The drive to establish the Continuity of Care Record
Health Imaging News
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September 8, 2005
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Industry News
There are many efforts for improving on the sharing of patient data
between healthcare organizations for better patient care and especially
to reduce dangerous medical errors. One of the key ongoing related
developments is the Continuity of Care Record (CCR), a standard for
patient care information that is being jointly developed by a number of
organizations including ASTM International, the Massachusetts Medical
Society (MMS), the Health Information Management and Systems Society
(HIMSS), and the American Academy of Family Physicians (AAFP).
As with any industry standard, there are a number of hurdles that must
be overcome before it can be widely applied. An expert in CCR, Jeff
Sutherland, chief technology officer of PatientKeeper, Inc., discussed
with Health Imaging News the urgency in determining a standard
specification and where he thinks it's headed.
What is CCR and where did it begin? The CCR [Continuity of Care Record] is an attempt to solve the
problem of moving information from one medical record system to another
so that patients who come in for treatment from a doctor in California,
for example, who happened to be a resident in Massachusetts, could have
easy access the records in Massachusetts.
Nowadays, particularly when [physicians] are prescribing, they really
need to know what medications a patient is already taking, and there
are really only two ways to determine that today. The patient is a very
unreliable source. The only way to determine that is to go to a
patient's insurance company that has a record of what medications have
been billed through insurance, or go through their pharmacist.
I was recently talking to Charlie Baker the CEO of Harvard Pilgrim
Health Care, and he said, 'Jeff, you're an expert on inpatient medical
error and there are hundreds of thousands of patients dying on the
inpatient side, but on the outpatient side how many physicians do you
think know the patient's medication list before he or she is treated?'
And I said, 'None!' And he said, 'You're right. In Massachusetts
[physicians] either have to contact us if they are a member of Harvard
Pilgrim or contact the pharmacy, because there aren't any physicians in
Massachusetts who will take the time to do that.' Therefore, every
physician is prescribing in the blind. And the outpatient error rate is
probably higher than the inpatient medical error rate. There is very
little data on that.
How could the CCR help address this problem? The Continuity of Care Record is an attempt to assess what is the
minimum amount of information that a physician needs to treat a patient
properly, given that today they often have virtually no information.
So, the probability of error is extremely high.
Are there competing standards out there? There are a number of standards bodies. The problem with that is
that the main standards body for health information is the HL7 (Health
Level Seven) organization. And most hospitals and the government and
many foreign countries all adhere to the HL7 standard.
HL7 does this through what they call Clinical Document Architecture
(CDA), which is a standard; but what they want to do is define
templates within that architecture that convey the minimal set of
information needed to treat a patient -- which is equivalent to
the CCR. So, there's some contention between the CCR and HL7, though
they are both government approved standards organizations.
The vendors, working under the HIMSS umbrella within an EHR vendor
committee, have tried to advocate standards in the electronic health
record area and they want to see one standard. No matter what it is,
there's got to be one.
The ASTM group doing the CCR is supposed to meet with the CDA group
from HL7 in an effort to harmonize what they're doing so that the same
information is being transferred in both standards so that one standard
could encompass the other.
The problem is that it's still an open issue and not resolved from the point of view of the healthcare community right now.
So, the CCR is in a process of evolution. Will just one standard eventually exist, or might they be combined? The government in the form of the CDC (Centers for Disease Control
and Prevention) and the FDA (U.S. Food & Drug Administration) are
all committed to HL7. The vendors just want one standard. They're
willing to implement either one, but they want one. So until there is
generally agreement between the standards bodies, it's hard for people
to move forward. The second-level issue of this is getting
[information] systems to interoperate.
The problem with healthcare is that we have isolated islands of
expertise. A patient as he or she moves through the system gets in
contact with multiple different people and processes and systems and
technologies and medications. One hand doesn't know what the next hand
is doing, and people fall through the cracks and die. Inpatient medical
error is the third leading cause of death (not including outpatient);
just the hospital error is killing more people than anything except
cancer and heart disease.
Of course, the CCR is the proposed solution to this problem.
What type of information does the CCR require? The CCR is a standard, though very specifically defined. It is a
bunch of header information about a patient which says who they are and
where they live and who their referring physician is. Then it has other
information, much of which is optional, which says here's the
medications the patient is on and here are the problems they are being
treated for. It's really a snapshot in a state in time. The latest
information from the system that is sending the information from the
place the patient was last seen.
Is it like a browser, or some type of portal or other software application? No, that's just a definition. In terms of implementation, that the
vendors and healthcare institutions need to figure out how they are
going to implement it. A company can do anything it wants to get that
information in that format.
Does the HL7 Clinical Document Architecture standard do something similar? Through the HL7, you could send just the medication information [of
a patient], or something more like the CCR which is more detailed, or
maybe the entire medical record from one system to another. The CDA is
designed to do that in a generic way. In terms of emulating the CCR,
that is just a template that is a small subset of what the CDA can
deliver. So, HL7 has been defining that template. The issue is whether
the data in that template are different or the same as the CCR. And if
they're different, how are they going to resolve that difference?
Does PatientKeeper plan to introduce a CCR solution? Right now PatientKeeper interfaces and integrates seamlessly with
many back-end clinical systems and our mission is to integrate with any
of them. So, let's take a system that we are already intimately
connected with such as Cerner. We can display on our handheld devices
and on our desktop web browser every clinical result in the Cerner
system that exists. From the point of view of saying what is the CCR we
could just say, well let's just send them the last day [of a patient's
medical history] and that will be the standard. That's how simple it is
for us to deliver. It's easy for us to change the format at will. The
question is: what's the standard way to send it so the receiving system
can interpret it?
It seems impossible for all of these different systems to be able to communicate. Is it? Well, PatientKeeper has a very different mission than a lot of the
vendors. From the beginning, it has been to be able to take any
back-end system and present it to any front- end device.
PatientKeeper's business is translating any clinical information from
any system into a format that is readable by another system or device.
All we have to do is have people decide on the standard and want to buy it.
Is it possible to discuss a timeline for delivery of a standard? It appears that HL7 moves fairly slowly and will not come to
closure with the template until at least next year. Worst case it could
even be the following year.
Yet, CCR is ready to go? Yes, CCR is ready to go.
About Jeff Sutherland:Dr. Jeff Sutherland holds a PhD,
MS Statistics and Mathematics from Stanford University and a Doctorate
in Biometrics, Medical Imaging, and Radiation Physics from the
University of Colorado School of Medicine. He is Object Management
Group/HL7 Liaison, Committee Co-Chair HL7 Orders and Observations
Technical Committee, Co-Investigator, Operating Room of the Future,
University of Maryland Medical System, and member of the Microsoft
Business Framework Advisory Council.
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