2 Exchange of Clinical Summaries Via CCR, CCD, and C-CDA

Section 2.10 Plan Exchange of Clinical Summaries via CCR, CCD, and C-CDA

Understand how you may generate and share clinical summaries and other health information with other providers and clients.

Time needed: 4 hours Suggested other tools: Section 1.3 Interoperability for EHR and HIE

How to Use 1. Review the basic structures for information exchange in order to understand the capability of electronic health record (EHR) vendors to produce clinical summary and other health information formats to support your exchange of health information with other providers and clients. 2. Appreciate the transition state of affairs as health care rapidly adopts EHRs and the means to electronically create, format, and transmit health information over a secure network. 3. Determining readiness of a health information exchange organization (HIO) in your area to support your agency’s health information exchange (HIE) requirements. 4. Note that HIE is a changing environment with standards that are evolving. As an organization you need to stay abreast of these changes. To keep abreast of the HIE environment in Minnesota we suggest you visit the Minnesota e- Health site1 on a periodic basis.

Information Exchange Structures Paper documents sent via postal mail, fax, email after being scanned, or on a CD via postal mail have been the predominant ways to exchange health information with those outside an organization (and sometimes even within an organization). These forms of exchange have been time-consuming, slow to deliver, often incomplete, non- standardized. While the documents may have been stored in and retrieved from a computer system, the information within them has not been able to be processed by a computer. Rapidly, health care is adopting new structures to support the exchange of both machine- and human-readable documents. The following is a brief summary of these structures:  Clinical Document Architecture (CDA) is a standard methodology, or architecture, to create health-related documents and templates. It was created in 1999 by the standards development organization Health Level 7 (HL7). The CDA supports the ability to store complete clinical summaries and other documents, structured data derived from documents, and multimedia.

1 http://www.health.state.mn.us/e-health/index.html

Section 2 Plan—Exchange of Clinical Summaries via CCR, CCD, and C-CDA - 1  Continuity of Care Record (CCR) is a recommended set of health data that provides a useful clinical summary. It was originally conceived by the Massachusetts Medical Society and others as a means to exchange more complete health information about a patient being referred from one provider to another. The data set was made into a recognized standard by the ASTM International (formerly the American Society for Testing and Materials) standards development organization in 2004.  Continuity of Care Document (CCD) is the result of HL7 and ASTM getting together in 2007 to provide a standard set of data (the CCR) in a document format (CDA), called the CCD. The CCD, along with specific terminology standards for certain data, is one of the structures that hospitals and physician offices which are receiving federal incentives for making meaningful use of EHR may use to exchange health-related documents. The CCD may be formatted as in XML or as a PDF file. For examples of these formats, see: o http://www.health.state.mn.us/divs/hpsc/ohit/hieguidance/plancomp are.html The examples are at the bottom of the page. • Consolidated Clinical Document Architecture (C-CDA), introduced at the end of 2011, is a significant improvement upon the CDA and CCR. It generates an improved CCD. In addition, it truly marries the features intended by the CDA to provide human-readable and machine-readable data for many contexts in which health information needs to be exchanged. The C-CDA supports document templates for generating the CCD as well as discharge summaries, history and physical exam records, progress notes, diagnostic imaging reports, and other structured documents. There are also section-level and entry-level (observational) templates, such as sections for advance directives, allergies, assessment, etc. Entry-level data collection templates include those for age, caregiver characteristics, instructions, medication activity, and many others. The C-CDA must be used by those hospitals and physician offices earning federal incentives in the second wave of the meaningful use (MU) incentive program. For home health agencies, the ability to create a clinical summary using Outcome and Assessment Information Set (OASIS) data compiled during an assessment can be achieved by using the CCD template within the C-CDA. This clinical summary can be rapidly accessed by anyone in the agency needing a snapshot of a client’s care. It can be given to the client upon request for the client to share with another provider or as a means to enter data into the client’s personal health record (PHR). The summary can be readily shared with a hospital or other provider if a client is readmitted or moves. Home health agencies will also find great benefit in receiving a clinical summary about a client in the C-CDA format, which can then contribute data automatically to the start of an assessment. Other C-CDA format clinical information from external resources, such as lab results, do not require manual entry into the EHR. Such data is available for viewing, processing by the computer into a graph or trend line, or compared with other data.

HIE Planning Depending on your use case, plan for the following:

Section 2 Plan—Exchange of Clinical Summaries via CCR, CCD, and C-CDA - 1  If acquiring an EHR, determine what capability the EHR vendor has to support HIE through the CCD (document construct only) or C-CDA (templates and structured documents). What format does the EHR support? Can the EHR be used to both generate and incorporate a summary of care record?  If upgrading an existing EHR, obtain information from the EHR vendor about whether and when the capability for CCD or C-CDA exchange will be supplied.  Whether or not you are using an EHR, if using Centers for Medicare & Medicaid Services (CMS) software to submit the non-HIT standards-enabled OASIS data set, determine from your HIO whether it can receive this format of the OASIS data set and transform it into a C-CDA structure for use as a standardized assessment and/ or a clinical assessment summary that can be made available to HIO participants.  In planning to participate in an HIO, determine whether you must know which format of CCD or C-CDA you must be able to generate for each transmission, or if the HIO reformats the summary of care information for each recipient’s needs.  In planning to use an HIO to exchange OASIS data, discuss whether additional data—such as medications, allergies, advance directives, and other data from the CCR data set—can be added to the OASIS data set, enriching it for more comprehensive uses.

Section 2 Plan—Exchange of Clinical Summaries via CCR, CCD, and C-CDA - 1