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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  4. 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 than competitive. Your technical arguments in support of the CCD can and should be achieved.
    Lawrence — as to your last point about context. Yes, the ARRA HITECH legislation ties reimbursement to “incumbent” markets — which is exactly the problem.
    What’s sacrosanct about assuming that hospitals/doctors are THE leverage point for creating a digital health system? What’s sancrosanct about assuming that existing EMR functionality is the key to broader adoption. The Nutting report suggests that registries, clinical decision support, & web portals have far more impact.
    fyi, this essay was originally posted on my own blog. If you’ve read this far, there are also many additional comments and perspectives at:
    Thanks for a great discussion.

  5. 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

  6. 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.

  7. 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 reasonable logic and facts:
    1) I have examined both CCR and CDA carefully. I have worked with many developers from both large and small companies, both from ‘incumbent’ markets such as EHRs, and ‘disruptive markets’ such as PHR applications. I know exactly what both standards do, and also exactly how difficult they both are to implement.
    2) I know of many use cases where CDA works but CCR does not. Other than emotional appeals, I have not yet heard any concrete use case where CCR is required and that CDA could not be used.
    3) The costs to maintain two standards here is substantial. Requiring both standards affects all consumers of the data which must implement readers to interpret both standards if communication is to occur. This effect impacts development organizations regardless of size, both in the ‘incumbent’ space, as well the ‘disruptive’ space, and also taxes standards developers which must account for all differences and duplications resulting from both standards.
    4) I’m a physician and see the wide variety of clinical needs that providers and patients have in the need to communicate. My intent (I hope yours too) is to improve communication across the full continuum of care. To me, promoting one standard for inpatient settings and another for outpatient/ambulatory is akin to mandating switching between two gauges of rail at every station while traveling across the continent.
    5) Because of the substantial costs in #3, having two standards increases the risk that communication will not occur or will be delayed. That’s bad for patients.
    You may not like my reasons, but I can assure you they would not change regardless of who I worked for. These reasons hold for both ‘innovators’ and ‘incumbents’
    Further, here are some of the problems I have with your line of argumentation.
    I support the ‘disruptive technologies,’ (just like nearly everyone I’ve met.) But to argue that ‘incumbents’ are opposed to CCR is because of fear of ‘disruption’ isn’t true. First, it is extremely unlikely that either CCR or CDA would be disruptive in ways to negatively impact the ‘incumbents’ (e.g., neither could ever support features such as inpatient CPOE, are both are unlikely to uproot HL7 v2.x for labs, adt, etc).
    Next, the assertion that CCR is better than CDA at encouraging ‘disruptive technologies’ is an opinion and entirely unsupported. In my opinion, CDA has far more potential to be ‘disruptive’. This is because:
    1. CDA has a mechanism for extension and formal constraint and therefore supports a much wider number of use cases. It therefore encourages use into new unseen areas.
    2. CDA has a mechanism for free text narrative, structured entry, and binding between these narrative and structured forms. Because of this, it is far easier to build progressively to a fully semantic interoperability. This ‘architecture’ encourages early dissemination of documents, the benefit of always being useful for human consumption, and leveraging of data used for other use cases.
    Also, CCR is not necessarily ‘better, faster, cheaper’ for ‘disruptive’ technologies unless all they do is produce data and never consume it. The chief reason that CCR may look ‘faster, cheaper’ is because it leaves everything optional. Thus, it makes it very easy to **create** a CCR. However, it does this by placing the entire burden on the **receiver** of the CCR. Receiving and understanding a CCR from anybody else is not ‘better, faster, cheaper’ because there is no common understanding of what to expect in that CCR. Also, because CDA is already required (as you acknowledge, only CDA addresses some of the needed use cases), then **adding** CCR can only add complexity to applications that wish to receive data. Unless the goal is only “for display purposes only” (ie foregoing sharing across the full continuum of care and providing pathways to support decision support, quality measurement and improvement, etc) adding CCR simply cannot be ‘better, faster, cheaper’ for receivers.
    Finally, I think it is important to note the context of the discussion. The context is a government stimulus where the law (ARRA) explicitly ties payment to those ‘incumbent’ markets. The intent of the law is to ensure that eligible hospitals and eligible providers align so that they can speak the same language and exchange data. Encouraging institutional markets and ambulatory markets to speak different languages does NOT help to ensure that those markets can communicate.

