overview of the continuity of care record claudia tessier, cae, rhia co-chair, astm e31 ccr...
TRANSCRIPT
Overview of the Continuity of Care Record
Claudia Tessier, CAE, RHIACo-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 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 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 to the next provider in order to deliver good patient care
CCR Header CCR Body CCR Footer
What’s in the CCR’s Core Data Set?
CCR FOOTER
CCR BODY
Note: Subsequent slides will detail information from this graphic.
CCR HEADER
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 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 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 Practitioner, person, system, or
organization
Purpose
The reason the CCR was created, e.g., Referral Transfer Discharge Personal health record Other….
CCR Body
Insurance Advance Directives Support Functional Status Problems Family History Social History Alerts Medications
Medical Equipment Immunizations Vital Signs Results Procedures Encounters Plan of Care Healthcare Providers
Patient administrative and clinical data/sections
Insurance Information
Basic information about patient’s payers, whether 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
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 Which are to be restricted, limited, or
avoided as addressed in such documents as
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., 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., 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 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 Relationship to patient Problem Status Other relevant data
Social History
Marital status Religion Ethnicity Race Language Smoking
Diet Exercise Employment Toxic exposure ETOH use Drug use
Information on social history, including
Alerts
Lists and describes any of the following that are pertinent to patient’s current or past medical history Allergies Adverse drug reactions (ADR) Alerts
Medications
Lists relevant current and past medications prescribed and administered 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., Implanted or external medical devices Durable medical equipment (DME)
Immunizations
Lists and describes immunizations 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 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., Cardiac cath, x-ray, etc. CABG, chemotherapy, etc. Health status assessments, e.g.,
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 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 Orders Appointments Referrals Procedures Services
Healthcare Providers
Includes information about all those healthcare providers who are participants in the patient’s care, e.g., 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., 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., Problems Medications
Data Groups
In addition to data elements specific to its purpose, each data group in the CCR Body and Footer also includes Data source
Who or what is the source of the information Internal CCR link
Defines internal CCR links, e.g., Problem to Healthcare Provider
Comment Any relevant information that doesn’t fit elsewhere
Reference 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 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 standards-compliant, interoperable CCR
Extremely strict regarding 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 To support standards-compliant interoperability To enable CCR to be prepared, transmitted, and
viewed 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 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 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 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 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 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
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 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 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 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 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 Point-of-care data entry, access,
transmission Transportability Connectivity to and interoperability with
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 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
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 $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
Notices of meetings and progress
For More Information
Claudia Tessier, CAE, RHIA
Co-chair, ASTM E31.28 CCR Workgroup
202-352-3019
THANK YOU!