Archive for the ‘CCD’ Category

There has been a great deal of discussion on what is happening – and will happen – with the two continuity of care standards. As a refresher, the two are:

• ASTM Continuity of Care Record (CCR):  an XML-based standard for the movement of “documents” between clinical applications. Furthermore, it responds to the need to organize and make transportable a set of basic information about a patient’s health care that is accessible to clinicians and patients.
• Continuity of Care Document (CCD):  the result of a collaborative effort between the Health Level Seven (HL7) and American Society for Testing Materials (ASTM) to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR) and HL7’s Clinical Document Architecture (CDA) specifications.

We ran a poll asking “if you could just vote for one, which would it be?” The results are outlined below.

• For CCD: 70%
• For CCR: 30%

We also wrote a post about Chilmark Research’s blog on the two patient care summary standards. Recently, I discovered a response to the Chilmark post, and it was by the e-CareManagement blog entitled Chilmark Needs to Chill Out on CCR/CCD Findings. From the post:

“Here’s another metaphor: asking a HIE whether they prefer CCR or CCD is like asking an ancient Roman whether they would prefer to converse in Latin or Swahili.  The obvious answer will be “Latin” — not because Latin is a better language, but  because they already have sunk costs into learning Latin. If you already speak Latin, it won’t bother you that Latin is complex, archaic and difficult to learn.”

Take a few minutes to read the blog post, and be sure to read all the comments below his post, including one from Chilmark Research.

Vince Kuraitis from e-CareManagement blog responded to one of our earlier posts with a similar argument. The argument is that CCR is more usable and appropriate for the ambulatory setting while CCD is geared more towards HIEs and larger health care institutions. The discussion is healthy. A few other highlights from others include:

• David C. Kibbe, MD MBA:  “This isn’t really a standards problem at all. It’s a business model problem. Businesses that want to exchange data have always found a means of doing so, and now, in health care, it’s gotten much, much easier to do so. It helps that the feds are behind this movement.”
• John at Chilmark:  “The issue is not Linux or .Net, Latin or Swahli, that is too simplistic. What is at issue is what standard will help an organization do the work they need to do. CCR may be fine in a small ambulatory practice with limited IT resources and simple data mgmt requirements/workflow. CCR though is not flexible enough to allow larger practices, clinics and hospitals to create document structures, add data types, etc. to meet their internal operational needs. As David rightly pointed out, it is a business issue.”
• John D. Halamka, MD, MS:  “We noted that CCR is a fine patient summary standard, but for other uses such as reporting the actors/actions/events in clinical workflow needed for quality measurement, CCD is preferred over CCR.”

In the Healthcare Standards IFR, it states that both CCR and CCD are allowed initially, but the direction needs to be move to one continuity of care “standard.” This consolidation needs to occur by 2013.

The arguments are correct – one is more heavy duty and the other easier to work with; one is for HIEs and large organizations, and the other is for ambulatory settings. In fact, the poll we conducted may reflect this sentiment. Thirty percent in favor of CCR may reflect more ambulatory responses than others, or it may be the people who have tried to work with the existing CCD standard!

At some point, CCD and CCR need to come together more closely. It will assist in the exchange of patient data between smaller ambulatory,  larger care delivery organizations, and HIEs. These type of exchanges will ensure really meaningful use, not just hype or getting half-way there. Green CDA may be the approach that resolves the discussion.

There is an interesting blog post made by Chilmark Research, a healthcare industry analyst firm, which is very relevant to the current discussion on CCD (HL7 Continuity of Care Document) vs. CCR (Continuity of Care Record). Their post is entitled CCD Standard Gaining Traction, CCR Fading. Other than Google Health, HL7 CCD seems to be the most requested approach.  (Google Health’s data specification is based on CCR.)

According to their blog post:

“Today, CCD is seen as a more flexible standard that is not nearly as prescriptive as CCR.”

Chilmark Research’s post is a quick read, and it is very relevant to our poll and the discussion taking place on these two healthcare standards.

