1. Overview of the Continuity of Care Record
Claudia Tessier, CAE, RHIA
Co-Chair, ASTM E31 CCR Workgroup
Executive Director, MoHCA

2. 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

3. 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)

4. 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….

5. 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

6. 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

7. What’s in the CCR’s Core Data Set?
CCR Header
CCR Body
CCR Footer

8. CCR HEADER
CCR BODY
Note: Subsequent slides will detail information from this graphic.
CCR FOOTER

9. CCR Header
Unique CCR identifier
Date/Time
Patient
From To
Purpose

10. 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

11. Date/Time
Exact clock time that specific CCR was created/generated

12. 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

13. 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

14. To Identifies the intended recipient/s of CCR
Practitioner, person, system, or organization

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

16. CCR Body Patient administrative and clinical data/sections 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Social History Information on social history, including Marital status
Religion
Ethnicity
Race
Language
Smoking
Diet
Exercise
Employment
Toxic exposure
ETOH use
Drug use

25. 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

26. 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

27. 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)

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. CCR Footer
Actors
References
Comments
Signatures

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

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

38. Comments Contains all comments referenced within the CCR
Free text only
Not for data that correctly belongs under other appropriate explicit fields/tags

39. Signatures
Contains all digital signatures relevant to the CCR

40. 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

41. 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

42. 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

43. Annex B: XML Schema (.xsd)
Derived from XML codes in Annex A
Represents how the CCR should be represented in XML

44. 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

45. 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
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

46. 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

47. 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

48. 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,

49. 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.

50. 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

51. 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.

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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)

58. 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

59. 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 communications

60. 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

61. 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

62. 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

63. 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 list
Notices of meetings and progress

64. For More Information THANK YOU! Claudia Tessier, CAE, RHIA
Co-chair, ASTM E31.28 CCR Workgroup
THANK YOU!