Transcript Continuity of Care Record

Continuity of Care Record
Claudia Tessier, CAE, RHIA
Co-Chair, ASTM E31 Workgroup on CCR
Executive Director, MoHCA
What Is the CCR?
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A snapshot in time: A core data set of the
most relevant facts about a patient’s
healthcare.
Organized and transportable.
Prepared by a practitioner at the conclusion
of a healthcare encounter.
To enable the next practitioner to readily
access such information.
May be prepared, displayed, and transmitted
on paper or electronically.
The CCR…
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Provides information that is
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Appropriate, succinct, organized, and up-to-date
Interoperable through use of specified XML code
A necessary bridge to a different environment, often
with new practitioners who know little about the patient.
Will address specific domains through
extensions: long-term care, acute care, disease
management, personal health record, etc.
Development of the CCR
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Unique standards development effort
Consortium of sponsoring organizations
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ASTM International
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
Additional sponsoring organizations pending
Sponsors represent:
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ANSI-recognized standards development
organization
Over 400,000 practitioners
Over 13,000 IT professionals
Over 12,000 institutions in the long-term care
community that provide care to over 1.5 million
elderly and disabled
Patients, patient advocates, data sources,
corporations, provider institutions….
This Unique Initiative Is…
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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
Content-focused
• Emphasis is on what providers need to know to
deliver good patient care
This Unique Initiative Is Also…
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Stimulating cooperation among
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Organizations, such as ASTM and HL7
Professional specialty organizations and their practitioners
Provider institutions
Vendors
These diverse groups are working together
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To develop and implement the CCR
To assure its interoperability
To develop demonstration projects
Generating interest among
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Patients and patient advocates
Federal agencies, payers, others
The CCR Is Not…
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An EHR
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A progress note, discharge summary, or
consultation
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It is not a complete electronic health record of a
patient’s lifelong health status and healthcare
It is not universally accessible
It does not have a universal patient identifier
It is not limited to information from a single encounter
It is not free-text based
A loose dataset of health information
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It is a defined set of core data in specified XML code
Why Is the CCR Needed?
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CCR addresses the lack of appropriate,
succinct, and up-to-date patient health
information for practitioners at a new
point of care.
CCR data is essential to good patient
care and serves as a necessary bridge
to a different environment, often with
new practitioners who know little about
the patient.
What’s in the CCR or Core Data Set?
CCR Identifying Info.
Info
re “from/to” Providers/Clinicians
CCR
Identifying
Information
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Date
InfoDocument
re “from/to”
Practictioners
Purpose
Dates
Purpose
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2
2 Patient Identifying Information
Patient Identifying Information
3
3 Patient
Insurance/FinancialInfo
Info
Patient
Insurance/Financial
4
Optional
Optional
Extension
Extension
CONCEPTUAL MODEL OF THE CCR
Optional
Extension
Optional
Extension
Optional
Optional
Extension
Extension
4 Patient’s
Health Status
Advance
Directives
Conditions/Diagnoses/Problems
FamilyHealth
History Status
Patient’s
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5
Adverse Reactions/Allergies/Etc.
Condition,
or Problem
Social Diagnosis,
History & Health
Risk Factors
Family
History
Medications
Immunizations
Social
History & Health Risk Factors
Vital Reactions/Allergies/etc.
Signs/Physiological Measurements
Adverse
Laboratory Results/Observations
Medications
Procedures/Imaging
Immunizations
Vital
Signs/Physiological
Advance
DirectivesMeas uremts.
Laboratory Results/Observations
Procedures/Imaging
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6 Care Documentation
Care Documentation
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7 Care Plan Recommendation
Care Plan Recommendation
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8 Practitioners
Practitioners
Mandated Core Elements of the CCR
Mandated Core Elements of the CCR
Clinical Specialty-specific information
Clinical Specialty-s pecific inform ation
Disease
Management-specific information
Optional
Extensions
Optional
Extensions
Disease Management-specific information
Enterprise-, Institution-specific info.
Enterprise-, Institution-specific info.
Care Documentation for Payers
Care Documentation for Payers
(Attachments)
(AttacHealth
hments)
Personal
Record information
Personal
Health
Rec ord information
Documented by
the Patient
Documented by the Patient
V12: 01/11/04
V13: 02/08/04
CCR Identifying Information
Section 1
Referring (“from”)
practitioner
 Referral (“to”) practitioner
 Date
 Purpose/reason for CCR
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CCR Identifying Information
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Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
Advance Directives
Patient’s Health Status
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-specific information
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attachments)
Personal Health Record information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
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5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Measuremts.
Laboratory Results/Observations
Procedures/Imaging
Patient Identifying Information
CCR Identifying Information
Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
Section 2
Advance Directives
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Patient’s Health Status
5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Meas uremts.
Laboratory Results/Observations
Procedures/Imaging
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-s pecific inform ation
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attac hments)
Personal Health Rec ord information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
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Required information to
uniquely identify the subject
patient
Not a centralized system or a
national patient identifier, but
a federated or distributed
identification system that
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Links various practitioners
Contains the core data set of
identifying information that
could be used by any record
system to assign the individual
their own identifier.
Patient Insurance/Financial Information
CCR Identifying Information
Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
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Advance Directives
Patient’s Health Status
5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Measuremts.
Laboratory Results/Observations
Procedures/Imaging
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-specific information
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attachments)
Personal Health Record information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
Section 3
Basic information from
which eligibility for
insurance benefits
may be determined for
the patient.
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Advance Directives
Section 4
Info re “from/to” Practictioners
Dates
Purpose
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
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Optional
Extension
Advance Directives
Patient’s Health Status
5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Measuremts.
