Chilmark Needs to Chill Out on CCR/CCD Findings

Picture 112 John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.

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:

  1. It’s no news that HIEs prefer CCD.
  2. HIEs are not representative of the broader health IT market.
  3. The narrow findings don’t justify the broad conclusion.
  4. 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.

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kippt.comstoryofahomekeeper.wordpress.comCarriThe EHR GuyLawrence McKnight, MD Recent comment authors
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Vince Kuraitis

David, Lawrence I’ll try to keep this short. There are clearly two schools of thought here, and there are strong proponents on both sides: 1) Technical focus: Specific, precise standards create opportunities for data transport and content. Technical standards come first, adoption follows. 2) Market adoption focus: simple, multiple standards facilitate data transport. Adoption/data liquidity first, the market will work out technical specs. You both make good cases for #1 — and to that extent this discussion is valuable and hopefully educates people in what is a confusing yet extremely important issue. The CCR and CCD are far more complementary… Read more »

The EHR Guy

Vince Kuraitis’ response blog post is a true masterpiece.
I’ve been posting comments with some disagreement with John’s post. From now on I will write a comment pointing to this blog post.
I have a feeling that John just wanted to initiate a discussion with his post since the CCD vs. CCR debate is very ambiguos.
The EHR Guy

Vince Kuraitis

David and Lawrence,
I want to acknowledge and thank you for your thorough & thoughtful comments. I’ve been traveling and am buried, and want to respond in a way that continues a constructive dialoge. So please give me a bit, and I’ll get back, perhaps in a separate blog post.

Lawrence McKnight, MD
Lawrence McKnight, MD

Hi Vince, I’m one of those ‘incumbent — cats’ you refer to (disclaimer I own both a dog and a cat and love both of them). I do work for a vendor that develops primarily hospital based solutions. However, I’m also a physician, and your arguments seem to imply that the only reason somebody like me might disagree with the use of CCR is because they have some selfish intent to protect their incumbent position. This is simply not true. There is no reason to invoke conspiracy theories about why I support CDA over CCR as they are based on… Read more »

David Tao
David Tao

Vince, thanks for your response. Your two examples — the hospital-physician “results sharing” process, and the CHF follow up process, along with the different economic incentives — were astute. I also commend you for seeking common ground. It would be great if all aspects of our nation, public and private, would work together toward common goals. You and I indeed share those goals. The main point of my first post was that we show respect and not assume that those who disagree with us must have certain motives (such as “protecting the status quo” or “incumbents’ economic interests”). In the… Read more »

Margalit Gur-Arie
Margalit Gur-Arie

Thanks, Vince. I think we will end up with one standard and it would be nice if it had various levels of complexity, with the simplest one being a CCR like structure and the most complex being the full CDA, and harmonization could probably accomplish that. We shall see….

Vince Kuraitis

Margalit, I think HHS/ONC (finally) got it right in the recently released Standards IFR when they allowed both the CCR and CCD standards to be used for summary records in Phase I. My read is that ONC is strongly suggesting that they would like to see one standard in Phase II and the future, and they are hoping the CCR and CCD could be harmonized further. They also recognize the value of getting market feedback in Phase I. Speaking as one member of the ASTM Steering Committee for the CCR, I think further harmonization of the CCR is possible and… Read more »

Margalit Gur-Arie
Margalit Gur-Arie

So Vince, if the economic incentives were realigned, say by instituting bundled payments or bonuses for reducing readmission rates, do you think hospitals and other incumbents would be amenable to using CCR and other innovative methods, or do you think they will insist that everybody learns Latin?

Vince Kuraitis

David Tao, Thanks for your comment. I can see how what I wrote could be confusing and I really don’t see us as very far apart at all. First, let me clarify my POV of the world. I work as a consultant assisting clients with business models and strategy, especially in areas relating to development of health care platforms, applications, & networks. My clients are dogs (innovators) and cats that recognize they need to become more doglike (incumbents who recognize the need to innovate, or it will be done TO them). My clients are not likely to be cats (incumbents)… Read more »

David Tao
David Tao

Vince, while I disagree with much of what you said, I was OK with your writing it until the last part of your response to Margalit. Please don’t speak as if you know the motives of the “cats” as you call them. There are plenty of reasons that honest people can have to support CCR, CCD, or whatever. But for you to say that the reasons is that they are “incumbents” and “feel threatened” is to attempt to put yourself into someone else’s shoes that you aren’t in. There have been plenty of well articulated reasons architecturally, technically, legally, and… Read more »

Wendell Murray

Leaving aside the discussion of CCR and CCD and the settings where one or the other is used, I agree regarding HIEs. An assessment of the HIE that an earlier head of the Office of the National Coordinator, Dr. Brailer, was involved in in Santa Barbara CA years ago – that included burning through a $10 million grant from the State of California with no positive result – clearly indicated that the prime reason for failure was lack of commitment from any party involved in maintaining the HIE. Plenty of participants who were happy to receive the funds, but no… Read more »

Vince Kuraitis

Margaret, I’m with you on your questions about HIEs. I keep asking the question “What’s the raison d’etre (reason for being) for HIEs if ONC continues to pursue the ‘Health Internet’ model currently under discussion.” I get back mostly silence. Blumenthal insists that we can pursue the new “Health Internet” and the older “Nationwide Health Information Network (NHIN)” model simultaneously. ONC is throwing $600M + at developing regional health information exchange infrastructure. But why? jobs? that’s a weak reason to spend all that money. The best answer I can give to my own question is that there truly is a… Read more »