  8. 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 spirit of discussing the issues rather than the motives, I have two points:
    1. On what basis did you make your original statement about the “more flexible CCR?”
    This is unfounded, considering that CDA can support far more data types and scenarios (see
    and http://www.himssehra.org/docs/HL7_CDA_CCD.pdf
    CCR is a fine “hammer” for the continuity of care “nail.” CDA is a broader “toolbox” including hammers, drills, and wrenches. (So I used a “tools” analogy in response to your “animals” analogy!) It’s no wonder that some vendors prefer a toolbox that can cover the broad gamut of their customers’ needs vs. one that can’t. Consider the ability of CDA to be a general summary (e.g., Medications) but also a very precise summary for hospitalizations (e.g., admission meds, meds administered, discharge meds; admission dx vs discharge dx). Yet it doesn’t impose hospital-level granularity on ambulatory scenarios. It can scale down to fit simple needs, but also scale up to include critically important information like Hospital Course, Physical Exam, and much more as needed.
    2. How did your Lab Results and CHF illustrations make a case in favor of either CCR or CCD?
    While they were excellent illustrations, it was a huge leap to conclude that CCD is suited for the first and CCR the second, or that CCR is “innovation” and CCD is not. What if the CHF follow up requires data that goes beyond both CCR and CCD (as I suspect it does)? Then flexibility becomes a big deal, and those are strengths of CDA, since CDA templates can easily be added to extend CCD.
    Let the decision about CDA/CCR be made for valid reasons, not based on incorrect assertions such as CCR being “more flexible” or broad-brush assumptions of feline intentions.

  9. 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….

  10. 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 would be positive for patients and care providers.
    I also understand several vendors have been working on CCR-CCD “translators”.
    To adddress your specific question, I’ll say that my classes in microeconomics have given me the most insight about behavior in the health care system and the world. People and organizations tend to pursue their (economic) self interests, so the role of government is to set the rules of the game to incentivize desirable public policy; just about everyone agrees the current fee-for-service Medicare payment system doesn’t work, but fixing it has become very politicized.
    The selection of CCR and/or CCD is a complicated decision, influenced by many factors, and probably is more directed by vendors than end users. The use of CCD and/or CCR standards also is just one of many factors in software design and purchase decisions.
    So my answer is — I don’t know how all these variable will play out. I’d like to see further harmonization of the CCR and CCD standards.

  11. 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?

  12. 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) defending existing economic interests.
    So let’s take “feelings” out of the equation. The ASTM CCR standard is a disruptive technology; HL7 CCD is not.
    BOTH standards need to exist to create a health care environment in which innovation and disruption can flourish.
    I am not in any way against the CCD. As a member of the ASTM Steering Committee guiding development of the CCR, I can tell you that in our wildest dreams there is no belief or intent that the CCR could be a substitute for the CCD.
    The CCR is a complement to the CCD; it enables lightweight applications — it’s “better, faster, and cheaper” for many applications that need to transport a subset of a patient’s record, e.g., a summary care record.
    But it doesn’t work the other way around. It’s not hard to imagine a world in which the CCD could be a complete substitute for the CCR. Many incumbents advocate such a world view.
    Incumbents have economic interests in protecting the status quo (again, take feelings out of it). Many incumbents (cats) don’t want to see the CCR as an alternative because it is a disruptive technology and doesn’t support incumbents economic interests.
    I also understand and believe that people supporting development of the CCD are well intentioned and want to create better health care for their families and patients. But you have to look at the structure and incentives of the organizations they work in.
    Let me expand on my examples of where the CCD is more likely to support internal processes and the CCR is more likely to be used by innovators creating new processes.
    A hospital lab needs to get test results to physicians; as I’m defining it, this is an existing internal process to the organization (and its partners). The hospital and doctors are highly motivated under current economic conditions to automate this process — the value proposition is efficiency and cost reduction. This is not a disruptive use of technology. The hospital (or HIE) is more likely to use the CCD standard to enable this process because it is already familiar with the standard, i.e., they already speak Latin.
    Consider another example of a CHF patient discharged from a hospital. Until recently, hospitals have no economic incentive to follow this patient at home, e.g., to make sure the patient doesn’t gain weight/retain fluids and stays compliant with medication. However, the payer (health plan or Medicare) does have an economic incentive, and thus the creation of disease management programs for CHF patients.
    Thus, from the hospital’s POV, following a CHF patient home after discharge is new, disruptive process that is counter to the hospitals existing economic interests. That’s why you’ve seen health plans pioneer many DM programs — their economic interests aren’t aligned with the hospitals. A DM company or remote monitoring company creating a CHF DM program is much more likely to employ the CCR standard because its simply a “better, faster, cheaper” way to move around a subset of the patient’s record.
    The cat/dog framework is a useful (and hopefully amusing) way to describe the differing economic interests and consequent actions of stakeholders in the health care system…and as I’ve noted before…
    “Cats and dogs now are ultimately working toward the same ends…how best to improve quality of patient care and reduce costs through the adoption and use of information technology. We have many common interests and goals.”