Laboratory Results/Observations
Procedures/Imaging
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
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Clinical Specialty-specific inform ation
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attachments)
Personal Health Record information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
Indicators that resuscitation
efforts are to be either
unrestricted or to be limited
in some way.
Includes what is commonly
known as the DNR (Do Not
Resuscitate) status of the
patient as addressed in
such documents as living
wills, healthcare proxies,
and powers of attorney.
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CCR Identifying Information
1
Patient Health Status
CCR Identifying Information
Info re “from/to” Practictioners
Dates
Purpose
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
Section 5
Optional
Extension
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Advance Directives
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Patient’s Health Status
5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Measuremts.
Laboratory Results/Observations
Procedures/Imaging
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-specific information
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attachments)
Personal Health Record information
Documented by the Patient
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V13: 02/08/04
Mandated Core Elements of the CCR
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Conditions/Diagnoses/Problems
Family History
Adverse Reactions/ Allergies/Clinical
Warnings and Alerts
Social History and Health Risk
Factors
Medications
Immunizations
Vital Signs and Physiologic
Measurements
Laboratory Results and Observations
Procedures/Imaging
This section may be amplified in
extensions for clinical specialtyspecific information regarding
patient.
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Care Documentation
Section 6
CCR Identifying Information
1
Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
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Advance Directives
Patient’s Health Status
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-specific information
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attachments)
Personal Health Record information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
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Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Measuremts.
Laboratory Results/Observations
Procedures/Imaging
Some detail on the
patient-practitioner
encounter history, such
as dates and purposes of
recent pertinent visits
and names of
practitioners seen.
May be significantly
expanded in future
extensions.
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Care Plan Recommendation
CCR Identifying Information
1
Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
Advance Directives
Patient’s Health Status
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-s pecific inform ation
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attac hments)
Personal Health Rec ord information
Documented by the Patient
V13: 02/08/04
Mandated Core Elements of the CCR
Section 7
Disease Management-specific information
Optional
Extensions
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Includes planned or
scheduled tests,
procedures, or
regimens of care for
the patient.
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Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Meas uremts.
Laboratory Results/Observations
Procedures/Imaging
Practitioners
CCR Identifying Information
Info re “from/to” Practictioners
Dates
Purpose
Optional
Extension
2
Patient Identifying Information
Optional
Extension
3
Patient Insurance/Financial Info
Optional
Extension
4
Section 8
Advance Directives
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Patient’s Health Status
5
Condition, Diagnosis, or Problem
Family History
Social History & Health Risk Factors
Adverse Reactions/Allergies/etc.
Medications
Immunizations
Vital Signs/Physiological Meas uremts.
Laboratory Results/Observations
Procedures/Imaging
6
Care Documentation
7
Care Plan Recommendation
8
Practitioners
Clinical Specialty-s pecific inform ation
Disease Management-specific information
Optional
Extensions
Enterprise-, Institution-specific info.
Care Documentation for Payers
(Attac hments)
Personal Health Rec ord information
Documented by the Patient
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V13: 02/08/04
Mandated Core Elements of the CCR
Information about those
healthcare practitioners
who are participants in
the patient’s care
Links as appropriate to
Conditions/Diagnoses/
Problems and Care
Documentation
encounters
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A Sample Data Group
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Medications
• Definition: Generic name of current and
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relevant past prescribed substances,
including OTC, herbal, and homeopathic
substances. Brand name is inadequate.
Comments/Examples: Medication:
Trimethoprim/Sulphamethozaxole
Required or Optional: Required
XML: <MEDICATION>
Extensions for Additional
Content
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Enterprise and institution-specific, e.g.,
acute care, LTC
Clinical specialty-specific, e.g, pediatrics,
nursing
Disease management
• Disease-specific information, performance
measures, guidelines, etc.
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Payers: financial information/attachments
Patient-entered Personal Health Record
The CCR Can Stimulate EHR
Adoption Because…
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Through specified XML code it is
interoperable, so it will enable EHR
systems to
• Import and export all CCR data
• Interchange the CCR between otherwise
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incompatible systems
Minimize workflow disruption for practitioners
More about XML and the CCR
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Through XML, CCR can be prepared,
transmitted, and viewed
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In a browser
In an HL7 CDA-compliant document
In secure email
In any XML-enabled word processing document
In multiple formats
It can also be
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Printed as a paper document
Stored on a portable storage device for use as a
personal health record
Why So Much Interest in the
CCR?
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Multiple uses
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Introduction to electronic documentation and
ultimately to EHR
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Referral, transfer, discharge, or other instance when
patient is seen by another provider
Other uses include personal health record, research,
and public health initiatives
Can stimulate use of computers in healthcare
Flexibility
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Whatever patient information is relevant can be
accommodated
Why So Much Interest in the
CCR?
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It is not a top-down approach
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It has support and leadership from organizations
representing end-users, who are
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End-users, i.e., practitioners have participated in its design
The originator determines the relevant content
Involving, advising, and assisting their constituents in its
adoption
It allows options for implementation
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Paper or electronic
It has potential to reduce inefficiencies and costs
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Practitioners won’t have to search for relevant information
Fewer repeat lab tests and other evaluations
Why So Much Interest in the
CCR?
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It offers support for patient safety and reduced
medical errors
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Through easy access to critical data such as medications
and allergies
It encourages patient involvement and improved
provider/patient relations
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It is patient focused
It offers patients easy access to their health information
Patients don’t have to repeat same information over and
over
It can help populate a personal health record
It can stimulate the patient to become more involved in and
informed about their healthcare
It can involve patient in transfer of information (USB)
In Summary:
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Practitioners, provider institutions,
patients, vendors, and other
stakeholders perceive the CCR as
• Relevant
• Doable
• Transportable and interoperable
• Valuable
Thank you!
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For more information on the CCR
• Claudia Tessier, RHIA
202-659-2699
[email protected]