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December 19, 2011

The CCD and Meaningful Use: A Mutually Beneficial Relationship
By Elizabeth S. Roop
For The Record
Vol. 23 No. 23 P.14

As the continuity-of-care document undergoes refinement, some view it as a lynchpin in the quest to effectively share patient information.

The Office of the National Coordinator for Health Information Technology (ONC) opted against specifying standards in its criteria for stage 1 meaningful use. However, in setting the expectations for how information follows patients as they transition across care settings, the agency may inadvertently have given favor to the continuity-of-care document (CCD) over the continuity-of-care record (CCR).

“Making the care record available for patients as they transition from one care setting to another—at a very high level—led to work at the ONC level to provide clarity around what it means, what format the summary care document should be in, and how to make it available,” says Ashish V. Shah, senior vice president and chief architect for Medicity, a health information exchange (HIE) technology provider.

Because it is more scalable, many in the industry believe the CCD is better suited to not only achieve the goals of meaningful use but also to pave the way for providers to meet future requirements. While both provide summaries, including problem, medication, and allergy lists, as well as patient demographics in interoperable formats, the CCD can expand to encompass the more detailed clinical documentation elements that will become the focus in stage 2 and beyond.

For example, the CCD, an XML-based markup standard that specifies the encoding, structure, and semantics of a patient summary clinical document for exchange, includes specifications for attachments and discharge summaries.

“The CCD encompasses … other things than just the care summary, whereas the CCR is just a care summary,” Shah says.

The CCD in Meaningful Use
Debates aside, the CCD plays a key role in meaningful use. Because it facilitates the sharing of information between systems and providers, it can be considered a foundational element for complying with many meaningful use criteria. Though it is expected to play a much larger role in future stages, the CCD is important even in stage 1.

A constraint on the Health Level Seven International (HL7) clinical document architecture (CDA) standard, the CCD contains a core data set of relevant demographic and clinical information about a patient. It allows providers to aggregate all of a patient’s data and share it with providers to support continuity of care as that patient moves from one setting to another.

Brett Marquard, senior interoperability consultant with standards-based HIE services and software provider Lantana Consulting Group, describes the CCD as the origin of common CDA templates that are reassembled into different document types, such as the CCD, history & physical, progress note, and discharge summary. As the concepts of information exchange, electronic queries, and quality reporting begin taking hold among providers, the blocks of information contained within these templates become very powerful and valuable.

“You throw terms around like ‘CCD,’ ‘CCR,’ and ‘HL7,’ but clinicians are not worried about the acronyms. They don’t care about the technical aspects. They just want the outcomes of that exchange. But when you describe what [the CCD] enables, they start to get very excited, particularly with the idea that when a patient transitions between care settings—for example, from a long-term care facility to a hospital—they will have updated allergy and medication lists,” says Marquard.

Getting clinicians excited about data sharing is important, but the bigger, initial role for the CCD in meaningful use may be its ability to address the lack of interoperability that is prevalent in HIT.

Marquard notes that while interoperability is important, the capacity to exchange data with other provider organizations has not been a driving force behind HIT purchasing decisions. Meaningful use, with its focus on information to support care transitions, has changed that.

“In general, the CCD facilitates the transfer of care between clinicians. … What’s cool about the CCD is that it starts people on the path toward data capture and sharing. It is setting the track for future sharing in stages 2 and 3 when we get into advanced clinical processes,” he says.

One example of how the CCD, with meaningful use as a catalyst, is helping overcome the industry’s interoperability struggles is the ONC’s HL7/IHE Health Story Implementation Guide Consolidation Project. The volunteer effort, a collaboration of Health Story, Integrating the Healthcare Enterprise (IHE), and HL7 sponsored within the ONC’s Standards & Interoperability Framework, has harmonized templates across nine different CDA implementation guides.

Two factors led to the project’s creation. One was feedback the ONC received regarding implementation challenges associated with the clinical content standards contained within the Standards Final Rule, in particular with HITSP C32. The second was implementer feedback received by the Health Story Project, HL7, and IHE expressing the need to consolidate the implementation guides, which address the exchange of common types of clinical documentation, and to provide a comprehensive library of reusable data elements or templates.

The consolidation project has sent its results out for two ballots, which received 500 and 350 comments, respectively. Those comments have undergone a line-by-line reconciliation process to ensure all are appropriately addressed.

“The different standards of development organizations developed their own template flavors, and the CDA consolidation project reconciled those to a common set. The standardized templates can be used in CCD and other CDA documents,” says Marquard. “It has taken a lot of work and compromise … but we don’t want to leave anyone out. In the end, we’ll have a set of building blocks folks can assemble and use in exchanges that are standard across the industry.”

Building a Better Repository
The ability to share patient information across care settings is the overarching goal of meaningful use. However, establishing a framework for doing so is only half the battle. Full realization of the CCD’s potential for achieving this goal lies in the construction of a robust repository of standardized patient information that can be accessed and queried when and where it is needed.

The ideal is a community repository that links information from multiple provider organizations and can eventually be hooked into the national health information network. However, until sufficient HIT adoption levels have been achieved and HIE has matured, many of the early repositories will be found within individual provider organizations.

