.18 Training more specialists cannot arrive in time; the leverage has to come from infrastructure.
Sources  2, 5 AMN Healthcare, 2025 · 17 AAMC, 2024 · 18 HRSA, 2022 · Full citations: slide 16. Photo: AI-generated illustration.
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The problem

Four long trends made the hallway disappear.

100M+
Demand keeps rising

Aging, chronic disease, and wider diagnostics push US ambulatory referral volume past 100M a year.1

69%
Supply cannot keep pace

of the thoracic surgeons the US needs by 2035 will exist, per HRSA; AAMC shortfalls reach 40,400 primary care physicians by 2036.17, 18

57%+
Pathways stayed manual

of authorized referrals never complete in the newest US Medicaid data (57 to 71 percent); referrals go out info-poor and rarely report back.15

77.6%
Care went distributed

of US physicians are now employed by hospitals or other corporate entities; care spans networks and multi-site systems, and the coordination layer was never built.21

A PCP once walked down the hallway and had a specialist's take in seconds. The hallway is gone, and nothing replaced it. Healthcare built deep infrastructure for documentation and billing; it never built infrastructure for two physicians managing the same patient together.
Sources  1 MedCity News, 2025 · 15 JABFM, 2025 · 17 AAMC, 2024 · 18 HRSA, 2022 · 21 PAI / Avalere, 2024 · Full citations: slide 16.
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45%of referral revenue from employed PCPs leaks out of network3
The problem

The referral decision is made alone, and the patient pays for it.

A PCP decides "this needs a specialist" with no specialist input, no protocol, and no feedback. The patient waits weeks, arrives without the right workup, or never arrives at all.

100M+
Referrals a year
specialty referrals a year in US ambulatory care; only about half are ever completed1
31 days
The average wait
average new-patient wait across 15 major metros (2025); gastroenterology 40 days2
206M
The follow-up inbox
in-basket messages in 2024 at one large academic system, up from 58M in 20174
Nothing about the episode, whether the referral was needed or what happened to the patient, ever feeds back into the next referral decision.
Sources  1 MedCity News, 2025 · 2 AMN Healthcare, 2025 · 3 Advisory Board, 2024 · 4 Journal of Arthroplasty, 2025 · Full citations: slide 16. Photo: AI-generated illustration.
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The problem

Six steps, and it fails at every one.

1
THE DECISION
The PCP decides alone: no specialist input at the moment it matters.
The intervention point everyone skips
2
THE ORDER
The referral goes out info-poor: question unstated, workup missing.
Specialists start over on arrival
3
THE QUEUE
Sorted by scheduling and prior auth, not clinical need.
31-day average wait; GI 40; Boston 652
4
THE PATIENT
Calls, portals, travel, cost. Many quietly give up.
~50% never complete;1 45% of revenue leaks3
5
THE VISIT
Starts from scratch; low-acuity crowds out the urgent.
Wasted slots on both sides
6
THE REPORT BACK
50% of referral loops never close;22 the next referral starts as blind as the last.
Nothing is learned, ever
The queue is still growing: the average new-patient wait rose 19 percent just since 2022 (26 to 31 days) and 48 percent since 2004.5 The queue is structural, not cyclical, and every current fix starts AFTER step 1.
Sources  1 MedCity News, 2025 · 2, 5 AMN Healthcare, 2025 · 3 Advisory Board, 2024 · 22 Regenstrief / IJMI, 2023 · Full citations: slide 16. Photos: AI-generated illustrations.
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Why it persists

Four structural failures, locked in by incentives.

Manual cognitive load

Specialists redraft the same common answers, case by case. Nothing is ever reused.

2/3 of Ontario's consults needed no visit;12 up to 13% even in US Medicaid15
No standard protocols

Answers vary with whoever reviews the case, and static guidance goes stale as guidelines churn.

PCPs need living pathways, not reference PDFs frozen in time
No outcome visibility

Nobody tracks which guidance resolved the case or which pathway actually worked.

No billing code exists for "referral avoided"
No learning loop

Every consult is answered as if the last one never happened.

This is why specialist expertise does not scale
Locked in by incentives: eConsult codes pay $19 to $75 with weekly caps,10 and adoption has tracked the payment model, not the clinical value.20 Nobody is paid for the consult that never needed to happen.
Sources  10 CodingIntel · 12 Innovation in Aging, 2022 · 15 JABFM, 2025 · 20 JAMA Network Open, 2022 · Full citations: slide 16.
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The consequences

The hidden work, and why today's fixes stay bolt-ons.

