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January 30, 2006

Building EMR Portability With The Continuity of Care Record
By Laura Gater
Radiology Today
Vol. 7 No. 2 P. 14

This digital dataset may play an important role in integrating images and medical record data into future electronic health records.

How many times have you heard a radiologist mention that some basic background information on the patient could help interpret what he or she sees on an image? That information is the idea behind the continuity of care record (CCR). The CCR is a standard specification being developed to reduce medical errors, improve continuity of care, and ensure at least a minimum standard of health information transportability. The common data set could help solve the problem of moving data from one vendor’s system to another.

“The continuity of care record is a core data set of the electronic health record [EHR],” explains C. Peter Waegemann, CEO of the Medical Records Institute in Boston. “It is a snapshot in time that contains only health status information and, in contrast to the EMR [electronic medical record], does not contain documentation of management or process information. The CCR will substitute for an EMR if the latter does not exist in a provider setting; it may be integrated into an EMR when a patient is seen for services and the provider has an EMR; and it is created from the EMR if the provider has one. The CCR is not to be mistaken for the discharge note.”

The CCR is being jointly developed by the American Society for Testing and Materials (ASTM) International E31 Committee on Healthcare Informatics, the Healthcare Information and Management Systems Society, the American Academy of Family Physicians, and the Massachusetts Medical Society (MMS).

EHR vs. EMR
An EHR is comprised of all of a patient’s health information—including diagnostic images—found at his or her family physician’s office, specialists’ offices, and previous clinics. The EMR is enterprise-specific and implemented at a hospital, physician’s office, clinic, etc. The EHR, in other words, is the umbrella term for many EMRs. Many CCRs contribute to an EMR, and many EMRs make up the EHR, notes Waegemann.

The CCR is provider focused because practitioners determine what information is most relevant to the next provider—items such as family history, insurance, advance directives, medications, immunizations, alerts (allergies and adverse drug reactions), vital signs, procedures, plan of care, and healthcare providers.

Dan Pollard, product line director at Misys EMR in Raleigh, N.C., says the CCR is really a standard way to move information in and out of an EMR, a concept central to the Bush administration’s objective of national network of interoperable EHR.

“The CCR was designed to address issues raised by the integration of EMR. The goal is to get a standardized definition of EMR, which HL7 [Health Level Seven] is working on. The CCR is the first standard to be created for the flow of that data,” says Jeff Sutherland, PhD, chief technology officer at PatientKeeper, Inc. in Boston. “The CCR is designed to be a snapshot of a patient at one point in time, and includes the patient’s demographic information, followed by clinical information.”

Thomas E. Sullivan, MD, past president of the MMS, points out that the CCR is a summary of the EMR and has great potential. “The CCR is not a document. It’s a dataset, a snapshot of a person’s medical record at any one time. Its most beneficial use is when a doctor refers a patient to another doctor and wants to send an extract of the EMR to the next doctor. He sends a standard dataset, the CCR, to give a snapshot, or a summary, of the patient’s EMR,” says Sullivan.

Despite some initial concern that the CCR plans were being overshadowed by the national health information system (HIS) plan, that doesn’t seem to be the case at all.

“The CCR is not being overshadowed,” says Pollard. “Part of the challenge could be people looking to do better things. The CCR is well defined. There are very broad standards in the healthcare industry. I think there is a risk of it being overshadowed by the national HIS, if people continue to push in other areas.”

The CCR is compatible with health information networks, according to Waegemann, and a number of regional health information organizations are planning to use the CCR as the “glue” to create a health network. He believes the CCR is a “great tool to establish nationwide health information networks.”

National Standards
“A national HIS needs a concise, relevant summary because it isn’t going to transmit everyone’s complete medical record,” explains Sullivan. “For example, when you go to an ATM that is a thousand miles from your bank, it doesn’t need your entire financial record to complete a transaction. The CCR is a selective summary. Without a standard summary, a nationwide HIS will mean nothing. We, as practitioners and clinicians, define what should be in the summary.”

Sutherland says the CCR data will be embedded in an HL7 message/template. A standards committee will be created, which would establish key CCR principles. Both the government and software vendors want one standard for storing clinical information. The problem, according to Sutherland, is will it be HL7 or something else?

“I think the CCR will improve the interoperability of the HIS system, and will become the foundation on which a lot of other capabilities will be built,” Pollard says. “The CCR will lead to other opportunities and innovations in healthcare records, such as moving information and integrating healthcare.”

