Transcript Status and Projects of the CCR (Continuity of Care Record)

Overview of the
Continuity of Care Record
Claudia Tessier, CAE, RHIA
Co-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
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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
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Not about what the system says to do but
about what patient information is most
relevant
 Provider-focused
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Practitioners determine what information is
most relevant to the next provider in order to
deliver good patient care
What’s in the CCR’s Core Data Set?
 CCR Header
 CCR Body
 CCR Footer
CCR HEADER
CCR
BODY
Note: Subsequent
slides will detail
information from
this graphic.
CCR FOOTER
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
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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
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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
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Practitioner, person, system, or
organization
Purpose
 The reason the CCR was created, e.g.,
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Referral
Transfer
Discharge
Personal health record
Other….
CCR Body
 Patient administrative and clinical
data/sections
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Insurance
Advance Directives
Support
Functional Status
Problems
Family History
Social History
Alerts
Medications
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Medical Equipment
Immunizations
Vital Signs
Results
Procedures
Encounters
Plan of Care
Healthcare Providers
Insurance Information
 Basic information about patient’s payers,
whether
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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
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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
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Which are to be restricted, limited, or
avoided as addressed in such documents
as
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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.,
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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.,
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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
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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
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Relationship to patient
Problem
Status
Other relevant data
Social History
 Information on social history, including
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Marital status
Religion
Ethnicity
Race
Language
Smoking
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Diet
Exercise
Employment
Toxic exposure
ETOH use
Drug use
Alerts
 Lists and describes any of the following
that are pertinent to patient’s current or
past medical history
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Allergies
Adverse drug reactions (ADR)
Alerts
Medications
 Lists relevant current and past
medications prescribed and administered
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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.,
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Implanted or external medical devices
Durable medical equipment (DME)
Immunizations
 Lists and describes immunizations
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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
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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.,
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Cardiac cath, x-ray, etc.
CABG, chemotherapy, etc.
Health status assessments, e.g.,
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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
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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
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Orders
Appointments
Referrals
Procedures
Services
Healthcare Providers
 Includes information about all those
healthcare providers who are participants
in the patient’s care, e.g.,
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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.,
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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.,
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Problems
Medications
Data Groups
 In addition to data elements specific to its
purpose, each data group in the CCR Body
and Footer also includes
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Data source
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Internal CCR link
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Defines internal CCR links, e.g., Problem to Healthcare
Provider
Comment
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Who or what is the source of the information
Any relevant information that doesn’t fit elsewhere
Reference
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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
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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 standardscompliant, interoperable CCR
 Extremely strict regarding
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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
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To support standards-compliant interoperability
To enable CCR to 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
To enable properly designed EHR systems to
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Point-of-care data entry, access,
transmission
Transportability
Connectivity to and interoperability with
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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
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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
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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
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$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
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Notices of meetings and progress
For More Information
 Claudia Tessier, CAE, RHIA
Co-chair, ASTM E31.28 CCR Workgroup
202-352-3019
[email protected]
THANK YOU!