The CCD/CCR Fork in the Road. Did Health IT Take the Wrong Path?

Items available. (2)Not so long ago, CCR and CCD were both common terms used in health IT. In fact, both CCR and CCD were compliant formats for sending patient summary data in the 2011 Edition of EHR certification. But since CCR was left out of the 2014 Edition of EHR certification as a valid way to send summary of care documents, the term has started to fade away.

As a refresher, CCR stands for Continuity of Care Record and it was an electronic document utilized for transferring patients. It started out as a paper document, and had a long history of providing appropriate clinical data so that the patient’s care could continue. CCR was an ASTM standard.

At the same time, HL7 developed their CDA standard that could apply to all types of documents utilized in a healthcare setting. To make a long story short, the content from a CCR was merged into a CDA format and the newly created document was called the Continuity of Care document, or CCD.

Even though CCD was meant to be the harmonization of CCR and CDA, CCR still stuck around for a while and was included in the original rules for Meaningful Use Stage 1. As a vendor testing for the 2011 Edition criteria related to Meaningful Use Stage 1, Corepoint Health had the choice in our test procedures to utilize a CCD or CCR to test for §170.306 (d)(1) Electronic Copy of Health Information. As an integration application, we also had OEM customers who utilized our application to test for this criteria. We would always ask, “Did you chose CCR or CCD for your testing?” Everyone would answer CCR. Why? Their response: “It’s just simpler.”

But now with Meaningful Use Stage 2 and the 2014 Edition of EHR certification there is no choice. Consolidated CDA, which includes CCD as one of its document types, is the standard of choice. To gauge the progress of using Consolidated CDA so far, JAMIA recently published a study. The study found that many EHR systems do not exchange data correctly using Consolidated CDA.

The study sampled 107 healthcare organizations using 21 EHR systems and found 615 errors and data expression variation across 11 key areas. The errors included missing data, incorrect coding terminology, and errors within the XML. The researches commented that “any expectation that Consolidate CDA documents could provide complete and consistently structured patient data is premature.”

With such apparent struggles for vendors and implementers to get the standard correct, you may be wondering, “Why did healthcare IT go the more complex route?” It was already apparent from the 2011 Edition EHR testing that vendors preferred the simplicity of CCR when given the choice. So why then does Consolidated CDA make sense for the path moving forward?

Consolidated CDA is made up of nine document types – including CCD, Discharge Summary, Diagnostic Imaging Report, Consultation Note, and others. And while the schema for CDA is much more complex that CCR, it can be applied to many more use cases. So while the bar is set high to get the summary of care document truly interoperable for Meaningful Use Stage 2, the bar should be much lower to allow for other types of Consolidated CDA documents to be added once interoperability is achieved for summary of care.

Did healthcare IT chose the wrong path by not choosing CCR? It certainly seems so at this point. But one must also step back and ask where the industry should be three to five years from now. Do we want Diagnostic Imaging Reports to be commonly exchanged as electronic documents? How about Consultation Notes?

If we are at the end of the road and in the future we only ever want to exchange documents for transition of care, then I say we definitely should have chosen CCR. It’s just easier. But if we have a longer term vision of interoperability that includes more document types than just for transition of care, then the price paid now to get Consolidated CDA working should speed up the progress of the utilization of all the document types included in the Consolidated CDA family.

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Rob Brull

Rob Brull is the product manager for Corepoint Health. He has worked with software products for over 15 years as both a product manager and sales engineer. Past companies and organizations include Tyco Electronics, Deloitte Consulting, and various distributors of software monitoring and control products. His main focus is to ensure his solutions enable customers to simplify healthcare integration complexities with user-friendly yet powerful software capabilities. This includes meeting applicable Meaningful Use requirements as well as fully supporting related healthcare standards such as CCD, CCR, and greenCDA. Rob is also a Certified HL7 CDA Specialist.