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March/April 2008
Feature

Technology Connects Medical Records

ASTM continuity of care standard improves data storage and exchange

laptop computer and stethoscopeThe ASTM International continuity of care record standard is helping to change the face of storing patient health care information, transporting it electronically and giving patients more control in the process.

In Singapore, a hospital pilots the use of CCR for transferring patient information to a primary care practitioner. Award-winning eClinicalWorks joins other medical records software firms in integrating CCR into its product offerings. And this spring, a meeting will be held in Germany to advance the understanding of CCR there in both medical and government circles.

CCR is shorthand for E 2369, Specification for Continuity of Care Record, the ASTM International standard that is a step toward portable, interoperable electronic health care information with the ultimate result of better patient care and reduced medical error. While much can and will still be done in this arena, CCR has been taking hold in the two-plus years since its publication in December 2005.

Before and Beginning the CCR

Patient records, and the software used to create them, have often been islands of data that are isolated and cannot be shared across electronic networks. So says Dr. David C. Kibbe, MBA, chair of ASTM International Committee E31 on Health Care Informatics, which developed the standard. “Software systems in health care tend toward proprietary and disconnected databases of records, of use primarily only within the four walls of the institutions who own them, but of little value in exchange of information between providers, such as between doctors or hospitals,” he says.

A summer 2003 meeting held at the Massachusetts Medical Society in Boston, Mass., and led by Dr. Thomas Sullivan, founder and co-chair of the CCR work group, provided the catalyst for changing that situation. Physicians, nurses and other interested stakeholders gathered that summer to look at health information and technology as part of a new model of care to meet patient needs, and an important part of the discussion was how to approach digital patient records and make them more easily transported across the Internet.

Attending that meeting was retired engineer, educator and entrepreneur Henry Frankel. Frankel, an ASTM International member since 1988, took his own approach to providing up-to-date information to his doctors about his complex medical and surgical history by loading scanned documents onto a portable electronic device. His approach and the group’s discussion spurred them on to starting work on a new standard for summary patient information in a secure digital format.

Frankel says, “We don’t have uniformity with medical records. We need to centralize on one. That’s where ASTM came in.”

During that Boston meeting, the group agreed to use extensible markup language (XML), widely used on the World Wide Web and for e-commerce data exchange, and hammered out the beginnings of the CCR standard. Initially known as the patient care referral form, the draft standard was renamed the continuity of care record by then-E31 chair Peter Waegemann, chief executive officer of the Medical Records Institute in Boston, Mass.

With the completion of E 2369 in 2005, an approach to connecting data islands came into being. “The standard is an innovative technology for interpreting and using personal health information across a wide variety of computer operating systems and applications, and for networking health care data, akin to the MP3 format for audio content,” says Kibbe. “It will help change health care in the 21st century.”

Development and Content

The standard guides what patient health information — administrative, demographic and clinical — is essential to provide continuity from one practitioner and/or place to another. Such details as patient demographics, insurance information, advance directives, diagnoses and problems, medications, allergies and care plan add up to a complete picture of a patient’s condition at a particular point in time. In turn, the continuity of information will enhance patient safety and reduce medical errors and costs.

A broad number of groups participated in the CCR’s development, including clinical specialty societies, professional organizations, insurers, vendors, health care institutions, state and federal agencies and patient advocacy organizations. Early on in the process, Microsoft Corp., whose online system for health care consumers, HealthVault, now accepts the CCR XML file from both individuals and providers, added its expertise for the XML coding integral to the standard.

Claudia Tessier, vice president of the Medical Records Institute, and co-chair of Subcommittee E31.25 on Health Care Data Management, Security, Confidentiality, and Privacy, which is responsible for the standard, emphasizes that physicians have been very involved in the project. “This should be physician-driven because it’s something they would be using,” she says. “Through them we have identified the most relevant patient information to be shared among providers. Thus, they and their patients will be its main beneficiaries.”

Throughout the process, Committee E31 worked with many sponsoring organizations, beginning with the Massachusetts Medical Society and expanding to include the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Medical Association, as well as the Healthcare Information and Management Systems Society, the American Health Care Association, and other health care associations.1 The sponsors represent more than 500,000 practitioners, more than 13,000 information technology professionals and more than 12,000 long-term care groups that care for more than 1.5 million elderly and disabled people.

Promising Outcomes

Interest in and use of CCR spans the globe, from Asia and Europe to locales around the U.S.

