Health Standards In The News: CCD and Consolidated CDA

It's always exciting to see Corepoint Health featured in health IT publications. It's especially cool when we get to talk about topics that are instrumental to our mission of helping customers meet their health data integration needs. That's exactly what happened in two recent Healthcare IT News articles that featured Corepoint Health Product Manger Rob Brull. The topic of each article is near and dear to our data integration hearts: healthcare standards. 

The articles address CCD and Consolidated CDA documents, respectively. Rob actually teaches a monthly training course on these topics

Why CCD and Consolidated CDA? Because they are two essential health data standards that will be commonplace in future health IT activities, yet very few of those working in health IT actually know much about either standard. In an article I published on the HL7Standards blog, Michael Planchart said that he travels to hospital systems around the country and he rarely encounters anyone who knows anything about CCD.

According to Meaningful Use Stage One criteria, CCD is the designated standard that EHRs must use to exchange data. In the Healthcare IT News article "5 Things to Know About CCD," Rob addresses:

What exactly​ is​ a CC​D document? 

CCD stands for Continuity of Care Document and it is based on the HL7 CDA architecture. CDA, or Clinical Document Architecture, is a document standard governed by the HL7 organization. The HL7 v3 standard includes both messaging and document standards. The document standard for HL7 v3 is CDA, and one of the documents within the CDA architecture is CCD.

What is the difference between ​a CCD document and a CCR document?

In the CDA & CCD First Steps class, Rob discusses the 3 C’s of healthcare: CCD, CDA, and also CCR (Continuity of Care Record). The CCD owes its existence to CCR and CDA. The CCR started out as a three-page paper document which was used in patient care referrals. It was created by the Massachusetts Department of Public Health, and included all the information that was necessary for providers to effectively continue care. Since it was a very successful document in the transfer of care scenario, the Massachusetts Department of Public Health teamed up with ASTM and the Massachusetts Medical Society to create an electronic version of CCR. Eventually, ASTM combined efforts with HL7 to construct the CCD document, which includes all the same content of the CCR, but under the architecture of the CDA.

Does a CCD offer the complete medical record?

A CCD document is not intended to be a complete medical history for a given patient. Rather, it is intended to include only the information critical to effectively continue care. This snapshot of information is broken across 17 different sections that include the clinical content as defined originally by the CCR. 

What is the primary purpose of a CCD?

HL7 defines CDA as a “standard that specifies the structure and semantics of ‘clinical documents’ for the purpose of exchange.” With CCD being a type of CDA document, its primary purpose is for exchange – specifically in the context of a patient being transferred from one care setting to another. 

Can a provider o​r patient use or view a CCD document without special software?

One of the most important characteristics of a CCD is that it must be human readable using any standard web browser. This is a requirement of any CDA document. The patient data within a CCD document is encoded using XML. The XML can be displayed on a web browser using a style sheet. Any clinician, or even the patient, can open the CCD document and view the patient health data with just an online web browser. Here is a glimpse of what a CCD might look like when viewed via a web browser.

So, what about CDA? In "6 Things to Know about Consolidated CDA," Rob addressed the following:  

Why Consolidated CDA?

With CDA and specifically CCD, which is a specific document within the CDA standard, there were many sources of truth. For example, in Meaningful Use Stage 1 rules, the document standard referenced was C32, which is a constraint of the CCD document defined by Health Information Technology Standards Panel (HITSP). Essentially this was HITSP’s version of CCD. So to understand the full meaning of C32, a user would have to traverse documentation from HL7 and HITSP. There were other organizations with constraints as well, such as Health Story and Integrating the Healthcare Enterprise (IHE). Consolidated CDA aims to organize all the documentation in one place.

What is the ‘Consolidated’ part of Consolidated CDA?

The consolidated part of Consolidated CDA refers to the development of a single implementation guide that can be the single source of truth. It represents harmonization of Health Story guides, HITSP C32, part of the IHE Patient Care Coordination, and the original CCD by HL7. The Consolidated CDA implementation guide defines templates used to structure the documents. With one implementation guide and all the templates defined in one place, the standard becomes much easier to analyze and implement.

How are templates used in the Consolidated CDA standard?

The Consolidated CDA implementation guide contains a library of CDA templates. These templates originate from HL7, IHE, and HITSP. The templates are defined at three levels: document, section, and entry. The document level templates define the type of CDA document, such as CCD. The section level templates define how data within specific sections will be structured, such as vital signs. Thus, vital signs will be structured the same in a CCD document as compared to a History and Physical document, with no need to recreate the wheel for different documents. Entry-level templates define how specific observations, procedures, etc., will be structured, making entries appear the same no matter what document or section they are a part of.

How many different types of documents are included in Consolidated CDA?

The Consolidated CDA implementation guide defines nine different types of commonly used CDA documents, including:

  • Continuity of Care Document
  • Consultation Notes
  • Discharge Summary
  • Imaging Integration, and DICOM Diagnostic Imaging Reports
  • History and Physical
  • Operative Note
  • Progress Note
  • Procedure Note
  • Unstructured Documents

Each of these nine documents has a document template defined in The Consolidated CDA implementation guide, which will now be the single source of truth for implementing these CDA documents.

What specifically did the proposed rule for Meaningful Use Stage 2 refer to?

The proposed rule for Meaningful Use Stage 2 referred to the “adoption of solely the Consolidated CDA standard for summary care records.” The proposed rule did not specifically mention the CCD document template within the Consolidated CDA standard. However, since the proposed rule refers to a “summary care record,” it is probably safe to assume that the CCD document will be the specific standard among the nine Consolidated CDA document types that will be utilized for Meaningful Use  Stage 2.

Is Consolidated CDA really new?

From a content perspective, Rob's answer would be, “Only slightly.” Ambiguities existed between the many sources of truth for C32, and those ambiguities will be fixed since now there will be only one implementation guide. Other tweaks have been made to the content as well, but for the most part, CDA document types, including CCD, will remain largely the same in the new Consolidated CDA implementation guide.

However from a documentation standpoint, Rob's answer would be, “Yes!” The CCD document in particular is now much easier to understand, implement, and analyze.