Continuity of Care Record (CCR) Standard

The Continuity of Care Record standard, often referred to simply as the CCR standard or CCR, is a patient health summary standard, widely used for secure, computable, electronic capture and transfers of personal health data from one health IT system to another, e.g. EHRs or EMRs, and to and from these to personal health record (PHR) applications, such as Google Health and Microsoft HealthVault. The CCR standard utilizes W3C compliant eXtensible Markup Language, XML, to create flexible documents that are intended to contain relevant summary health information about a person for the purposes of coordination of care, continuity of care, and access on networked systems.

Because the output of the use of the CCR standard creates an xml file, it is easily rendered in human readable digital formats such as in a web browser (HTML), Microsoft Word (.doc), portable document format (PDF) and others, through the use of XSLT transforms and other web technologies. CCR files may be viewed in a large number of devices, including the iPhone from Apple.

This example shows a CCR file downloaded from a Google Health account displayed on an Apple iPhone, compliments of Health Cloud and Ford Parsons

Origins of the Continuity of Care Record Standard

The CCR standard was developed under the auspices of the standards development organization (SDO) ASTM International, and was contributed to by members of several endorsing organizations, including the American Academy of Family Physicians, the Massachusetts Medical Society, the American Academy of Pediatrics, and the American Osteopathic Association.

The first meeting of the Continuity of Care Record community occurred in August, 2003, at the headquarters of the Massachusetts Medical Society, near Boston. Thomas Sullivan, MD, a cardiologist and then President of the MMS had envisioned the CCR standard as an XML document that would replace the 3-page paper transfer of care document, required in Massachusetts when a patient is moved from a hospital to a nursing home. Dr. Sullivan had invited individuals from a wide spectrum of health care interests, including physicians and nurses, representatives from several health IT companies, and patient advocates.

At this meeting a group consensus was arrived at to make the CCR standard a more general purpose health summary document, one that would capture the most relevant personal health information into a "snap shot" that would then be available to patients and providers a the "next encounter" with the health care system, wherever and whenever that might be. The group decided to move forward on work towards an XML standard, and to convene this development work within the ASTM E31 Technical Committee on Healthcare Information, then chaired by C. Peter Waegemann.

Work was then begun to define the content of the CCR standard; its expression in XML in a manner that would be in accord with broad computer industry standards; and fulfillment of the somewhat complex and time consuming processes that are required of an ANSI-accredited standard development and maintenance initiative. The CCR standard was ballotted in late 2005, and Version 1.0 was released in early 2006. The formal designation for the standard is ASTM E2369 Specification for Continuity of Care, CCR. Version 2.0 is in progress and balloting is expected in summer, 2009.

Individuals who had a significant impact on the early work of the CCR standard included Thomas Sullivan, MD, Richard Peters, MD, an Emergency Room physician with Kaiser Permanente in San Diego, Roberto Ruggieri of Microsoft, Ken Miller of Solventus, Inc., Adrian Gropper of MedCommons, and David C. Kibbe, MD MBA, director of the Center for Health IT at the American Academy of Family Physicians. However, there were many others who contributed time and skill to the effort, and continue to do so.

Contents and Data Elements Included in the CCR Standard

In addition to information in a header section about the purpose of the CCR xml file, its sender and receiver, and time and date stamps, the body of the CCR xml file may contain various sections including patient demographics; insurance information; diagnosis and problem list; medication list and prescribing information; and laboratory results. In all, there are 17 possible sections, or data objects, expressible within a CCR xml file that conforms to the CCR standard's xsd, or schema.

CCR standard sections or data objects permissible (at least one is required in addition to the header) include: Insurers/Payers; Providers; Problems; Medications; Alerts; Vital Signs; Immunizations; Results; Procedures; Encounters; Family History; Social History; Functional Status; Support; Advance Directives; Medical Equipment; Plan of Care; Comments.

Organizations and developers that use the CCR standard may publish the elements and data objects which they wish to support with their partners, including reference instructions regarding the use of particular coding sets and vocabularies, to increase computability and semantic interoperability when exchanging data using the CCR standard. This set of specifications is known as a CCR profile. Below is a schematic of the subset of the CCR standard's data objects used by Google Health. Note that each section (data object) and all elements can be sourced and date stamped. For additional information, there is a full reference document on the Google Health use of the CCR standard.

In this diagram, which shows the structure of the CCR standard data objects supported by Google Health, elements to the right on a particular branch in the tree are extensions of the elements to their left.

