However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” on THCB. He writes: “In a number of interviews with leading HIE [Health Information Exchange] 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.”
I have four beefs with John’s essay:
- It’s no news that HIEs prefer CCD.
- HIEs are not representative of the broader health IT market.
- The narrow findings don’t justify the broad conclusion.
- The CCD and CCR standards are more complementary than competitive
Let’s look at these one at a time.
1) It’s no news that HIEs prefer CCD.
First, let’s separate findings from inferences.I don’t dispute John’s findings that HIEs prefer the CCD standard.
My reaction to this finding is: “duh”.
Asking HIEs whether they prefer CCR or CCD is akin to asking Bill
Gates whether he thinks Windows or Linux is the better operating system.
The CCD is a standard designed and created for heavy duty health care institutional use — exactly what HIEs are created to do.
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.
2) HIEs are not representative of the broader health IT market.
HIEs have struggled to create a sustainable business model. John, as you yourself wrote less than two weeks ago:
As we have seen in
a number of failed HIEs to date, stating in writing a sustainable
business plan and actually having one that works are two very different
things…While the funding [HITECH] is welcomed by many in the industry,
creating regional and statewide HIEs will prove challenging as to date,
there are still no demonstrable and repeatable business models to
create such exchanges that are truly self-sustaining.
In that same essay, you also noted that most HIEs today are
not capable of the type of interoperability envisioned by the HITECH
Sure, there are
countless HIEs today, but the vast majority of these are within a given
Integrated Delivery Network (IDN), but these are closed systems.
…and the recent KLAS report on HIEs points out that vendor hype does not always match reality:
Though marketing by
some vendors would suggest that many examples of successful health
information exchanges (HIEs) have been built on their solutions, the
reality of HIE adoption is quite different. According to a new report
from KLAS, only a relatively small number of vendors have risen to the
challenge enough times to claim a proven, repeatable model.
3) The narrow findings don’t justify the broad conclusion.
The fact that HIEs prefer CCD says nothing about adoption
patterns in the broader market. John broad conclusion “CCD Standard
Gaining Traction, CCR Fading” isn’t justified by the narrow findings.
4) The CCD and CCR standards are more complementary than competitive.
As my colleague Steven Waldren MD and I have written:
We see at least two different HIT “nations”.
- One is populated by large institutions that are comfortable speaking Latin (i.e. HL7 CDA, UCUM)
- One populated by ambulatory tribes — small to medium size physician
practices, clinics, patients with PHRs, and innovative early stage
companies with limited health IT budgets – that prefer multiple less
sophisticated, yet effective dialects.
Let’s consider one example: the differing use of summary care record standards in institutional and ambulatory settings.
The HL7 CCD standard is more likely to be used in institutional settings:
- By organizations that have already adopted HL7 (e.g., large delivery systems)
- To support existing business models
- In non-disruptive applications that achieve costs savings and/or
quality improvements by automating EXISTING processes that are INTERNAL
TO THE ORGANIZATION (or with existing trading partners), e.g.,
hospitals sending test result information to doctors.
- Where implementers have already incurred significant fixed costs to adopt HL7 as a broader enterprise standard
The ASTM CCR standard is more likely to be used in ambulatory settings:
- By organizations that have not yet adopted any standard (e.g., early stage companies)
- To support new business models
- In disruptive applications that achieve costs savings and/or
quality improvements by creating NEW PROCESSES, often involving parties
that are not currently exchanging information, e.g., improving patient
chronic care management with the goal of avoiding ER visits and
- Where the implementers are highly sensitive to incremental costs of
IT resources and view the CCR as a “better, faster, cheaper”
John, referencing a recent movie — “I Love You, Man”…but I can’t agree with you on this one.