Overview of the Continuity of Care Record

Claudia Tessier, CAE, RHIACo-Chair, ASTM E31 CCR Workgroup

Executive Director, MoHCA

The CCR: A Snapshot in Time

A core data set of the most relevant current and past information about a patient’s health status and healthcare treatment

Organized and transportable Prepared by a practitioner at the

conclusion of a healthcare encounter Enables the next practitioner to readily

access such information

Unique Standards Development Effort Consortium of sponsoring organizations

ASTM International E31 Committee on Health Informatics

Massachusetts Medical Society HIMSS American Academy of Family Physicians American Academy of Pediatrics American Medical Association Patient Safety Institute American Health Care Association National Association for the Support of LTC Mobile Healthcare Alliance (MoHCA)

Sponsors represent…

ANSI-recognized standards development organization

Over 400,000 practitioners Over 13,000 IT professionals Over 12,000 institutions in the long-term

care community providing care to over 1.5 million elderly and disabled

Major stakeholders in m-Health Patients, patient advocates, data sources,

corporations, provider institutions….

What About HL7?

ASTM and HL7: memorandum of understanding to harmonize ASTM’s CCR and HL7’s EHR functionality, CDA, and RIM standards

Work is ongoing to achieve that aim

This Unique Initiative Is…

Patient-focused Not about what the system says to do but

about what patient information is most relevant

Provider-focused Practitioners determine what information is

most relevant to the next provider in order to deliver good patient care

CCR Header CCR Body CCR Footer

What’s in the CCR’s Core Data Set?

CCR FOOTER

CCR BODY

Note: Subsequent slides will detail information from this graphic.

CCR HEADER

CCR Header

Unique CCR identifier Date/Time Patient From To Purpose

Unique Identifier

Generated by originating entity Unique identification of each instance of a

CCR Defined within generating system Must be unique to and within each CCR But not considered unique across the

universe of CCRs

Date/Time

Exact clock time that specific CCR was created/generated

Patient Identification

Not a centralized system Not a national patient ID Rather, based on a federated or

distributed ID system Contains a core data set of ID information

that can be used by any record system to assign the individual its own identifier

From

Identifies practitioner, person, system, or organization that generated the CCR

Also defines the healthcare role that each entity is playing when generating the CCR

To

Identifies the intended recipient/s of CCR Practitioner, person, system, or

organization

Purpose

The reason the CCR was created, e.g., Referral Transfer Discharge Personal health record Other….

CCR Body

Insurance Advance Directives Support Functional Status Problems Family History Social History Alerts Medications

Medical Equipment Immunizations Vital Signs Results Procedures Encounters Plan of Care Healthcare Providers

Patient administrative and clinical data/sections

Insurance Information

Basic information about patient’s payers, whether Insurance Self-pay Combination

Insurance Information Payer

Each payer—insurance or self-pay or other—and all pertinent data needed to bill to and collect from that payer

Dates/times relevant to payer and patient relationship, e.g., Effective date, termination date

Type, e.g., Self-pay, primary, supplemental, Medicare Prescription

Drug Benefit, Worker’s Compensation Payment provider Subscriber All relevant IDS for patient relative to defined payer, e.g.,

Subscriber #, group #, plan code Authorization, e.g.,

For service, encounter, product/device, medication, immunization, procedure

Advance Directives

Itemizes specific requests of patient and family regarding clinical interventions and specific resuscitation efforts to be undertaken in event of specific clinical outcomes or complications Which are to be restricted, limited, or

avoided as addressed in such documents as

Living wills Healthcare proxies Powers of attorney for healthcare

If none or unknown, this must be stated

Support

Lists patient’s sources of support, e.g., Immediate family Relatives Guardian Durable power of attorney for healthcare Spiritual advisor/clergy

Individuals or organizations Not healthcare providers, which are

identified in another section

Functional Status

Lists and describes patient’s current functional status, e.g., Ambulatory status Activities of daily living Mental status Home/living situation Ability to care for self

Problems

Lists and describes all relevant clinical conditions, diagnoses, and problems For referrals, in order of importance Otherwise, reverse chronological order of

onset is preferred

Family History

Identifies the health or health risk of a patient relative to health conditions seen in the family, including that family member’s Relationship to patient Problem Status Other relevant data

Social History

Marital status Religion Ethnicity Race Language Smoking

Diet Exercise Employment Toxic exposure ETOH use Drug use

Information on social history, including

Alerts

Lists and describes any of the following that are pertinent to patient’s current or past medical history Allergies Adverse drug reactions (ADR) Alerts

