- The exchange of patient summaries is a central requirement of the EHR Incentive Programs, but prior to the publication of the Stage 2 Meaningful Use requirements multiple standards were available for use.
Those two were the continuity of care document (CCD) and the continuity of care record (CCR). Developed by Health Level Seven International, the first standard constrained the HL7 clinical document architecture (CDA), the specification for both textual and optional structured content with the latter enabling the creation of a framework for referencing coding systems (e.g., SNOMED, LOINC).
Its core data set comprises administrative, demographic, and clinical patient health information.
The second, CCR, came into being through the partnership of nine healthcare organizations, ranging from American Society for Testing and Materials (ASTM) International and the Healthcare Information Management Systems Society (HIMSS) to the American Medical Association (AMA) and American Academy of Family Physicians (AAFP).
The CCR standard mandate six sections of core elements:
- Patient identifying information
- Patient financial and insurance information
- Health status of the patient
- Care documentation
- Care plan recommendation
Stage 1 Meaningful Use requirements allowed both the CCD and CCR as acceptable formats for demonstrating the capacity for exchanging clinical care summaries.
Beginning with Stage 2 Meaningful Use, the second phase of the EHR Incentive Programs no longer included support for the CCR for the exchange of clinical documents. The writing on the wall was perhaps apparent during Stage 1 when EHR vendors were opting to use the CCD rather than the CCR for their certified EHR technologies (CEHRTs). Exchanging patient summaries in Stage 2 requires the use of the Consolidated CDA (C-CDA), a single guide for implementing and analyzing CDA documents. According to HL7, the C-CDA takes advantage of both the CCR and CCD.
Unlike in Stage 1, eligible providers working to demonstrate meaningful use in Stage 2 must use the C-CDA standard to exchange data related to transitions of care comprising elements in the Common MU Data Set — patient demographics, laboratory test, care plans, etc. — and potentially diagnoses, immunizations, discharge instructions.
Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions, procedures and care team members.
Proposed Stage 3 Meaningful Use and EHR certification requirements introduce the possibility of popular emerging standard to play a role in how health data access and exchange works with CEHRT. The standard is Fast Healthcare Interoperability Resources (FHIR), and it could play a central role in Stage 3 given the emphasis on application programming interfaces (APIs) by the Office of the National Coordinator for Health Information Technology (ONC) in the proposed 2015 Edition certification criteria.
"In addition, we believe that this approach supports future, innovative approaches to be used," the ONC explains in the proposed rule. "The intent behind this certification criterion is to allow for, but not require, health IT developers to implement the Fast Health Interoperability Resource (FHIR®) REST API and accompanying FHIR standard specification."
The FHIR standard relies on web-based API technologies which enable the exchange of EHRs, both new and legacy platforms, and already has the support the American Medical Informatics Association and top EHR vendors.
FHIR's role in Stage 3, however, is not guaranteed. The proposed rule is now published and open for public comment. That being said, its status as a potential game-changer in health IT interoperability continues to increase and significant pushback will be required to prevent this modular approach to health data exchange from becoming a mandate.