The CCR standard gained traction soon after its publication. In 2006, among the many response efforts following Hurricane Katrina’s Gulf Coast destruction was the New Orleans Health Recovery Week. E 2369 played a supporting role as the thousands who gathered for medical and dental treatment could create a CCR file along with a PDF version of their compiled health care information. “Many health records were destroyed by the flood in New Orleans and as a result there was no history to look back on,” says Richard Benoit, program manager, standards, for Intel Corp.’s Digital Health Group, who was involved in the service project. “A lot of those things could have been alleviated had a permanent secure digital record been somewhere that they could have tapped into.”

One of the latest steps is the pilot of a CCR-based system in the Community Access Program of Arizona and Mexico, which primarily serves seasonal farm workers. The system involves a Web-based application hosted at a data center that will allow both the most recent and earlier CCRs to be viewed and edited.

Another CCR project is under way in Singapore, where Dr. Lee Kheng Hock and Dr. Patrick Chia of Singapore General Hospital report that the Family Medicine and Continuing Care Department is piloting use of the CCR for transfers of care records from the hospital to primary care practitioners. In addition, the hospital also generates an HTML version of the document for easy viewing.

In addition, a spring meeting in Germany is being organized by Dr. Sebastian Semler and Professor Rolf Engelbrecht, who will bring together physicians from the U.S. CCR team and from the German medical community as well as government representatives to broaden its discussions about the CCR standard and its use. A group involved with the CCR standard’s development traveled to Germany last year at the invitation of the European Institute for Health Records. This year’s meeting will build on those discussions.

On the technology side, MinuteClinic, a subsidiary of CVS Caremark Corp., creates patient summaries using CCR throughout its more than 400 locations (see sidebar). Among the growing number of technology firms using the CCR, a list of which can be found on the AAFP Center for Health Information Technology Web site is eClinicalWorks, Westborough, Mass., a medical software company that has integrated CCR into its product offerings.

The Next Step: PDF Best Practices Guide

Committee E31 has continued with its quest to improve patient care through medical information standards and has completed of a best practices guide developed under a memorandum of understanding between ASTM International and AIIM – the ECM Association (electronic content management) with participation from a number of interested organizations and companies. AIIM/ASTM BP01-2008, Portable Document Format for Healthcare; A Best Practices Guide, describes how PDF can support XML standards, for example, with electronic health records organized according to the CCR scheme and expressed as PDFs.

The guide describes how to use PDF as a means to capture, exchange, preserve and protect health care information among doctors, hospitals and individuals. The PDF format, already a de facto standard for information exchange, provides accessibility and security while preserving XML standards of interoperability and is widely used and accepted. As a result, any health care information developer can implement the functionality detailed in the document.

“We brought together a lot of differing opinions as well as different types of organizations to make this happen; it’s a remarkable feat,” says Benoit, who led the task group that developed the guide. He adds that while the best practices guide is robust, the task group anticipates feedback that will improve future revisions.

Getting the Word Out

Thanks to the CCR standard and the PDF best practices guide, strides are being made toward meeting U.S. President George W. Bush’s goal for portable computerized health records for all Americans.

To raise additional awareness of E 2369 and accelerate its use in electronic health record software, AAFP launched Project Continuity of Care. AAFP, through its Partners for Patients, has also organized a CCR Acceleration Group, which promotes CCR interoperability and represents a wide range of providers, vendors and other interests.

An ASTM International Technical and Professional Training course is spreading the understanding of how the CCR standard applies to recording and transporting health care data electronically. The course, ASTM Continuity of Care Record: Emerging Standards and Best Practices for Health Data Portability and Interoperability, covers the CCR standard and its XML schema in detail as well as integrating CCR into other products and services, and its use for information exchange. This year, the course will be taught four times in cities from coast to coast, and is also being held on site for several large medical organizations.

And a Web site, www.CCRstandard.com, maintained by Kibbe and fellow AAFP physician and E31 member Dr. Steven Waldren, details current use of the ASTM CCR standard for health data and information exchange.

Whether the information exchange is needed for a mom taking the next step in care for her kids or a cancer patient taking information about the disease’s complicated treatments from one specialist to another, the CCR and the best practices guide are breaking new ground in portable and transportable health records.

Many groups and individuals continue to spread the word about the publications and their usefulness. “We’re all disciples — we have a strong belief in this standard and a desire to share,” Tessier says. And the final goal benefits all: better patient health care.

Note
1 The sponsoring organizations included the American Academy of Family Physicians,
the American Academy of Pediatrics, the American Health Care Association, the American Medical Association, the Healthcare Information and Management Systems Society, the Massachusetts Medical Society, the Medical Group Management Association, the Mobile Healthcare Alliance, the National Association for the Support of Long Term Care and the Patient Safety Institute.