Literature Review and Environmental Scan: Evaluation of Personal Health Records Pilots for Fee-for-Service Medicare Enrollees. Continuity of Care Record Versus Continuity of Care Document as the Basis for Interoperable Information


Document standards are essential to achieving interoperability between PHR systems and between PHRs and EHRs.[166] Two types of common document standards are the Continuity of Care Record (CCR) and the Continuity of Care Document (CCD). The CCR and CCD are standard specifications developed by different groups of organizations to achieve similar goals: improved continuity of healthcare, a reduction in medical errors, and improved health information transportability between patients, providers, and health care institutions. It is particularly important to note that the CCD or CCR is not the underlying personal health record itself; rather it is an interchange. The CCD and CCR provide the ability for one record to extract information, and for the next record to insert the information extracted into its own system.

The CCR is a standard specification that has been developed by ASTM International, the Massachusetts Medical Society (MMS), the Health Information Management and Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics.

ASTM’s CCR is an XML-based set of data from health care records, medical legal documents, and health care encounters. The CCR is the clinical record of the patient’s current and historical health care status. [167],[168] The basis for CCR is a Patient Care Referral Form developed by the Massachusetts Department of Public Health. Basic patient information is included, such as patient and provider information, insurance, patient health status, recent care provided, care plan information, and reason for referral or transfer.[169] One of the CCR’s goals is to foster health information transportability between providers, such as when a patient is referred, transferred to, or seen by another provider. The CCR was designed to ensure that adequate information is collected on a patient prior to referral or transfer so that the information can be exchanged.

The Continuity of Care Document (CCD) was developed as a result of collaboration between ASTM and HL7. HL7 is a not-for-profit, international standards development organization that is accredited by the ANSI. Both ASTM and HL7 were working independently to develop a standard for health information exchange. ASTM developed the CCR, while HL7 focused on developing the Care Record Summary. Both ASTM and HL7’s efforts were targeted at developing a standard to produce an electronic patient care summary that could be exported and read by EHRs and PHRs.[170] In 2005, ASTM and HL7 signed a memorandum of understanding to collaborate and create the CCD.

The CCD has been said to combine the ‘best of HL7 technologies’ and the ‘rich experience of ASTM’s CCR with clinical data representation.’[171] The CCD describes the use of the CCR standard dataset so that it can function within the HL7 Clinical Document Architecture (CDA). HL7 members were balloted regarding the adoption of CCD. The CCD was a successful ballot, concluding on January 7, 2007, and termed a ‘very significant development for healthcare IT’ and ‘a milestone in the standards world.’[172]

In February 2007, the Health Information Technology Standards Panel (HITSP) of the American National Standards Institute (ANSI) approved the CCD, recognizing the harmonization of the ASTM and HL7’s standards.[173] Currently, both the CCD and the CCR are used to transfer health information electronically among providers.

Some experts have questioned the adequacy of the minimum data set used in the CCR and CCD. A CCR can have up to 17 categories of information, and each category contains structured fields rather than free text. However, one key concern is whether the CCR and CCD capture all of the necessary information resulting from a health care encounter. The National Committee on Vital and Health Statistics Subcommittee on Privacy and Security noted that the CCR and CCD’s minimum data sets may be unnecessarily omitting important health information, if this information does not fit neatly into one of the structured data fields.[174] In other words, consumer friendly language and informal medical data needs to be mapped to the structured, technical medical jargon.

Since the development of CCD, there has been some controversy regarding whether the CCD or the CCR should be the basis for interoperable information for PHRs. Specifically, should PHR vendors use the CCD or CCR? According to Donald Mon, Ph.D., Vice President of Practice Leadership at AHIMA, larger vendors, which have likely adopted many of HL7’s specifications already, may find it easier to use the CCD. This is because the CCD is already part of the HL7 CDA architecture. Other vendors that do not utilize the HL7 CDA architecture can choose to use either the CCD or CCR just as easily.

The PHR-S functional model, developed by the HL7 work group, is agnostic in terms of specifying the CCD or CCR, so that the market can decide which approach to adopt. According to an expert from the HL7 work group, both CCD and CCR-related activities are proceeding.

Vendors have also adopted the various standards. Microsoft’s HealthVault, while not a PHR, is a platform that has the ability to service numerous personal health applications (PHAs) – and thus, is important to the future of PHRs. Taking a ‘standards agnostic’ approach to interoperability, Microsoft has created data exchange interfaces that are compliant with both the CCD and the CCR.[175]

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