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The Continuity of Care Document

Prior to the approval of the Continuity of Care Document (CCD) as an ANSI Standard in 2007, electronic data exchange of clinical data could utilize one of two formats: HL7 Clinical Document Architecture (CDA) or ASTM Continuity of Care Record (CCR).

Both formats allow providers to share clinical summary information about patients to referring physicians, pharmacies, EMR systems and other providers. Both formats also have the ultimate goal of improving patient care. But although they are similar in this way, they are not compatible with each other.

In an effort to combine the two closely related formats, the CCD was created. CCD provides a consolidated, single standard for clinical documents in the healthcare community. It harmonizes the two separate standards by using CCR within the broader context of CDA.

The goal of CCD is to increase the quality and efficacy of patient transfer between points of care. Its use is also instrumental in driving the increased adoption of EMR systems and electronic health records (EHRs), and the move towards more modern communication methods for patient data exchange.

Two Competing Standards

What is HL7 Clinical Document Architecture (CDA)?

CDA is an XML-based, electronic standard used for clinical document exchange that was developed by Health Level 7. CDA conforms to the HL7 V3 Implementation Technology Specification (ITS), is based on the HL7 Reference Information Model (RIM), and uses HL7 V3 data types. It was known earlier as the Patient Record Architecture (PRA).

CDA is a flexible standard and is unique in that it can be read by the human eye or processed by a machine. This is due to its use of XML language, which also allows the standard to be broken into two different parts.

A mandatory free-form portion enables human interpretation of the document, while an optional structured part enables electronic processing (like with an EMR system). Text, images and even multimedia can be included in the document.

CDA does not specify a transport mechanism and can be utilized within a messaging environment or independently of it. Transport methods can include HL7 V2, HL7 V3, DICOM, MIME-encoded attachments, HTTP, or FTP. CDA is flexible enough to be compatible in a wide range of environments.

What is the ASTM Continuity of Care Record (CCR)?

CCR is also an XML-based standard used for clinical data exchange, but was developed by ASTM International. CCR provides a “snapshot” of treatment and basic patient information – it is not comprehensive like an EHR. Its primary function is to ease the transition of a patient from one provider to the next.

The information included in the record focuses on the diagnosis and reason for referral rather than symptoms and treatment chronology. It may include information from only a single provider visit or may be more extensive to include data from multiple visits. The amount of information included varies by provider and patient.

CCR is a concise standard that uses a defined set of core data and is based on XML. However an important distinction between CCR and CDA is that CCR uses only specified XML code. It does not support/allow narrative text (free-text) which can sometimes be hindering to physicians, and it is not electronically acceptable by all systems.

Also unlike CDA, CCR was intended to remain neutral with technology and so can be transmitted electronically or on paper. Therefore the patient can manually carry the CCR to the referring physician’s office, if desired – a characteristic that is advantageous when no connectivity exists.
_________________________________________________________________________ To download a complete verison of The Continuity of Care Document, follow the PDF link below.