Presentation on theme: "Continuity of Care Record"— Presentation transcript:
1 Continuity of Care Record Claudia Tessier, CAE, RHIACo-Chair, ASTM E31 Workgroup on CCRExecutive Director, MoHCA
2 What Is the CCR?A snapshot in time: A core data set of the most relevant facts about a patient’s healthcare.Organized and transportable.Prepared by a practitioner at the conclusion of a healthcare encounter.To enable the next practitioner to readily access such information.May be prepared, displayed, and transmitted on paper or electronically.
3 The CCR… Provides information that is Appropriate, succinct, organized, and up-to-dateInteroperable through use of specified XML codeA necessary bridge to a different environment, often with new practitioners who know little about the patient.Will address specific domains through extensions: long-term care, acute care, disease management, personal health record, etc.
4 Development of the CCR Unique standards development effort Consortium of sponsoring organizationsASTM InternationalMassachusetts Medical SocietyHIMSSAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAmerican Medical AssociationPatient Safety InstituteAmerican Health Care AssociationNational Association for the Support of LTCAdditional sponsoring organizations pending
5 Sponsors represent: ANSI-recognized standards development organization Over 400,000 practitionersOver 13,000 IT professionalsOver 12,000 institutions in the long-term care community that provide care to over 1.5 million elderly and disabledPatients, patient advocates, data sources, corporations, provider institutions….
6 This Unique Initiative Is… Patient-focusedNot about what the system says to do but about what patient information is most relevantProvider-focusedPractitioners determine what information is most relevantContent-focusedEmphasis is on what providers need to know to deliver good patient care
7 This Unique Initiative Is Also… Stimulating cooperation amongOrganizations, such as ASTM and HL7Professional specialty organizations and their practitionersProvider institutionsVendorsThese diverse groups are working togetherTo develop and implement the CCRTo assure its interoperabilityTo develop demonstration projectsGenerating interest amongPatients and patient advocatesFederal agencies, payers, others
8 The CCR Is Not…An EHRIt is not a complete electronic health record of a patient’s lifelong health status and healthcareIt is not universally accessibleIt does not have a universal patient identifierA progress note, discharge summary, or consultationIt is not limited to information from a single encounterIt is not free-text basedA loose dataset of health informationIt is a defined set of core data in specified XML code
9 Why Is the CCR Needed?CCR addresses the lack of appropriate, succinct, and up-to-date patient health information for practitioners at a new point of care.CCR data is essential to good patient care and serves as a necessary bridge to a different environment, often with new practitioners who know little about the patient.
11 CCR Identifying Information Section 1Referring (“from”) practitionerReferral (“to”) practitionerDatePurpose/reason for CCR
12 Patient Identifying Information Section 2Required information to uniquely identify the subject patientNot a centralized system or a national patient identifier, but a federated or distributed identification system thatLinks various practitionersContains the core data set of identifying information that could be used by any record system to assign the individual their own identifier.
13 Patient Insurance/Financial Information Section 3Basic information from which eligibility for insurance benefits may be determined for the patient.
14 Advance Directives Section 4 Indicators that resuscitation efforts are to be either unrestricted or to be limited in some way.Includes what is commonly known as the DNR (Do Not Resuscitate) status of the patient as addressed in such documents as living wills, healthcare proxies, and powers of attorney.
15 Patient Health Status Section 5 Conditions/Diagnoses/Problems Family HistoryAdverse Reactions/ Allergies/Clinical Warnings and AlertsSocial History and Health Risk FactorsMedicationsImmunizationsVital Signs and Physiologic MeasurementsLaboratory Results and ObservationsProcedures/ImagingThis section may be amplified in extensions for clinical specialty-specific information regarding patient.
16 Care Documentation Section 6 Some detail on the patient-practitioner encounter history, such as dates and purposes of recent pertinent visits and names of practitioners seen.May be significantly expanded in future extensions.
17 Care Plan Recommendation Section 7Includes planned or scheduled tests, procedures, or regimens of care for the patient.
18 Practitioners Section 8 Information about those healthcare practitioners who are participants in the patient’s careLinks as appropriate to Conditions/Diagnoses/ Problems and Care Documentation encounters
19 A Sample Data Group Medications Definition: Generic name of current and relevant past prescribed substances, including OTC, herbal, and homeopathic substances. Brand name is inadequate.Comments/Examples: Medication: Trimethoprim/SulphamethozaxoleRequired or Optional: RequiredXML: <MEDICATION>
20 Extensions for Additional Content Enterprise and institution-specific, e.g., acute care, LTCClinical specialty-specific, e.g, pediatrics, nursingDisease managementDisease-specific information, performance measures, guidelines, etc.Payers: financial information/attachmentsPatient-entered Personal Health Record
21 The CCR Can Stimulate EHR Adoption Because… Through specified XML code it is interoperable, so it will enable EHR systems toImport and export all CCR dataInterchange the CCR between otherwise incompatible systemsMinimize workflow disruption for practitioners
22 More about XML and the CCR Through XML, CCR can be prepared, transmitted, and viewedIn a browserIn an HL7 CDA-compliant documentIn secureIn any XML-enabled word processing documentIn multiple formatsIt can also bePrinted as a paper documentStored on a portable storage device for use as a personal health record
23 Why So Much Interest in the CCR? Multiple usesReferral, transfer, discharge, or other instance when patient is seen by another providerOther uses include personal health record, research, and public health initiativesIntroduction to electronic documentation and ultimately to EHRCan stimulate use of computers in healthcareFlexibilityWhatever patient information is relevant can be accommodated
24 Why So Much Interest in the CCR? It is not a top-down approachEnd-users, i.e., practitioners have participated in its designThe originator determines the relevant contentIt has support and leadership from organizations representing end-users, who areInvolving, advising, and assisting their constituents in its adoptionIt allows options for implementationPaper or electronicIt has potential to reduce inefficiencies and costsPractitioners won’t have to search for relevant informationFewer repeat lab tests and other evaluations
25 Why So Much Interest in the CCR? It offers support for patient safety and reduced medical errorsThrough easy access to critical data such as medications and allergiesIt encourages patient involvement and improved provider/patient relationsIt is patient focusedIt offers patients easy access to their health informationPatients don’t have to repeat same information over and overIt can help populate a personal health recordIt can stimulate the patient to become more involved in and informed about their healthcareIt can involve patient in transfer of information (USB)
26 In Summary:Practitioners, provider institutions, patients, vendors, and other stakeholders perceive the CCR asRelevantDoableTransportable and interoperableValuable
27 Thank you! For more information on the CCR Claudia Tessier, RHIA