Continuity of Care Record - What Does It Mean?

From the American Academy of Family Physicians (AAFP) Website:

"The Continuity of Care Record (CCR) is a new XML document standard for a summary of personal health information that clinicians can send when a patient is referred and that patients can carry with them to promote continuity, quality, and safety of care. The CCR is being sponsored and developed by the AAFP, The Mass. Medical Society, and HIMSS, with input from many other individuals and organizations, under the standards-development organization ASTM. Initial balloting on the standard is expected in late 2003, and pilot projects anticipated to start in early 2004.

Isn’t it time that patients are able to obtain a digital file containing their basic health information, such items as diagnoses, medication list, allergies, and recent procedures? Having this information readily available at the time of care or in emergencies could significantly improve patient quality and safety, and reduce medical errors from faulty or incomplete information.The CCR is that digital file, producible using readily available software like Microsoft Word, or generated from hospital and practice electronic health record (EHR) systems when a patient leaves the ER, office, or is referred from a primary care physician to a subspecialist. Because the CCR is being designed to be simple XML document, it will be possible for different EHR systems to exchange – import and export – the information contained in the CCR, and to update that information after each encounter or visit. Data in XML documents can be displayed in a variety of formats, such as HL7 messages, HTML (browser), PDF, and Word, and thus printed versions of the CCR will be available for patients who desire them.

Adoption of the CCR by the medical community and IT vendors will be a first step in achieving interoperability of medical records. Additional information on the CCR, including how to join ASTM and participate in balloting of the CCR and a Concept Paper which describes the CCR in greater detail, can be accessed from the ASTM Web site.

Posted 11/12/03"

From the American Society for Testing and Materials (ASTM) comes the following (as well as a really nifty PowerPoint presentation at http://www.astm.org/COMMIT/E31_CCRJuly04.ppt):

"WK4363 Standard Specification for the Continuity of Care Record (CCR)
Work Item Type: New
Developed by Subcommittee: E31.28
See Related Work by this Subcommittee
Date Initiated: 03-03-2004



1. Scope


The Continuity of Care Record (CCR) is a core data set of the most relevant and timely facts about a patientÆs healthcare. It is to be prepared by a practitioner at the conclusion of a healthcare encounter in order to enable the next practitioner to readily access such information. It includes a summary of the patientÆs health status (e.g., problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and care plan recommendations. It also includes identifying information and the purpose of the CCR. (See Section 3.1.2 for a list of the required sections of the CCR and Annex A for the details of the CCR.)
1.1.1 Data sets for extensions of the CCR to address such areas as clinical specialties and disease management are not included in this specification. These will be developed and balloted separately.
1.2 The CCR may be prepared, displayed, and transmitted on paper or electronically, provided the information required by this standard specification is included. However, for maximum utility, the CCR should be prepared in a structured electronic format that is interchangeable among electronic health record (EHR) systems. To ensure interchangeability of electronic CCRs, this standard specifies that XML coding is required when the CCR is created in a structured electronic format. XML coding provides flexibility that will allow users to prepare, transmit, and view the CCR in multiple ways, e.g., in a browser, as an element in an HL7 message or CDA compliant document , in a secure email, as a PDF file, as an HTML file, or as a word processing document. It will further permit users to display the fields of the CCR in multiple formats. . Equally important, it will allow the interchange of the CCR data between otherwise incompatible EHR systems.
1.3 The CCR is an outgrowth of the Patient Care Referral Form (PCRF) designed and mandated by the Massachusetts Department of Public Health for use primarily in inpatient settings. However, unlike the PCRF, the CCR is designed to be used for all clinical care settings.
1.4 Information contained in a CCR should be confirmed wherever possible prior to being used in clinical or other decision-making. For example, the CCR insurance information fields should not be construed to address all reimbursement, authorization, or eligibility issues. Current medications and other critical data should always be validated.
1.5 ASTM International Committee E31 on Healthcare Informatics gratefully acknowledges the Massachusetts Medical Society, HIMSS (Health Information Management and Systems Society), the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Medical Association as co-leaders with ASTM in the standardÆs development and adoption, and joins them in inviting the collaboration of all stakeholders, including clinical specialty societies, other professional organizations, insurers, vendors, other healthcare institutions, departments of public health, and other government agencies.
1.6 This standard does not purport to address all of the safety and legal concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health and legal practices and to determine the applicability of regulatory limitations prior to its use.

