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Overview of the Continuity of Care Record

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1 Overview of the Continuity of Care Record
Claudia Tessier, CAE, RHIA Co-Chair, ASTM E31 CCR Workgroup Executive Director, MoHCA

2 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

3 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)

4 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….

5 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

6 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

7 What’s in the CCR’s Core Data Set?
CCR Header CCR Body CCR Footer

8 CCR HEADER CCR BODY Note: Subsequent slides will detail information from this graphic. CCR FOOTER

9 CCR Header Unique CCR identifier Date/Time Patient From To Purpose

10 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

11 Date/Time Exact clock time that specific CCR was created/generated

12 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

13 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

14 To Identifies the intended recipient/s of CCR
Practitioner, person, system, or organization

15 Purpose The reason the CCR was created, e.g., Referral Transfer
Discharge Personal health record Other….

16 CCR Body Patient administrative and clinical data/sections 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

17 Insurance Information
Basic information about patient’s payers, whether Insurance Self-pay Combination

18 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

19 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

20 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

21 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

22 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

23 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

24 Social History Information on social history, including Marital status
Religion Ethnicity Race Language Smoking Diet Exercise Employment Toxic exposure ETOH use Drug use

25 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

26 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

27 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)

28 Immunizations Lists and describes immunizations Recently received or
Pertinent to patient’s health history

29 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

30 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

31 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

32 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

33 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

34 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

35 CCR Footer Actors References Comments Signatures

36 Actors Includes all detailed identifying information about each person, organization, location, or system referred to within the CCR, including the Patient

37 References Lists the details concerning all references within the CCR to external data sources, e.g., Living will Durable power of attorney for healthcare

38 Comments Contains all comments referenced within the CCR
Free text only Not for data that correctly belongs under other appropriate explicit fields/tags

39 Signatures Contains all digital signatures relevant to the CCR

40 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

41 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

42 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

43 Annex B: XML Schema (.xsd)
Derived from XML codes in Annex A Represents how the CCR should be represented in XML

44 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

45 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 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

46 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

47 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

48 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,

49 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.

50 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

51 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.

52 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

53 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

54 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

55 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

56 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

57 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)

58 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

59 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 communications

60 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

61 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

62 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

63 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 list Notices of meetings and progress

64 For More Information THANK YOU! Claudia Tessier, CAE, RHIA
Co-chair, ASTM E31.28 CCR Workgroup THANK YOU!

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