Standards rivals’ collaboration could have major impact

By: Joseph Conn / HITS staff writer
Story posted: February 13, 2007 – 10:56 am EDT

The compromise reached between two sometimes rival standards development organizations could have far-reaching implications for the development of a national healthcare information network, experts close to the effort say.

The collaboration, called the Continuity of Care Document, or CCD, is the handiwork of Health Level 7, Ann Arbor, Mich., and ASTM International, Conshohocken, Pa., which jointly announced its release Monday after required formal balloting was completed. Initial development efforts by both organizations was aimed at developing patient care summaries but has since broadened in scope.

The CCD is a melding of HL7’s broader Clinical Document Architecture, or CDA, and the Continuity of Care Record, or CCR, developed by ASTM in collaboration with the Massachusetts Medical Society. Balloting on the much-anticipated CCD began on Dec. 6, 2006, and concluded Jan. 7. It took two ballots to pass muster among HL7 members and other interested parties who reviewed the development, according to Robert Dolin, an Orange County, Calif.-based physician lead for national terminology services for the Kaiser Permanente Medical Group, a member of the HL7 board of directors and the editor-in-chief of CCD for the standards development organization.

Richard Peters, also a physician, is chairman of the ASTM International Committee on Healthcare Informatics and serves as ASTM’s lead in the collaboration on the CCD.

Peters could not be reached for comment by deadline.

“I am the primary editor, and I voted no on it on the first ballot,” Dolin said. “We had enough time so we tightened up all the constraints and the language to use to express the constraints that were a little ambiguous. We went through each section of the CCR and went through it line by line,” he said, making sure it dovetailed with the CCD.

In October 2006, the federally funded Healthcare Information Technology Standards Panel recommended to HHS Secretary Mike Leavitt its first batch of “harmonized” IT standards aimed at facilitating specific healthcare data transmission tasks chosen by HHS. Among those was a recommendation by HITSP that the then-unfinished CCD be adopted for the exchange of certain clinical information, including patient demographics, medications and allergies.

HITSP Chairman John Halamka, the physician chief information officer of Harvard Medical School, in an e-mail called the successful CCD ballot “a very significant development for healthcare IT” and “a milestone in the standards world.”

“HL7 and ASTM worked together seamlessly to incorporate the best of their standards into a work product that will now form the basis of many HITSP Interoperability Specifications,” Halamka said. “CCD was included in the HITSP interoperability specifications submitted to Secretary Leavitt last October. We’ll ensure any updates to CCD are included in our next release of interoperability specifications which will be voted on in May.

Work by ASTM on the electronic CCR flowed out of an initial effort by physicians in Massachusetts to develop a standard, paper-based discharge summary for patients leaving the hospital bound for nursing homes.

Dolin said a similar interest by HL7 members to develop a standard for patient summaries led HL7 to come up with on its own Care Record Summary, or CRS. But the parallel development work of ASTM on the CCR and HL7 on its CRS led to strained relations between adherents of the two standards—what Dolin diplomatically described as “all this politics going on between HL7 and ASTM.” Cooler heads apparently have prevailed and with the collaboration leading to the successful balloting, “CRS is now sunseted by CCD,” Dolin said.

A major event at the IT trade show, Toward the Electronic Patient Record, last May in Dallas, was a demonstration of the CCR by more than a dozen vendors of electronic medical-records systems. At the time, most of the participating vendors could export documents in the CCR format and at least one vendor could import a CCR document and seamlessly place discrete data elements from the record in the fields of the receiving vendor’s EMR.

The demonstration showed the potential of peer-to-peer communication between physicians with different EMR systems.

Peter Waegemann, chief executive officer of the Medical Records Institute, sponsor of the show, said development of the compromise CCD “is really a win-win situation.”

Vendors and users of large IT “legacy” systems that are backers of HL7’s Clinical Document Architecture will gain the most benefit from the CCD because they will be able to use the CCR format in their systems, Waegemann said. But the collaboration with HL7 on the CCD further establishes the CCR, he said.

“Both have a community and both are good for the doctors and everyone else,” Waegemann said.

The American Academy of Family Physician’s Center for Health Information Technology operates an online list of EMR and personal health record system vendors that have committed to using ASTM’s CCR. The list, currently with 31 vendors, also includes the status of their CCR incorporation efforts.


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