Medications

Lists relevant current and past medications prescribed and administered Brand and generic names Dose strength and units Form or presentation Quantity, route, frequency Directions Refills Fulfillment Current status And more

Also OTC medications, vitamins, etc. Can be linked to problems and to

practitioners

Medical Equipment

Lists and describes any medical devices or equipment relevant to patient’s health, treatment, or support, e.g., Implanted or external medical devices Durable medical equipment (DME)

Immunizations

Lists and describes immunizations Recently received or Pertinent to patient’s health history

Vital Signs

Includes pertinent vital signs, e.g., Blood pressure Pulse Respiratory rate Height Weight Body mass index Head circumferences Crown-to-rump length Pulse oximetry Pulmonary function tests

Results

Captures detailed laboratory, diagnostic, and therapeutic results data

Includes such information as Test or observation Data/time sample obtained Substance Test type Value and units Method Status And more

Procedures

Lists and describes any diagnostic and/or therapeutic procedures pertinent to the patient’s current health status or relevant past history, e.g., Cardiac cath, x-ray, etc. CABG, chemotherapy, etc. Health status assessments, e.g.,

Functional assessments Ambulatory status Suicide risk assessment

Encounters

Lists and describes any healthcare encounters pertinent to the patient’s current health status or relevant health history, including Hospitalizations Office or clinic visits Emergency room visits Home health visits Any other relevant treatment or therapy

Plan of Care

Lists and describes any active, incomplete, or pending events of clinical significance to the current and ongoing care of the patient, including Orders Appointments Referrals Procedures Services

Healthcare Providers

Includes information about all those healthcare providers who are participants in the patient’s care, e.g., Primary physician Any active consultants, clinicians,

therapists, counselors

CCR Footer

Actors References Comments Signatures

Actors

Includes all detailed identifying information about each person, organization, location, or system referred to within the CCR, including the Patient

References

Lists the details concerning all references within the CCR to external data sources, e.g., Living will Durable power of attorney for healthcare

Comments

Contains all comments referenced within the CCR

Free text only Not for data that correctly belongs under

other appropriate explicit fields/tags

Signatures

Contains all digital signatures relevant to the CCR

Annex A: Data Groups and Data Fields A spreadsheet providing detailed list of

CCR data groups and data elements within the CCR header, body, and footer, e.g., Problems Medications

Data Groups

In addition to data elements specific to its purpose, each data group in the CCR Body and Footer also includes Data source

Who or what is the source of the information Internal CCR link

Defines internal CCR links, e.g., Problem to Healthcare Provider

Comment Any relevant information that doesn’t fit elsewhere

Reference Pointer to another data source or document that

provides more information, e.g. living will, images. May include location where it can be found

Data Fields

Detailed information is provided for all data fields within each data group, including XML code Definition Explanations, descriptions, requirements, and

restrictions Comments and examples Specification of whether the field is required or

optional

Annex B: XML Schema (.xsd)

Derived from XML codes in Annex A Represents how the CCR should be

represented in XML

Annex C: Implementation Guide (IG) Instructions for using the CCR XML .xsd

(in Annex B) for generation of a standards-compliant, interoperable CCR

Extremely strict regarding Requirements on use and formatting of the

CCR XML Content allowed within each field/XML tag

The .xsd (see Annex B) must be used with the IG for validation of a CCR

XML Schema (.xsd) and Implementation Guide (IG) Strict adherence to .xsd and IG is required

when preparing CCR in structured electronic format To support standards-compliant interoperability To enable CCR to be prepared, transmitted, and

viewed In a browser In an HL7 CDA-compliant document In secure email In any XML-enabled word processing document In multiple formats

To enable properly designed EHR systems to Import and export all CCR data Interchange the CCR between otherwise incompatible

systems Minimize workflow disruption for practitioners

Coding

Detailed coding is recommended whenever practical within the CCR

The coding system and version must be specified

Coding systems are identified for Problems Procedures Products and agents Results

Coding Problems

Code at highest level using most recent pertinent national or international reimbursement codes at time CCR is generated, ICD-9 CM codes in US, for example

In addition, code with SNOMED CT codes to as granular a level as possible to support reporting, data analysis, and decision support

Coding Procedures

Code at highest level using most recent pertinent national or international reimbursement codes at time CCR is generated, e.g., CPT codes in the US

In addition, code with LOINC codes to as granular a level as possible to support order entry, results reporting, data analysis, and decision support,

Coding Products and Agents

Code with appropriate products codes (such as RxNorm for medications in the US) to as granular a level as possible

In addition, may code with another standard as applicable (e.g., NDC) or proprietary (drug information database) code with the type of code and source and version clearly defined.