Waegemann says the CCR has been successfully balloted and was released in November 2005 as an ASTM standard. “Some 60 EMR and PHR [personal health record] vendors are ready to implement it, and so are a number of providers,” he says. “We are also being approached by many specialty domains, such as long-term care, to develop regional pilot projects. Next, the CCR will be ‘internationalized’ and we will work on international implementations.”

According to Sutherland, the CCR has already been implemented by MedicAlert (a provider of 24-hour personal and medical ID alert services) for database structure of a personal patient record to be distributed to hundreds of thousands of MedicAlert clients.

“One of the CCR advantages is the fact that it can be printed out on paper and be given to the patient. It can be faxed to a provider who does not have an EMR, and so on. HIM [healthcare information management] professionals will be involved in these processes,” explains Waegemann.

Digital Snapshot
Since the CCR provides a snapshot of a patient’s most relevant information, it should lead to improved patient safety and decrease the risk for medical errors.
“Not all EMR data is relevant, and much of it is sensitive and should be protected,” Sullivan says. “The CCR will make HIM professionals’ jobs easier because they won’t have to guess what’s pertinent or what information is relevant. Doctors and patients will determine what is relevant to the CCR.”

Proponents believe the CCR will make obtaining patient information much easier. With CCR—and an EMR—physicians can access patients’ records by going online. In years past, when patient records were needed, physicians had to call one another, request the information by fax or mail, and wait for it to arrive (if it didn’t get garbled in the fax machine or lost in the mail). According to Sutherland, EMRs save healthcare staff members at least 1.5 hours per week—improving clinical productivity.

“The CCR solves the problem of what medications the patient is on because patients are a very poor mechanism for determining medications,” Sutherland says. “The only way physicians can be sure of what meds they are taking is by calling the patient’s pharmacy or pharmacies, or by calling the insurance company. This is a huge patient safety issue, along with having access to lab test results. In Massachusetts, the safety benefits were a central driving force of the state’s national health data system, and the CCR will also contain this basic information that a physician needs [in order to improve patient safety].”

Sharing Data
Pollard explains that the CCR will provide an opportunity to reduce duplicate work and more efficiently share data with patients and other organizations. The CCR will change the focus of electronic patient data to the interpretation of data. “I think the CCR will simplify sharing data and change the nature of data sharing,” he says.

As far as HIPAA is concerned, Sutherland says security and privacy guidelines and specifications for CCR document use and access will be published.

CCR implementation will cost little, according to Waegemann. “There is a nominal price that has not been established yet—around $50—if someone wants to buy the full standard with all the details. Alternatively, an ASTM membership is $75 per year and provides free access to all ASTM Standards, including the CCR,” he explains.

Sutherland says costs may be borne by vendors because adding the CCR to current EMR software wouldn’t take more than a few days to develop. “Larger vendors might not have an easy way to integrate CCR with their systems, but for those vendors with advanced software technologies that support internal operations and have integrated engineering functions that already support HL7, versions two and three, it is a minor task to integrate CCR,” says Sutherland. “There is a huge effort to build regional IT centers to operate EMR software, including CCRs, and if this succeeds, the infrastructure of all healthcare in the United States will be significantly upgraded.”

The ASTM has even considered the CCR being free to the healthcare community because of its importance to patient safety, says Sullivan. The cost of the CCR is minimal—it consists of taking an EMR program and interfacing it with CCR—but somewhat variable, depending on the cost of the EMR software. Thirty to 40 vendors are already adding CCR to their EMR applications as an update or as a standard. The CCR merely requires a standard XML interface. Vendors simply add the CCR as an update to current software—one that can import and export data from an EMR.

CCR benefits such as improved patient safety and more knowledgeable healthcare providers far surpass the ultimate cost.

“Physicians and other clinicians sometimes provide patient care without knowing what has been done previously and by whom, resulting both in wasteful duplication and in clinical decisions that do not take into account critical data related to patient health,” says Waegemann. “Some experts believe that the fact that most practitioners have to act ‘blindly’ is the main reason for most medical errors. The CCR is designed to improve continuity of care and reverse the effects of providing patient care without knowing what has been done previously.”

— Laura Gater’s medical and business trade articles have been published in Medical Imaging, 24x7, Podiatry Management, Veterinary Forum, Corrections Forum, and other national and online publications.

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