Documentation Necessary for Implementation and Use of the CCR Standard

The CCR standard's documentation includes two components: an Implementation Guide including a spread sheet describing each permissible data element, and an adjunct which is a schema (XSD) file. The schema determines the representation of the data elements within an XML file produced in compliance with the standard, subject to the constraints specified in the Implementation Guide. For those unfamiliar with XML technology, a schema (XSD) is a type of file used to set requirements in terms of content and structure, against which an XML file that is prepared must validate in order to be interpretable by standard-compliant software.

The CCR standard documents and schema (ASTM E2369-05) may be obtained from ASTM International. The Active Standard and Adjunct can be purchased by developers and organizations that wish to utilize the CCR standard in their products and services for a one-time fee of $100. There are no royalties or fees for use. Individuals who become members of ASTM E31 Technical Committee on Healthcare Informatics pay a yearly dues of $75, and are entitled to a free copy of the CCR standard documents and schema.

Examples of Current Uses of the CCR Standard

There is no formal registry to document the many uses of the CCR standard by individuals and groups in this country and internationally. What follows are several brief descriptions of known implementations of the CCR standard as of April, 2009. Others may be added here as appropriate.

Microsoft utilizes the CCR standard to establish clinical connectivity between its HealthVault personal health record platform and other information systems. In April, 2009, a Microsoft press release announced that Microsoft had established a partnership with New York Presbyterian Hospital to share information between NYP's Amalga UIS and HealthVault, using the CCR standard. From the press release:

"Also when authorized by the patient, Amalga UIS 2009 can push patient data generated at the hospital, including test results, medications and discharge summaries, to the patient's HealthVault record via the ASTM Continuity of Care Record (CCR) industry-standard specification. The patient can then use and share this information, as desired, with other clinicians or caregivers. As a result, patients can play a more active role in managing their care together with providers and more easily involve family members in their care as well."

Google Health, the personal health record platform offered by [1], supports a subset of the CCR standard's data objects, and uses the CCR standard exclusively for exchanges of health data with health data sources, such as CVS Pharmacy, Walgreen's, Cleveland Clinic, and Beth Israel Deaconess Medical Center. Information on the Google Health's implementation of the CCR standard, along with other information for developers on how to view and send health data in the form of Google Data feeds is available on the Google Health Data API home page. There is a large and growing number of companies who belong to the Google Health "ecosystem," all of whom share data with Google Health account holders using the CCR standard. Websites that permit authorized users to grant viewing privileges or to automatically send and update information to the users' Google Health profile include Allscripts ePrescribe, Blue Cross Blue Shield of MA, Medco, Quest Diagnostics, CVS MinuteClinic, CVS Pharmacy, Walgreens Pharmacy, and RxAmerica. Other websites offer personal health services of many kinds, which may be activated by sharing the contents, or portions of a user's profile, with the website automatically. These include the Cleveland Clinic MyConsult service, DestinationRx, ePillBox.info, Physician's Wellness Network, and TrialX.org. Finally, there are a number of companies that offer tools activated by sharing a users' data via the CCR standard. These include Diabetes Risk Assessment, Go Red Heart Checkup, MyDailyApple, and a Heart Attack Risk Calculator from the American Heart Association.

MinuteClinic is the country's leading retail clinic provider, with over 500 in-store nurse practitioner-staffed clinics located in CVS Pharmacies in 30 states. According to Cris Ross, MinuteClinic's Chief Information Officer, the CCR standard is utilized many thousands of times a day to support clinical supervision, provide personal health records to customers, and to send clinical summaries to the offices of doctors who are identified by MinuteClinic customers as continuity providers. Customers who register for MyRecords at MinuteClinic can securely access their medical information, and also choose to upload their information via the CCR standard to Google Health and/or to Microsoft HealthVault accounts.

References

1. ASTM CCR Continuity of Care Record http://www.astm.org/cgi-bin/SoftCart.exe/DATABASE.CART/PAGES/E2369.htm?L+mystore+luuu5949+1167331453

2. http://e-caremanagement.com/untangling-the-electronic-health-data-exchange/

External Links and Resources

• ASTM CCR Standard E2369-05
• CCRStandard.com
• Medical Records Institute - CCR
• Center for Health Information Technology (CHiT)
• CHiT/AAFP list of ASTM CCR (Standard E2369-05) Compatible Software Products
• CCR Java library