We are starting a new healthcare standards poll today (see lower right column of this site). In the Healthcare Standards IFR, Stage 1 (2011) calls for an option:  (1) Use the Continuity of Care Record (CCR) standard or (2) HL7 Continuity of Care Document (CCD) standard. It is your choice, but it will be “converged” later.

“Converging” or “harmonizing” CCR and CCD is a good direction, as pointed out in a recent ZDNet healthcare blog post, yet too many options create hurdles which need to be overcome and add time to implementation schedules.

With all of the effort being placed on implementing projects to achieve Meaningful Use, clarity - rather than vagueness – is essential. By not clearly defining a direction upfront, healthcare providers have to support the complexity of multiple healthcare standards rather than focusing implementation efforts on a more definitive approach. This is frustrating, especially when it is stated that this will be converged later.

In 2008, we wrote a satirical blog entitled What If There Was an Election on Healthcare Standards? In retrospect, it is closer to where we are today than we knew!

Regardless, now is your opportunity to vote. Rather than wait until after 2011 to determine which one wins, let’s vote today. Which standard should be used — CCD or CCR? Vote now to clarify the direction!

Recently, a poll was posted here asking, “Are you electronically exchanging Continuity of Care Documents (CCD) today?” The most popular answer showcased the steady migration towards electronic records occurring across the healthcare landscape with 57% of respondents selecting, “We have plans to exchange CCDs electronically.” More telling, however, is that 78% indicated they either plan to, or are already exchanging CCDs electronically.
Below are the complete results:

• We have plans to exchange CCDs electronically. – 57%
• No. We do not send or receive CCDs electronically today. – 21%
• Yes. We do send and receive CCDs electronically today. – 14%
• We only receive CCDs electronically today. – 7%

We welcome your suggestions for future poll topics. Please email us your ideas.

In the September 2009 edition of Hospitals & Health Networks, an article entitled “Connecting All Your Docs” appeared highlighting a survey that was conducted with all hospitals – Most Wired and the rest. The interesting finding was on the question regarding the ability to accept Continuity of Care Documents (CCD). From the article:

“The difference in the results is obvious from the data. Nearly 70 percent of the Most Wired can accept continuity of care records prepared from a physician office EMR regardless of whether the record is coming from employed or independent physician practices… That’s more than double the rate for the typical survey respondent and more than 11 times greater than the least wired.”

In the chart, it shows the numbers:  53% of all surveyed cannot accept a CCD from a physician office EMR, while only 16% of the Most Wired 2009 cannot accept a CCD from a physician EMR. Going to the least wired, the number that cannot accept a CCD jumps to 87%.

Two observations:

1. Yes, it is logical that organizations focused on being “wired” should be able to do more than those that are not.
2. There is a difference between having the ability to accept a CCD and actually accepting one. It would be interesting to know how many healthcare organizations are actually accepting a CCD from another provider. Today, there is much discussion on CCD, but the real use of it is still really unknown. With HITECH, however, the use of CCD will grow considerably in the next five years. Being prepared is a must.

The poll which is being run on HL7 Standards asks the question on the real use of the CCD today. See the poll at the right and let us know if you are electronically exchanging CCDs today. We know that there are many organizations that have the capability to accept CCDs, now the question is how many really are.

If you have specific experiences with CCD, please share your comments as well.

Explore more CCD topics on this blog.

Prior to the approval of the Continuity of Care Document (CCD) as an ANSI Standard in 2007, electronic clinical document exchange could utilize one of two formats: HL7 Clinical Document Architecture (CDA) or ASTM Continuity of Care Record (CCR). In an effort to combine the two closely related formats, the Continuity of Care Document was created.

CCD harmonizes the two separate standards by using CCR within the broader context of CDA. It shares summary information about the patient in an easy-to-read format, using CCD templates to constrain the data. The information can be read by the human eye or processed by a machine (such as an EMR system), and can be sent electronically or manually carried by the patient.