Coding Results

Code with the most recent and appropriate result codes at the time the CCR is generated, e.g., in the US CPT and LOINC for Procedures LOINC for Result and Test in the US

Security

Data contained in the CCR are patient data and if identifiable End-to-end CCR document integrity and

confidentiality must be provided Conformance to regulations or other security,

confidentiality, or privacy protections as applicable must allow only properly authenticated and authorized access to the CCR document instance or its elements

Additional ASTM E31.20 Subcommittee on Security and Privacy guides, practices, and specifications will be published in support of security and privacy needs of specific CCR use cases.

CCR Significance

Addresses lack of appropriate, succinct, and up-to-date patient health information for practitioners at a new point of care

Improves continuity of care by providing a method to easily communicate the most relevant clinical information about a patient among practitioners, institutions, and other entities

Enables a practitioner To readily access information about a patient’s

healthcare at any point in an encounter To easily update the information at any time,

particularly at the end of an encounter or when the patient goes from one provider to another

Intent of CCR

To enhance patient safety To reduce medical errors To reduce costs To enhance efficiency of health information

exchange To assure at least a minimum standard for

health information transportability when a patient is referred, transferred, or otherwise seen by another practitioner

Who Will Use the CCR and When?

The CCR will be completed by providers, e.g., physicians, nurses, and ancillary practitioners, for Referral (inpatient or outpatient) Transfer (from an inpatient or institutional

setting) Discharge without a referral or transfer Personal health record Other uses, e.g., home health monitoring,

school health, public health reporting

Potential Domain-specific Applications

Enterprise- and institution-specific information Hospital to nursing and rehab facilities or

home care agencies, and vice versa Disease management-specific information, e.g.,

Diabetes, congestive heart failure, asthma, etc. May be utilized by health plans,

pharmaceutical companies, patient advocacy groups, others interested in promoting “best practices”

Payer-related information, e.g., claims attachments

Patient-entered personal health information

The CCR…

Is an introduction to electronic documentation and the EHR

Accommodates any relevant patient information, on paper or electronically

Supports patient safety and reduced medical errors Easy access to critical data, e.g., allergies

Has potential to reduce inefficiencies and costs Don’t have to search for relevant information Fewer repeat lab tests and other evaluations

Is not a top-down approach End-users, i.e., practitioners have participated in its design Originator determines the relevant content

The CCR and the Patient The CCR encourages patient involvement,

education and improved provider/patient relations It is patient focused It gives patients easy access to their health

information Patients don’t have to repeat same information

over and over It can populate a personal health record It can stimulate patient to be more involved in

and informed about their healthcare It can involve patient in transfer of information

(USB, mobile devices)

CCR and the Personal Health Record

Widespread interest to use CCR as part of Personal Health Record Government Payers Provider institutions Vendors Patient advocates Patients

m-Health and the CCR

CCR is completed at close of each encounter, so…

Mobile devices and applications offer Point-of-care data entry, access,

transmission Transportability Connectivity to and interoperability with

Source practitioner’s central system Target practitioner Patient’s web-based PHR Secure email communications

Current Status on CCR Development and Adoption

ASTM E31.22 Subcommittee on EHR Preparing CCR for ballot in February 2005 Only ASTM E31 and E31.28 members may vote

Sponsoring organizations Promoting CCR adoption among their constituencies

and beyond Vendors Technical Advisory Group

Providing expertise Participating in demonstration projects Preparing to adopt standard

ASMT E31.20 Subcommittee on Security Developing CCR security specifications

International Interest

Widespread interest throughout Europe, Asia, Middle East, South America, etc.

ASTM International will explore possibilities with foreign ministries of health, EC, WHO How to adapt/adopt standard Electronic translation of core data

elements

In Summary

Practitioners, provider institutions, patients, vendors, and other stakeholders perceive the CCR as

Relevant Doable Transportable and interoperable Valuable

They are working together to finalize materials and move toward widespread adoption

How to Become Involved

Join ASTM E31 Committee on Health Informatics and its E31.28 Subcommittee on EHR $75/year Participate in CCR development Have voting rights Free virtual access to CCR standard and all

E31 standards Join non-member CCR email list

Notices of meetings and progress

For More Information

Claudia Tessier, CAE, RHIA

Co-chair, ASTM E31.28 CCR Workgroup

202-352-3019

ctessi@attglobal.net

THANK YOU!