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A Self-Fulfilling Prophecy: The Continuity of Care Record Gains Ground As A Standard

Brian KlepperWe live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand conceptions of possibilities and, then, the persistent focused toil that is required to bring ideas to useful fruition.

We could see this in a relatively quiet announcement this week at HIMSS 09. Microsoft unveiled its Amalga Unified Intelligence System (UIS) 2009, the next generation release of the enterprise data aggregation platform that enables hospitals to unlock patient data stored in a wide range of systems and make it easily accessible to every authorized member of the team inside and beyond the hospital – including the patient – to help them drive real-time improvements in the quality, safety and efficiency of care delivery.”

The announcement was amplified by a New York Times article, earlier this week by Steve Lohr about New York Presbyterian’s collaboration with Microsoft, now beyond the pilot stage, to transfer patient data into consumer-controlled personal health records (PHRs). The article acknowledges that Google, as well as Microsoft, are now actively engaged as well with major health care institutions – Mayo Clinic, Cleveland Clinic, Kaiser Permanente – to automatically move patient data into PHRs.

The facilitating technology in all these efforts is the Continuity of Care Record (CCR) Standard. Here is the Wikipedia entry, cited in the Microsoft announcement, describing the CCR. It is”a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to another.

Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application. A CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft Word 2007 format).”

The creation of a new industry standard is an immense undertaking of breathtaking audacity, vision, skill and hope. It starts from scratch to craft a highly useful, flexible tool that can be easily adopted by developers, who are focused on wide-ranging aspects of common problems.

The CCR Standard was developed by a collaborative – the Massachusetts Medical Society[1] (MMS), the HIMSS (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors – under the auspices of ASTM International, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. David Kibbe MD, my friend, colleague and often co-author on the Health Care Blog, was a co-developer of the CCR, and serves as the 2008-2010 chair of the E31 Technical Committee on Healthcare Informatics, the leadership group within ASTM that works with
individuals and organizations on the implementation and use of the CCR standard in the US and abroad,

The CCR’s increasing adoption by major players is testament to the soundness of its vision and its utility. It’s advance will allow patient health data to be easily transported from one platform to another, intact and with integrity, so that better decisions can positively impact care, health, and the costs of achieving them.

This is something we can all acknowledge and admire, because it fulfills the common mission – better, more affordable care for better health – that brings us together on this site.

Brian Klepper is a health care analyst based in Atlantic Beach, FL.

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ArchieAbigaelbev M.D.MD as HELLDavid C. Kibbe, MD MBA Recent comment authors
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Archie
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Abigael
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Abigael
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David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Margolit: Sorry, the confusion about “experiment” was mine, not yours! I know we’re on the same page here.
MD as HELL: You’re right. Any application that physicians use should not be “clickety-click” hundreds of times, and unimaginative. Doesn’t have to be that way at all! DCK

Margalit Gur-Arie
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David, I apologize for the misunderstanding. The “experiment” description was referring to the CCR transmission through SureScripts, not the electronic prescriptions. I am intimately familiar with the e-Prescribing process and its daily volumes, including the pros and cons, as “MD as Hell” notes above. I do agree that the HITECH money would be better spent on facilitating simple data transfer, as opposed to complex data entry. Whichever existing network is selected for that will have to be seriously tweaked and expanded and the costs are not going to be negligible. I would suggest that whoever makes these decisions does not… Read more »

bev M.D.
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bev M.D.

I have to agree with MD as HELL regarding the reality of office and hospital computer systems. It seems there is a disconnect between the people talking about all the wonderful things these systems can do, and we physicians whose experience with the things in the real world is almost uniformly negative, to neutral at best. Some argue that this is generational, but I don’t think that explains all of the discrepancy. Some of the people with big visions need to visit a hospital or large doctors’ office sometime and see how these things actually work (or don’t).