The hidden work
58M → 206M
The inbox exploded
in-basket messages at one large academic health system, 2017 to 2024. The referral system's dropped work lands here.4
15.2 hrs/wk
The hidden workload
of total active EHR time for high-volume PCPs. US primary-care burnout is the worst of 10 wealthy nations, at 43 percent.6, 23
50%+
Fixes get overridden
of interruptive decision-support alerts are overridden, up to 98 percent in some studies. Interruptive fixes fail.7
Today's fix · and why it falls short
The workaround: the eConsult

Ask a specialist before referring. It works clinically, in the US, UK, and Canada. But every US version is bolted on OUTSIDE the decision moment, with questions hand-drafted every time.

The clinical idea is right; the delivery is wrong.

What it costs today
  • Outside vendor networks answer case by case, billed to the system, outside the chart8, 9
  • The billing rail is thin: CPT 99446 to 99452 pays $19 to $75, chronically under-billed10
Why bolt-ons underperform
  • They start after the decision; the avoidable referral already exists.
  • They add a new destination for the busiest person in the building.4
  • They measure activity, not patient outcomes.
The gap is not another queue. It is judgment, at the decision moment, inside the tool already open.
Sources  4 Journal of Arthroplasty, 2025 · 6 JAMA Internal Medicine, 2025 · 7 PMC systematic review, 2023 · 8 AristaMD · 9 RubiconMD · 10 CodingIntel · 23 Commonwealth Fund, 2025 · Full citations: slide 16.
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The landscape

Five categories try; each solves a slice.

Every category below is a real tool health systems use today. Each improves a step; none of them owns the loop from question to verified outcome.

CategoryRepresentative playersWhat it deliversWhere it stops
Clinical knowledge platformsUpToDate, OpenEvidenceEvidence-based answers on demandGeneric knowledge, not case-specific guidance; no connection between the two physicians
Secure messaging railsEpic In Basket, TigerConnect, DoximityA channel between cliniciansA pipe with no clinical intelligence; the busiest inbox in the building4
EHR-native eConsultsEpic, Oracle Health, athenahealth modulesAsynchronous questions inside the chartHand-drafted questions, variable quality, adoption stalls without workflow and staffing design
External eConsult networksRubiconMD, AristaMDOutside specialists answer within hoursManual answers outside core workflow; externalizes the system's own specialist relationships8, 9
Collaborative care programsProject ECHO, specialty hubs, Oshi HealthStructured collaboration and shared managementProgram-heavy and people-bound; proves the model but does not ship as reusable software
The common ceiling across all five: specialist expertise is still delivered as case-by-case manual responses, never as reusable, versioned, learning clinical pathways. That is the layer nobody built.
Category framing follows the specialty-collaboration market landscape; players named for orientation, not comparison claims. Sources  4 Journal of Arthroplasty, 2025 · 8 AristaMD · 9 RubiconMD · Full citations: slide 16.
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A new infrastructure layer for specialty care collaboration.Encode specialist knowledge into living protocols, embed it at the decision moment, learn from outcomes. A specialist resolves most eConsults in under 20 minutes,19 and most never needed the visit at all.12
Why now

The moment is changing, and it makes a new layer possible.

Five tailwinds, converging now
1
Capacity has to come from leverageSystems accept that headcount cannot close the access gap (slide 2); they are buying extension, not recruitment.
2
Protocolization is finally feasibleSpecialties publish guidelines; modern AI can turn them, plus real practice patterns, into structured, versioned pathways.
3
Collaboration models are proving demandeConsult programs, specialty hubs, and enablement platforms all point at the same missing infrastructure.
4
AI can now do the assembly workSummarize the chart, structure the question, draft the guideline-aligned answer, under physician oversight.
5
EHR embedding is expectedBuyers reject standalone dashboards; embedded decision-moment tools are the requirement, not the differentiator.
Sources  12 Innovation in Aging, 2022 · 19 PLOS ONE, 2024 · Full citations: slide 16. Photo: AI-generated illustration.
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The solution

Crossbeam: the digital hallway, rebuilt as infrastructure.