The Continuity of Care Record, CCR, is a standard specification that has been developed jointly by ASTM International, the Massachusetts Medical Society, the Health Information Management and Systems Society, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Medical Association. The CCR has been developed in response to the need to organize and make transportable a set of basic patient information consisting of the most relevant and timely facts about a patientÆs condition. It is intended to foster and improve continuity of patient care, reduce medical errors, improve patientsÆ roles in managing their health, and assure at least a minimum standard of secure health information transportability.
Due to the tremendous benefit and need for such a standard, as well as the expanding interest in its adoption, the E31.28 Subcommittee voted (32-1-0) to use the ASTM Fast Track process to approve this standard. This means that the ballot is being distributed concurrently to the ASTM E31.28 Subcommittee and the full ASTM E31 Committee.






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Keywords
advance directives, adverse reactions, allergies, care documentation, care plan recommendation, CCR, clinical specialties, clinical warnings, condition, Continuity of Care Record, core data set, data group, diagnosis, discharge, disease management, electronic health record, EHR, extension, family history, health risk factors, health status, imaging, immunizations, insurance eligibility information, laboratory results, medications, patient health record, patient health status, patient identifying information, patient insurance/financial information, PHR, physiological measurements, practitioner, procedure, referral, required data , social history, transfer, vital signs, XML, XML coding, XML schema.



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The title and scope are in draft form and are under development within this ASTM Committee.

Interesting concept...

Sounds almost Clintonian (i.e. Hillary?). But it's important to have patient records available throughout the healthcare system. Unfortunately, last I checked for an XML interchange (for use with the HL7 standard), the cost was prohibitive- software were available from $5000 (WebMD) thru over $150000.00.

Now, from the website at http://www.astm.org/COMMIT/E31_ConceptPaper.doc:

Distinguishing the CCR from Other Documents [i.e. what it is NOT]

The CCR is not a/an

1) EHR: Although the CCR is meant to address the need for continuity of care from one provider or practitioner to any other practitioner, it is not designed to be a mini EHR. Lab and x-ray and other testing results are included only to the extent the provider completing the document finds them relevant. It does not list symptoms as its primary function. Rather it lists diagnoses and the “Reason for Referral” to the next provider or diagnostician. The “Reason for Referral” may include problems or symptoms but not in the manner in which a traditional EHR uses them as the starting point for a documentation of the SOAP-type note. Nor does it include a chronology of events, in the fashion expected in an EHR.

2) Progress Note: Completion of the CCR should not be thought of as mandatory after every visit to a primary care physician (PCP) or specialist or other clinician who is delivering care to the patient. Thus, it is not replacing a progress note used in the traditional record. However, if the clinician is planning to refer the patient to another provider, then the CCR should be updated and prepared specifically for the next anticipated provider and customized to assist at the next “point of care”. Any relevant information for the next provider should be added to the CCR, just prior to the referral, if feasible.

3) Discharge Summary: The CCR differs from the Discharge Summary mainly in that the CCR is much more concise, involves less narrative or free text, and emphasizes the brief care plan for the next steps to assist the patient to recover or be rehabilitated following the most recent episode of illness/care. The CCR highlights or spells out the next appointments and follow-up visits and instructions to assist the Visiting Nurse or other next caregiver regarding expectations of the followup encounter from the perspective of the clinician completing the form.

4) Consultation Note: The CCR is not intended to replace the initial consultant’s note to the referring physician. There is, however, a potential for the CCR to be used in lieu of the consultant’s note back to the referring PCP after the second visit, provided the lengthier summary of findings and plan of care were documented after the first visit and sent to the original provider.

Microsoft Office 2003 now does XML, which seems like will be the defacto standard for electronic interchange. Whether it'll replace the popular VB/VBA is something to be determined still.

Regards,
Al

Participating commercial EMRs will automate the process of creating a CCR document. eClinicalWorks already has a CCR menu and Import/Export commands, though I don't believe they are functional yet. Of course, it will be easy for eCW, which already uses XML.

/Mr Lynn