“Being able to share information is as important as the CCD itself. Building the infrastructure that has the connections is more important than the format itself,” says Shah, noting that the leading adopters are those “who have adopted sophisticated HIT platforms and are using them nicely and are using information exchange. This is where the CCD repository comes into play.”

One such organization is Iowa Health System (IHS). Based in Des Moines, it has relationships with 25 hospitals in Illinois and Iowa and records more than 2.5 million patient visits per year. According to John Hendricks, executive director of interoperability and business solutions, the health system’s goal—like that of meaningful use—is to securely exchange patient data to enable providers to have the information they need regardless of care settings.

A second goal is to allow for patient population and clinical data to be aggregated and analyzed for use in improving care on local and regional levels. To that end, “IHS is developing an internal HIE and contributing to the development of the state of Iowa’s HIE,” says Hendricks, adding that the system is working with Medicity on the build and support of its CCD repository.

Bringing in a third party to help with the construction was a decision IHS made after assessing the project’s complexity, which first involved analyzing the EMR landscape.

Like many health systems, IHS is connected to multiple systems. This increases the variety of document exchange standards that the repository must support and adds another layer of complexity to patient identification.

“One of the critical steps when multiple EMRs are involved is to establish a community ID for patients or a process for the unique identifying information about each patient to be sourced from each EMR. This way, records for a given patient can be matched as they come from different EMRs,” says Hendricks.

Shah notes that early efforts like those under way at IHS are critical first steps toward creating community-based CCD repositories. In many instances, the organizations are utilizing the CCD to create their own repository but are also contributing information to an external repository during specific events.

For example, upon discharge from the hospital, a C32 summary document would be created and transmitted to the community repository, while the more detailed record remains within the originating organization. The summary document follows as the patient goes from one setting to another.

“We are starting to see a lot of platforms … upgrade to generate a CCD and submit it to a community CCD repository led by an HIE initiative,” Shah says. “It’s still an emerging technology, but community repositories do exist. A lot of the technologies are getting wrapped into standard services built into HIE specifications that allow communities to interact with the data. … You may see more and more try to evolve into some sort of CCD-centric repository, although that is yet to be determined.”

Applications Beyond Meaningful Use
Like any game-changing innovation, the success of the CCD depends on its longevity. While achieving meaningful use may be responsible for the current flurry of activity surrounding its refinement and adoption, its future uses will likely make or break it as the de facto clinical documentation standard.

For example, Marquard points to the scalability of the consolidated CCD template library to accommodate things like the attachment of electronic claims, which opens new connections and possibilities not currently considered under meaningful use.

“The measure of a successful standard is not a finished document—it’s a standard that is in use,” he says. “The consolidated templates lay the groundwork for claims attachments to be sent electronically and in the same format as a clinical document. It’s an area that I really encourage because it’s good for everyone.”

In the more immediate future, many view the CCD and repositories as keys to the success of new payment models and initiatives such as accountable care organizations (ACOs) and patient-centered medical homes, which are central elements of healthcare reform.

In these models, provider organizations are assuming far greater financial risk. Survival hinges on access to comprehensive patient data.

“Not being able to share information as an episode spans care settings will be a nonstarter. It represents a fundamental shift in how care is delivered,” says Shah.

Hendricks agrees, noting that while many organizations are still implementing EMRs, others are already looking beyond to building ACOs or participating in HIEs. The CCD is an important tool, one that can be leveraged now and in the future.

“Even if an organization is still making decisions with regards to a direction for HIEs, there are still opportunities to begin preparations,” Hendricks says. “IHS first focused on putting certified systems and coding in place. Those systems are being standardized with certified nomenclature. Taking these steps will ensure less overall confusion between providers when patient information is exchanged.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.


A Physician-Friendly CCD
Like any technology, successful adoption of the continuity-of-care document (CCD) as the standard for capturing patient data for health information exchange hinges on clinician acceptance. In that respect, one of the most significant challenges is the need for physicians to adapt their documentation styles and processes to accommodate the CCD’s data input needs.

Meaningful use requires clinicians to electronically record patient information such as problem and medication lists. And while the CCD helps standardize that data so they can be stored and exchanged, it often means physicians “can’t say words in the manner they are used to or use the colloquialisms in the way they are used to,” says Brian Levy, MD, senior vice president and chief medical officer of Health Language, which provides software solutions that incorporate medical vocabulary and coding standards into HIT applications.

Further complicating the issue is the fact that meaningful use also “requires patient summary information to be presented back to the patient in a way they have to understand,” says Levy.

To overcome these challenges, a growing number of healthcare organizations are looking toward software that allows clinicians to continue using the terminology they are comfortable with. Those data are then codified for integration into the CCD. It’s an approach that helps ensure the appropriate level of detail is provided at the front end so the data generated on the back end can serve their intended purpose of facilitating information sharing as patients transition across care settings.

This “helps to codify the information that needs to be put into the CCD according to the specifications required by meaningful use,” says Levy, adding that the sheer volume of clinical terminology standards makes it nearly impossible to manage documentation without some sort of automation.

“There are well over 150 different terminology code sets, and we send out over 600 updates each year. It’s constantly changing,” he says. “One of the main goals of provider-friendly terminology [software] is to allow physicians to use the words of medicine that we’re used to in our dictation and paper charting.”