THE VISIT
ASSESS
DECIDE
This is where it happens.
ORDER
THE REFERRAL DECISION MOMENT. The specialist's judgment, at the decision moment, inside Epic. One platform: automated consult triage and routing, protocol-driven workup and orders, asynchronous specialist oversight. The PCP opens the panel by choice; no pop-ups, no hard stops, ever.
1OPEN

Mid-visit doubt: "does this need GI?" The PCP opens the Crossbeam panel by choice. Uninvited support gets overridden;7 invited support gets used.

2SEE

The matched protocol (P1): this system's own pathway, version-stamped, authors named. The chart context it used (P2), listed item by item.

3CHOOSE

Three real doors, below. The clinician picks; suggested orders are only ever pended for signature. The plain referral stays one click away.

4LEARN

What was chosen and what happened over 6 to 12 months, from claims and chart data (P4), feeds the next protocol version.

Step 3, expanded · the three doors
1 · MANAGE IN PRIMARY CAREprotocol says safe to treat or watch here; suggested orders pended for the PCP's signature
2 · SEND eCONSULTone click; question and context pre-assembled, routed on Epic In Basket rails to the specialist rota
3 · REFER, ENHANCEDthe specialty's preferred workup attached; a complete referral, the right queue, kept in network
Advisory only, and nothing new to learn. No new logins, no new queue: it rides In Basket rails already in place. The basis is always visible, the clinician always decides, and the full referral is always one click away.11
Sources  7 PMC systematic review, 2023 · 11 FDA, Clinical Decision Support Software guidance, 2022 · 16 Crossbeam venture record (product workflow), 2026 · Full citations: slide 16.
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How it works · Step 1 · illustrative concept design

The panel at the decision moment.

EHR SIDEBAR · ADVISORY PANEL · DEMO DATALIVE DEMO: demo.crossbeamhealth.com
1
Opened by choiceNever interruptive. Decision support that fires uninvited gets overridden up to 98 percent of the time.7
2
Shows its workProtocol version, authors, and every data point used are on screen before anything is signed.
3
Three real optionsManage, eConsult, or refer enhanced. The plain referral stays one click away, always.
4
Defensible for the PCPFollowing your own institution's versioned protocol is a documented act, not a leap of faith.
Illustrative concept design with demo data and a fictional patient; not a screenshot of any EHR product. Sources  7 PMC systematic review, 2023 · Full citations: slide 16.
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How it works · Step 2 · illustrative concept design

The eConsult, pre-assembled; answered in minutes, not months.

1
Drafted, not dictatedQuestion and attachments assembled by software from the pathway and the chart; the PCP edits and sends.
2
Pre-loaded, versioned protocolsEvery draft draws on pre-loaded protocols authored by the system's own specialists, versioned like software. We start with one clinical pathway first, and expand only as it proves out.
3
Asynchronous specialist oversightThe specialist answers on their own schedule, fast: Ontario's (Canada) provincial service runs a median 0.9-day reply across 100,000+ cases.12
4
Nothing lostReply, disposition, and protocol version are written back to the referral record and tracked against claims (P4).
eCONSULT COMPOSER · DEMO DATALIVE DEMO: demo.crossbeamhealth.com
Illustrative concept design with demo data; fictional patient and clinicians. Sources  12 Innovation in Aging, 2022 · Full citations: slide 16.
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The solution

Four pillars, and autonomy that is earned rung by rung.

P1 · EncodeSpecialist-authored, system-specific protocols, versioned on a named cadence, with the specialty's preferred workup and orders.
P2 · ContextualizeAuto-assembled chart context with the basis visible item by item.
P3 · EmbedConsult triage and routing at the referral decision moment in Epic: PCP-initiated, never interruptive.
P4 · LearnOutcomes tracked on claims and chart data, feeding the next protocol version.
RungWhat the product may doUnlocked by
v1 · Advisory floorOn-demand panel, protocol match, auto-context, disposition menu with pended orders. The clinician signs everything.Day one. This is the permanent floor.
v2 · Auto-draftedeConsults and referral workups arrive fully drafted; the clinician reviews and signs.Measured accuracy and edit-rate thresholds on v1, reviewed by the clinical governance committee.
v3 · Narrow, earned auto-resolutionLowest-risk pathway steps only (repeat-lab scheduling per protocol), opt-in per authoring division, audit-trailed.Claims-verified avoidance at a pre-registered effect size AND a sub-1 percent adjudicated miss rate, re-reviewed with FDA counsel.
Every capability the market is naming, and where it lives in the product
Collaborative care platformThe whole product: the four pillars, working as one loop.
Automated consult triage and routingP3: the three doors at the decision moment.
Protocol-driven workup and ordersP1: the specialty's preferred workup, pended for signature.
Specialist capacity expansionAsynchronous oversight: a 20-minute review instead of a full visit.19
Outcome-driven protocolsP4: real-world outcomes write the next protocol version.
Sources  16 Crossbeam venture record (autonomy ladder and evidence gates), 2026 · 19 PLOS ONE, 2024 · Full citations: slide 16.
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How it works · Step 3 · the evidence loop