MD as HELL
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MD as HELL

I don’t care which system is adopted. ePrescribing is tedious and cumbersome. It interferes with my educating and interacting with my patients. It decreases my time efficiency and therefore costs me money. It is not a onetime cost. It is with every patient encounter forever, if I am forced to do it. I do not do it now, although I have tried it. BTW, why is everyone wanting to “mandate” or “require” me to do something just to make some centralized system of records work. It is always someone selling a system that wants the gov’t to require me to… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Margalit: As usual, you ask the smart questions. Surescripts, of course, has a registry for all of the physicians who use their network for e-Prescribing, and knows all of the devices, EHR technologies, at the receiving ends — both pharmacies and doctors offices — because these must “certify” their capability to send and receive the ePrescribing data necessary to do ordering and fulfillment of prescription medications. This isn’t an experiment; it’s used millions of times a day to send data back and forth between pharmacies and physicians using health IT for ePrescribing. It’s paid for by the pharmacies. Not by… Read more »

Margalit Gur-Arie
Guest

David, I wasn’t aware of the SureScripts CCR experiment, but obviously Dr. Oates is. Very nice. But as I said above, someone needs to maintain a directory of all EHRs and the physicians associated with each one and expose that directory to every EHR user that may want to send a CCR through. Whether it’s SureScripts or Google, it still needs to be done and it will be much more complicated then sending claims to payers. The issue I have with Google is that the post office does not usually maintain copies of all the letters that it handles. I… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Margalit and Randall: There is network already established for transmittal of CCR xml files, and it’s being used today. It’s called Surescripts. Now, before you jump all over me, let me say that there will certainly be other national, certified networks able to connect one EHR with another EHR. I grant you that. But consider that CVS MinuteClinic is already sending many thousands of CCR xml files from its EHR via the Surescripts network, where they are either routed electronically to practices in xml format (not many yet) or transformed into PDF and sent electronically or faxed. There is no… Read more »

Margalit Gur-Arie
Guest

Right on, Dr. Oates! I must admit that I too am guilty of making the assumption that a small set of data may be useful to other physicians (like med & problem lists, some test results, maybe allergies, etc.). I am partial to CCR since it is so very simple and straightforward, but how would we use it…. exactly? How does it get from one EHR to another EHR? I know the canned answer is “web services over SSL”. That may work fine for exporting to Google or CMS, but how we do it for two disparate client/server EHRs, each… Read more »

Randall Oates, M.D.
Guest

Should there be evidence that any proposed approaches to interoperability will actually succeed in the real world before we declare such approaches as required?
Otherwise, who can determine what approaches to interoperability will prove acceptable to the majority of medical practices?

Tim Cook
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Tim Cook

The CCR is great at what it does. It enables the transfer of a summary. Definition of summary may vary here and there. however it does nothing to add to real semantic interoperability. Short term the CCR is helpful. But the US health information industry has been thinking short term for more than 40 years. There is an interesting advancement posted on another blog http://ascannerbrightly.blogspot.com/2009/04/guest-blog-collective-clinical-wisdom.html that requires some lonng term thinking but will deliver computabillity (real decision support anyone?) and semantic interoperability. All the while allowing clinicians to do what they do best and software engineers do what they do… Read more »

Sean Nolan
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The CCR is indeed a great workhorse for moving data. You know a standard like this is successful when the purists start complaining that it is being abused — and we hear that about CCR every day. 🙂 The kudos that were the original point of this post are well deserved. In particular the CCR authors recognized the need for our industry to “ease into” structure … the format does a great job of encouraging coding and normalization without creating an unrealistic bar — this is a tough tightrope to walk! That said, Vince has it spot on — Both… Read more »

Vince Kuraitis
Guest

Margalit, don’t see any disagreement betwixt us. For many applications — espec ambulatory and small company — CCR is a complete solution. Hospitals can also deploy CCR for specific applications.
However, hospitals will not view CCR as complete data exchange solution for all applications. Hospitals will need to adopt HL7.
Yes, vast majority of hospitals today are on HL7 2.x . While HL7 3.x is incompatible with 2.x, my assumption is that hospitals view “eventual” migration to 3.x as necessary, albeit dreaded because of reasons you cite.