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CCD Standard Gaining Traction, CCR Fading

In a number of interviews with leading HIE vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future.  The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.  This HIE vendor did state that one client did ask for CCR, but only to enable data transfer to Google Health.

CCR was created by ASTM with major involvement by AAFP wih the objective to create a standard that would be far easier to deploy and use by smaller physician practices.  At the time of CCR formation, the dominant standard was HL7’s CDA, a beast of a standard that was structured to serve large hospitals and based on some fairly old technology and architectural constructs.  With competing CDA and CCR standards in the market, there was a need for some rationalization which led to the development of CCD, a standard that combined some of the best features of CCR and CDA.

Today, CCD is seen as a more flexible standard that is not nearly as prescriptive as CCR. This allows IT staff to structure and customize their internal HIT architecture and features therein for their users and not be confind to a strict architectural definition such as that found in CCR.  (Note: such strict definitions are not always a bad thing as they can greatly simplify deployment and use, but such simplicity comes at a price, flexibility.)

Unfortunately for Google Health, who has built its system on top of a modified version of CCR, this trend   likely lead to increasingly difficulty in convincing healthcare providers to provide patient health records in a CCR format.  Google would be wise to immediately begin the work necessary to bring CCD documents into their system as the writing on the wall is getting clearer by the day.  CCR is a standard that will fade away.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

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10 replies »

  1. Hi,

    I have provided Sample CCD with good data with covering C32 and MU standards. For your request of bulk loading process, if you require I can put some time of creating it.

    If interested send an email to this ID : Mohan_raj_3000@yahoo.co.in

  2. I am looking for a sample CCD for bulk-loading demograhics. Can someone send or point me to a link where I can get the document? Thanks in advance.

  3. One of the most asked questions I have been receiving these last few months from companies, developers and physicians alike is: “What standard should I use, CCD or CCR?”.
    I respond: “Both!”. Why? Well, we never know what the customer wants until they have made their choice.
    Microsoft also decided to do this as well, obviously for some reason.
    Now, I’m sure that the one to take off will be the most documented one so that people can refer to for learning.
    As far as I know, and I learned this at HIMSS 10 yesterday, a CDA book is being written by a well-known standards and interoperability guru. So if this book gets out there and is used by many to learn how to implement CDA CCD and if the actual contents are simple to understand by most, then CDA CCD will probably have an advantage over CCR soon.
    I have not heard of anyone writing a book on CCR. Who’s going to be the first?
    But wait, there was never a book on DICOM until 2008, and it is a very basic one. And what happened because of lack of easy to understand documentation? Well, vendors started implementing DICOM using their own interpretation of the standard. Then with all the mess that was created and interoperability continued to be a nightmare, IHE was born to “harmonize”.
    So, I just suggest that everyone work on both standards and then leave it to IHE to create a profile for clear use cases that have been discovered or defined.
    That’s healthcare IT for you!
    Thanks,
    The EHR Guy

  4. Hurray! We’re discussing the actual use of health data exchange standards that use XML (extensible markup language, the lingua franca of the Web). This was a major purpose of creating the CCR standard in 2004-05, as a means of enabling movement of health data over the Web and Internet, you know, as other industries have done to share data and make it computable using web services. So, simply having the choice of two XML clinical summary standards that can be computably exchanged is real progress.
    But there’s still a long way to go until any EHR technology can reliably and consistently exchange structured summary health data with any other EHR technology using one or both of these standards. As Google Health, CVS MinuteClinic, Microsoft HealthVault, and a growing ecosystem that includes all the major pharmacies, a number of clinical decision support and pharma decision support firms, several Apple iPhone apps companies, a couple of EHR vendors, and others have shown, the CCR standard is quite serviceable for the purpose of secure and structured health data exchange in XML. What hasn’t occurred is for the broader health IT industry to work out the details — and there are quite a few — of this kind of useful, practical exchange over the Web.
    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.
    Beware of the complex solutions that must be “perfect” and agreed upon by all the incumbents before they can be deployed. Respect the choice made by those who accept loose consensus and working code. They usually win the race in the end.
    Regards, and thanks. DCK

  5. FYI – In ONC’s presentation today at the National eHealth Collaborative – the NHIN Limited Production Implementation uses a limited C32 Continuity of Care Document (CCD)
    • Demographics
    • Allergies
    • Medications
    • Problem List
    and by July 31, 2010 they expect to use
    – HITSP C32 subset
    – Add’l ICIB-Defined/HEC Approved Data
    Sherry – Alliance4Health

  6. I don’t know what the exact situation on the ground is, but ONC is allowing for both standards to coexist in Stage 1 of MU, with the caveat that the choices will be narrowed. If you look at the Standards Committee proposals, there is no mention of CCR.
    Is it possible that the regulatory choice was already made in DC?

  7. Disclaimer: I was a co-developer of the ASTM CCR (I was also an editor on the CCD), therefore I am biased toward the CCR. Although I am an advocate for discrete data exchange that improves quality, safety, and efficiency regardless of the standard used.
    My first comment is that many vendors like the CCD because they can produce Level I and Level II CCDs and not have to worry about highly structuring clinical data (this requires a Level III CCD through the use of clinical statements). If you are only going to wrap HTML with a CDA header and section headers, why not increase the flexibility even further and wrap it in a general PDF?
    Very few times when an HIE vendor tells me that they use the CCD that they can provide me with real-world examples of Level III structured CCDs that a recipient could do more with than display on the screen, electronically file, or print.
    From my interviews with PHR, EHR, and HIE vendors, the CCR requires less than 20% of the effort to implement than the CCD, even among those with experience with CDA. We are seeing several efforts to create simple interoperability because the complex engineering projects of the last 10+ years have not gotten us much closer to wide-scale interoperability. Just look at Project hData or the new HL7 project “Micro-ITS” or the soon to be discussed NHIN Direct. They are all taking a play from the ASTM CCR playbook and making interoperability easier for developers to implement and cheaper to deploy.
    I hope the CCD succeeds, but I know the CCR will not fade, at least not in the near future.
    Best,
    Steven
    P.S. The AAFP was not the only sponsor of the CCR, so was AAP, AHA, AMA, HIMSS, MMS, and others

  8. John, it’s odd but from my anecdotal discussions I’m not seeing this trend (but am glad it’s occuring if is). If you’re interested, we could get a survey started at HITSphere.com to get some objective evidence from the vendor community. Or, perhaps as you ask around more vendors next week at HIMSS we might get some additional information. Thanks for posting this article.

  9. John,
    Are there any handy metrics that we non-HIT followers might reference re: the adoption shift you have identified? I’ve no reason to doubt you, but without evidence, it looks like you’re merely editorializing here, with an n of one vendor providing support for your assertion.

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