What we must prove, and the console that keeps us honest.

51% (self-reported)
Ontario (Canada) PCPs reporting a contemplated referral avoided, on a mandatory closeout census of 60,474 eConsults13, 14
13% at most
of eConsults (5 to 13 percent) resolved without a referral in the category's newest real-world review, on program records: 2,505 US Medicaid eConsults, 202515

Both numbers can be true; only one is bankable. Vendors quote the first kind. A buyer's actuary finds the second. So Crossbeam commits to claims-verified outcomes from day one, and the protocol console (right) is that commitment built into the product: every KPI is labeled by how it was measured, and self-report is demoted to secondary telemetry.

Three questions we are validating now: Is the referral decision moment where clinicians actually want help? Who inside a health system owns this problem, clinical leadership, finance, or the board? Does advisory guidance change behavior enough to show up in claims? And the five failure modes we design against: clinical governance, patient trust, over-standardization, workflow friction, change management.
PROTOCOL CONSOLE · CLAIMS-VERIFIED · DEMO DATALIVE DEMO: demo.crossbeamhealth.com
Console: illustrative concept design, all numbers fictional. Sources  13, 14 Ontario eConsult program studies, 2022 · 15 JABFM Medicaid eConsult review, 2025 · Full citations: slide 16.
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We are validating with clinicians now.
Tell us where this is wrong.

  • Where in your day would this panel genuinely help, and where would it annoy?
  • Would you trust pathways authored by your own system's specialists more than generic guidelines?
  • Who in your organization owns this problem today, honestly?
  • If referrals dropped 10 to 15 percent, who in your building would fight it?

DRAFT

See it live

Try the live demo

demo.crossbeamhealth.com

We'd love your feedback

docs.google.com/forms/d/e/1FAIpQLSd4RZGojA5Xu4BtR1aX9DELviqutIoHa0PhGe2HYstL_UyHYA/viewform

Scan or click. About 5 minutes.
Blunt is better than polite; we are looking for the reasons this fails.
Confidential draft for clinician feedback, July 2026. "Crossbeam Health" is a draft working name, a concept in validation. Not an offering; no product claims are made. Photo: AI-generated illustration.
Appendix

References.

1. "The Referral Is Broken: Why Healthcare's Last Bottleneck Still Lacks Innovation." MedCity News, Dec. 2025 (100M+ US specialty referrals a year; about 50 percent never completed). medcitynews.com/2025/12/the-referral-is-broken-why-healthcares-last-bottleneck-still-lacks-innovation/

2. AMN Healthcare. "2025 Survey of Physician Appointment Wait Times." AMN Healthcare Insights, 2025. amnhealthcare.com/amn-insights/physician/whitepapers/2025-survey-of-physician-appointment-wait-times/

3. Advisory Board. "How to Reduce Referral Leakage." Advisory.com, Dec. 2024. advisory.com/topics/physician/2024/12/reduce-referral-leakage

4. Analysis of in-basket message volume growth at a single large US academic health system, 2017 to 2024 (58M to 206M). The Journal of Arthroplasty, 2025. sciencedirect.com/science/article/abs/pii/S0883540325008204

5. AMN Healthcare. "New Survey Shows Physician Appointment Wait Times Surge: 19% Since 2022, 48% Since 2004." AMN Healthcare Newsroom, May 2025. ir.amnhealthcare.com/news-releases

6. Analysis of portal message volume and EHR time among 280,700 US outpatient physicians (total active EHR time 15.2 hrs/week for PCPs with 40+ visits/week, up 7.8 percent from pre-pandemic). JAMA Internal Medicine, 2025. Summary: ama-assn.org/practice-management/digital-health/phone-calls-stable-patient-portal-messages-keep-piling