CCD is widely compatible with new and existing technology/standards because it is based on HL7 CDA – a RIM-based specification. It can work with existing applications, browsers, EMRs and even legacy systems. Because of its small fixed XML tag set, CCD can be rendered as HTML or PDF, and requires no specialized communication efforts or changes to existing processes.

For patients, this means less loss of meaning and misinterpretation of data by providers. For physicians, this means easier access to vital health information and better patient care.

Moving into the future

New CCHIT certification criteria require all ambulatory and inpatient EHRs to be CCD compatible, making CCD the preferred standard for clinical document exchange as we move forward into the future. The new criteria is also instrumental in encouraging the use of an electronic health record within the healthcare community.

Those implementing CCD will be readily compatible with new technology, while simultaneously opening the doors to greater compatibility and better care for patients.

The Continuity of Care Document (CCD) defines a detailed set of constraints, or templates, for CDA elements. Each template may have further supporting templates as required. The data contained in each of the templates is set by CCR.

Below is an overview of the templates (excludes supporting templates) and how they are used.

Header
Defines the type of document being created, who the document is regarding (patient, physician, author) and how the document relates to other existing documents (if applicable).

Purpose
States the reason the document was generated, but only if a specific purpose is known (i.e., a referral, transfer, or by request of the patient).

Problems
Provides a list of relevant clinical problems, both current and historical, that are present for the patient at the time the document was created.

Procedures
Provides a list of all relevant and notable procedures or treatments, both current and historical, for the patient.

Family history
Gives relevant family health information that may have an impact on the patient’s healthcare risk profile.

Social history
Describes the patient’s lifestyle, occupation, and environmental health risks plus patient demographics such as marital status, ethnicity and religion.

Payers
Provides payment and insurance data pertinent to billing and collection, plus any authorization information that might be required.

Advance directives
Includes information about wills, healthcare proxies and resuscitation wishes, including both patient instructions and references to external documents.

Alerts
Provides a list of allergies and adverse reactions that are relevant for current medical treatment.

Medications
Provides a list of current medications and relevant historical medication usage.

Immunizations
Gives information the patient’s current immunization status plus pertinent historical information about past immunizations.

Medical equipment
Provides a list of medical equipment and any implanted or external devices relevant to patient treatment.

Vital signs
Details information about vital signs for the time period including at a minimum the most recent vital signs, trends over time, and a baseline.

Functional stats
Details information about what is normal for the patient, deviations from the norm (both positive and negative) and extensive examples.

Results
Lists lab and procedure results, and at a minimum lists abnormal results or trends for the time period.

Encounters
Details relevant past healthcare encounters including the activity and location.

Plan of care
Lists active, incomplete or pending activities for the patient that are relevant for ongoing care – including orders, appointments, procedures, referrals and services.

For additional information on getting started with CCD, please read the post on the quick start guide provided by EHRVA.

HIMSS EHRVA developed a Quick Start Guide for implementing the Continuity of Care Document (CCD). HIMSS EHRVA is a trade association of Electronic Health Record (EHR) vendors. Included in the file are two sample CCDs. The guide seems to be a useful resource for implementers of integrated healthcare systems.

A few past posts and insights that you may want to explore:

• What is the CCD?
• EMR Interfacing Best Practices
• Comparing HL7 Messages to HL7 Documents

Please post any experiences that you have in implementing the CCD or using this Quick Start Guide.

By now, you may have had enough of primaries and election results. What if, however, we applied the primary election process to healthcare standards? What would happen?

Just as there are factions the political candidates are trying to pull together to win, they probably have not seen as many factions as there are in healthcare standards. There is a major faction called the HL7 Standards, but emerging factions are getting noticed which are XML related – from Continuity of Care Record (CCR) to a faction-within-a faction, that is, HL7 V2, HL7 V3, HL7 Clinical Document Architecture (CDA), and HL7 Continuity of Care Document (CCD).

We don’t need new healthcare standards. We just need to enforce the ones we have.