  13. 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 clinically in favor of CDA (not just CCD which is only one example of CDA). No one says it’s perfect or can’t be improved and simplified, and there are efforts underway. One of the trouble w. blogs is that some people tend to caricature the other side. I’m not going to say bad things about CCR or ASTM or those favoring CCR in this post, and I’m not going to assume that they all have ulterior motives. Isn’t it possible that someone has technical or other reasons, besides fear and vested interest, to favor CDA/CCD? Could it be that CDA advocates, including those who work for vendors, are real people who passionately care about better healthcare for their families and all patients? I look at the long list of CDA supporters and I don’t see fearful dummies scheming in a back room. Rather, I see a bunch of really smart people, many of whom are physicians who care for patients and want to share information, and who are willing to engage in dialog through an open consensus process.
    Your assertion that CDA is oriented toward processes INTERNAL to an organization is puzzling to me, considering what you just said about HIEs and how CCD would naturally appeal to them. HIEs are certainly not targeted at the internal workings of an organization! So much of CDA and other interoperability work such as XDS has been designed specifically for cross-organizational (not just internal) scenarios.
    There’s more than enough political posturing and “demonizing” others. I hope that we’ll talk about these HIT issues using facts and reasoning rather than assumptions and conspiracy theories.
    David Tao

  14. 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 one ultimately “invested” in seeing that something resulted from their use.
    This will almost certainly be the result of spending vastly more money now, as will it likely be the case of spending the $30 billion in ARRA-allocated funds. No commitment from those who are supposed to benefit from the use of the technology that is paid for by tax-payers.
    The likely result is a flow-through of most of the funds to private software and hardware vendors and high-overhead system installers who will bill out at absurdly high rates because there is no incentive to economize on the use of funds.

  15. 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 significant local governance role needed to optimize local health information exchange….but even this doesn’t justify what seems to be an expensive and duplicative local technological infrastructure.
    Back to CCR & CCD. I applaud HHS for allowing both standards to be used for summary record exchange under the recently released Standards IFR.
    Aneesh Chopra and the philosophy of Gov 2.0 seem to be a major reason that the lighter weight and more flexible CCR has been included. The dogs (innovators) have much to bark about; cats (mostly incumbents and supporters of the CCD) feel threatened. Perhaps that’s my biggest disappointment with John’s essay, as I know he’s a dog at heart.

  16. I am having tremendous difficulty with this entire HIE business. There are many millions of dollars thrown by ONC at establishing HIEs all over the place, but the grant money is going to run out in a couple of years. If you read the proposals from various HIEs, you will see that their idea of becoming self sufficient is to eventually charge providers for their services.
    Regardless of the obvious governance issues, I think there is a slim to none chance that the ambulatory tribes will be willing to pay for HIE. The question then becomes what is to happen to all these entities when government money runs out? Do we find ourselves obligated to continue paying for them with taxpayer money because they are already there?
    And why should providers pay for communicating over the internet? There are plenty of applications communicating (securely) over the internet without an intermediary. Is this about “collecting” data as it passes through?
    Oh yeah… we are talking about CCR and CCD…. Well, when an entity is trying to insert itself in the midst of any transaction, it will attempt to make the transaction process look very difficult and complicated in order to justify its existence, so CCD it must be.

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