7. Systematic review of override rates for interruptive clinical decision support alerts. PMC, 2023. pmc.ncbi.nlm.nih.gov/articles/PMC10491420/

8. AristaMD. "eConsult ROI Calculator." AristaMD.com. aristamd.com/specialty-care/care-delivery/econsults/econsult-calculator/

9. RubiconMD. Small-practice per-provider subscription pricing; larger groups quoted individually. RubiconMD.com. rubiconmd.com/buy-now

10. CodingIntel. "Interprofessional Internet Consultations (CPT 99446 to 99452)." CodingIntel.com. codingintel.com/interprofessional-internet-consultations/

11. US Food and Drug Administration. "Clinical Decision Support Software: Guidance for Industry and FDA Staff." FDA.gov, 2022. fda.gov/media/191560/download

12. "eConsult Improves Access to Specialist Advice for Primary Care Providers" (Champlain BASE, Ontario; 100,000+ cases, median 0.9-day response, about two-thirds resolved without a face-to-face visit). Innovation in Aging, 2022. pmc.ncbi.nlm.nih.gov/articles/PMC9771088/

13. Mandatory closeout census of 60,474 Ontario eConsults: PCP-reported referral avoidance (self-reported). PMC, 2022. pmc.ncbi.nlm.nih.gov/articles/PMC9199054/

14. Ontario eConsult program evaluation. JMIR Formative Research, 2022. formative.jmir.org/2022/4/e32101

15. "Evaluating the Impact of an eConsult Platform on Specialty Care Access for Medicaid Patients" (2,505 eConsults: 5 to 13 percent resolved without referral; 57 to 71 percent never completed). Journal of the American Board of Family Medicine, 2025. pmc.ncbi.nlm.nih.gov/articles/PMC12616798/

16. Crossbeam Health venture record (internal, unpublished working papers): 27-entity whitespace matrix, product workflow and autonomy ladder, validation frameworks. July 2026.

17. AAMC. "The Complexities of Physician Supply and Demand: Projections From 2021 to 2036" (10,100 to 19,900 surgeons; 20,200 to 40,400 primary care; 65+ population +34.1 percent, 2021 to 2036). AAMC, Mar. 2024. aamc.org/media/75236/download

18. HRSA National Center for Health Workforce Analysis. "Physician Workforce: Projections, 2020 to 2035" (2035 supply adequacy: thoracic surgery 69, ophthalmology 70, nephrology 79 percent). HRSA, Nov. 2022. bhw.hrsa.gov/data-research/projecting-health-workforce-supply-demand

19. Yale New Haven Health system eConsult program evaluation (9,380 completed eConsults; 53 percent reviewed in 10 minutes or less, 87 percent under 20). PLOS ONE, Sept. 2024. medicine.yale.edu/news-article/econsult-programs-strategies/

20. "Trends in Utilization of Electronic Consultations Associated With Patient Payer and Language Among US Academic Medical Centers During the COVID-19 Pandemic." JAMA Network Open, 2022. jamanetwork.com/journals/jamanetworkopen/fullarticle/2794786

21. Physicians Advocacy Institute / Avalere Health. "Physician Employment and Practice Ownership Trends, 2019-2023" (77.6 percent of US physicians employed by hospitals, health systems, or other corporate entities as of Jan. 2024). Apr. 2024. physiciansadvocacyinstitute.org/PAI-Research

22. Savoy, A., et al. (Regenstrief Institute). "Referral loop closure in primary care" (one-third to one-half of referral loops are never closed). International Journal of Medical Informatics, 2023. DOI 10.1016/j.ijmedinf.2023.105265. sciencedirect.com/science/article/pii/S1386505623002265

23. Commonwealth Fund. "Causes and Impacts of Burnout Among Primary Care Physicians in 10 Countries" (US PCP burnout worst of 10 wealthy nations at 43 percent; 44 percent of burned-out PCPs blame time-consuming administrative tasks). Nov. 2025. commonwealthfund.org/publications/surveys/2025/nov/causes-impacts-burnout-primary-care-physicians-10-countries

Superscript markers on slides 2 to 14 refer to these numbered sources (abbreviated MLA format; descriptive titles are used where a formal title is not restated). Internal analyses are labeled as estimates where they appear.
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