What about the X12, DICOM, NCPDP, ASTM, LOINC, and SNOMED factions? And, let us not forget the common person’s healthcare standard – plain ol’ CSV file formats.

If the United States was going to eventually elect a healthcare standard to lead us in the 21st century, which one would win? All we need is a little harmony.

Harmony may be over-rated. How could someone from SNOMED endorse the LOINC? What do you mean CCR is campaigning with CCD? If these events happened, some people may just sit out the healthcare standards election.

What about the special interests? Each healthcare vendor has their own standard. Let’s hope that someone doesn’t “swift boat” one of the healthcare standard candidates.

The campaign slogans:  Healthcare standards are broken. We just don’t need to move the same standards to different chairs. We need to stand for change. We need hope! We need a healthcare standard ready to solve all of our problems Day 1!

Or, maybe what we need is another healthcare standard – a “third party” candidate – that can just end all of the “politics” and work for the people in health care. A “uniter” of healthcare standards. Some standard that can “reach across the aisle” and reach consensus.

Can’t we all just get along in the healthcare integration world?

Yes, this is a parody of sorts on healthcare standards, but it is the practical world that we live in. There are many standards, and we do all need to get along in order to deliver the best possible care for patients. Each healthcare standard faction delivers an essential piece in the healthcare puzzle, but putting the puzzle together can be challenging at times.

Maybe the final rallying cry should be:  “Read my lips. No new healthcare standards!”

While HL7 V3 is still in the “early adopter” phase, there are now over 100 registered projects in progress worldwide involving V3 – the overwhelming majority being outside the United States. Some important points to keep in mind with this HL7 standard still in an early adopter phase:

• Most deployments turn out to be rather custom based on realm-specific changes and that the current V3 standard is used as a starting point for a project – rather than the ending point.
• V3 appears to be morphing even more into a reference model and less of a messaging standard.
• Things are still in a relative state of flux as far as how V3 will be implemented by entities as evidenced with the National Health Service’s shift in the UK from using “V3 messaging” to “V3 CDA” for the Spine.

Keeping the above caveats in mind, it is still a good idea to prepare for V3 by acquainting yourself with some fundamentals.

With V3 being a model-driven standard, a logical starting point for preparation means starting with the information model upon which all V3 standards are based on – the Reference Information Model (RIM). This means that both V3 HL7 messaging standards (e.g., Inpatient Encounter, Ambulatory Encounter, etc.) and V3 Documents standards (e.g., CDA, CCD, etc.) are all based on the RIM.

As a side note, HL7 users in the United States generally think “HL7” means HL7 2.X messaging standard. Thus, when they think V3, they think about V3 messages replacing the V2 messages. While this is technically possible, market forces are not likely to make the leap to V3 for HL7 messaging anytime soon. If you work for a healthcare provider in the United States, outside of Clinical Document Architecture (CDA), there appears to be little movement towards V3. Some of these topics on the HL7 standards – V2 and V3 – are covered in more depth in a 14-page white paper entitled, The HL7 Evolution (PDF).

With this understanding, we can now get back to V3 and the RIM. With the RIM being an object-oriented methodology implemented via XML, a good starting point to understanding it is to familiarize yourself with the six core classes of the RIM:

1. Act – represents the actions that are executed and must be documented as health care is managed and provided
2. Participation – expresses the context for an act in terms such as who performed it, for whom it was done, where it was done, etc.
3. Entity – represents the physical things and beings that are of interest to, and take part in health care
4. Role – establishes the roles that entities play as they participate in health care acts
5. ActRelationship – represents the binding of one act to another, such as the relationship between an order for an observation and the observation event as it occurs
6. RoleLink – represents relationships between individual roles

With a firm understanding of the above six core classes and their associated attributes (see the latest HL7 Version 3 Normative Edition for details on associated attributes), you should be better prepared to more quickly analyze and implement your first HL7 Standard V3 interface, regardless of whether it is a V3 message or V3 document.