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Articulos escogidos en Español
 February 2005 Feature
Claudia Tessier,
co-chair of ASTM International’s Subcommittee E31.28 on Electronic Health Records and its Continuity of Care Record workgroup, is executive director of MoHCA (Mobile Healthcare Alliance), headquartered in Washington, D.C. She is also a consultant in healthcare documentation.
Toward a Continuity of Care Record

A Q&A with Claudia Tessier

ASTM International Committee E31 on Healthcare Informatics is developing a highly anticipated standard that will improve the way clinicians and healthcare institutions record and share information on patient care. The ASTM draft standard (WK4363) will standardize the continuity of care record, or CCR, and is being sponsored by several major healthcare organizations and societies (see sidebar below).

Sponsoring Organizations
ASTM International Committee E31 on Healthcare Informatics is working with a group of sponsoring organizations to develop the ASTM standard that will specify the components of the continuity of care patient record.

• American Academy of Family Physicians
• American Academy of Pediatrics
• American Healthcare Association
• American Medical Association
• Healthcare Information and Management Systems Society
• Massachusetts Medical Society
• Mobile Healthcare Alliance
• National Association for the Support of LTC
• Patient Safety Institute

These sponsors represent over 400,000 practitioners; over 13,000 information technology professionals; over 12,000 institutions in the long-term care community, which provides care to over 1.5 million elderly and disabled; major stakeholders in mobile health; as well as patients, patient advocates, data sources, corporations, and provider institutions.

In addition, ASTM Committee E31 and HL7, or Health Level 7, are working closely, through a memorandum of understanding, to harmonize ASTM’s CCR standard and HL7’s Clinical Document Architecture, Reference Information Model, and Electronic Health Record Functionality Standard. HL7 is an accredited U.S. standards developer that provides standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of healthcare services.

What is the continuity of care record?

The CCR is a snapshot in time of a patient’s healthcare, a core data set that shows the most relevant facts about a patient’s health status and the physician’s treatment of that patient. Like a doctor’s handwritten notes, the CCR is to be prepared by a practitioner at the conclusion of a healthcare encounter.

But unlike traditional notes, the CCR will be formatted in XML, a computer markup language that structures, stores, and sends information. This will ensure that the record can be transported in any electronic format; it can be printed and transferred as a paper document, of course, but also on a compact disc, a USB drive, a smart card, via e-mail, and so on. There is also the potential, which some vendors of electronic healthcare products are investigating, for transmitting the CCR via PDAs [personal digital assistants] or cell phones.

The CCR standard specifies required and optional data elements for a patient’s healthcare record. This data set consists of identifying information (name of patient, physician, date, etc.), patient administrative and clinical data (such as insurance information, advance directives, family history, procedures undergone, plans of care, and so on), and reference information.

In addition to the XML format, another key benefit of the CCR is the fact that data elements are either required or optional. Critical data elements such as allergies are, of course, going to be required, but by and large, practitioners using the CCR will have great latitude in determining which elements are the most relevant to a particular healthcare encounter and to the patient’s overall plan of care. [See sidebar below for sample data groups of patient administrative and clinical data.]

Patient Administrative and Clinical Data
Below are some of the required and optional data elements in the planned continuity of care record standard.
• Insurance information
• Advance directives
• Support
• Functional status
• Conditions/diagnoses/
• Family history
• Social history and health risk factors
• Adverse reactions/allergies
/clinical warnings and alerts
• Medications
• Durable medical equipment
• Immunizations
• Vital signs and physiologic measurements
• Laboratory results and observations
• Procedures/imaging
• Encounters/appointments
• Care plan
• Practitioners

What stakeholder groups are represented in the subcommittee developing the CCR standard?

Representatives of clinical specialty societies, professional organizations, insurers, vendors, healthcare institutions, departments of public health and other state and federal agencies, and patient advocacy organizations are involved.

How is the CCR, which contains many elements you’ll find in most physicians’ current hand-written records, more advantageous than the kind of record being kept today?

In almost any way you can think of. As we all know from using searchable word processing documents and the Internet, it’s much easier to find specific information in electronic format than if you are using a paper document. The CCR contains the patient information that the most recent practitioner has determined to be the most relevant in order to inform the next practitioner. This gives clinicians who see the patient subsequently the most reasonable starting point for delivering care.

In addition, as I mentioned before, the XML basis of the record makes the CCR interoperable, allowing the interchange of data between otherwise incompatible systems. And, from the provider’s perspective, the simplicity and interoperability of XML minimizes workflow disruption for practitioners and their staffs.

How will the standard, once developed, become the norm for patient record-keeping across most, if not all, institutions? In other words, how do you ensure buy-in from the user community?

Much of the stimulus for the development of the CCR came from the use, by physicians throughout Massachusetts, of the state-mandated Patient Care Referral Form. Because my co-chair in this activity is Dr. Thomas Sullivan, who was, at the time this activity began, the president of the Massachusetts Medical Society, his society very quickly said they wanted to come on board as a co-sponsor. From that base, we have steadily received sponsorship from a variety of professional organizations [see sidebar opposite].
Much of the word about the CCR is getting out through these sponsors, as well as other organizations that are very supportive of our efforts, and these together represent thousands of physicians and other interested parties. In addition, vendors of electronic medical records are involved in the standards development activity; their use of the ASTM standard, once it’s developed, for their products will itself encourage physicians and facilities to use the CCR.

One of the appeals of the CCR to the practitioner community is that, not only have we involved them and their professional societies in the standard’s development, we also leave it to the clinician to determine what information is to be included in the CCR. Other than where there is general consensus within the community of practitioners that a particular data element (such as allergies) should be required, the inclusion of many elements is up to the physician.

Patient advocacy groups are also very interested in this. The interoperability of the CCR means that patients will have access to their personal health records. Patient advocacy groups see this as a way to facilitate the doctor-patient relationship by better educating and involving patients in their healthcare.

We’ve also received some very positive press about this upcoming standard. We believe that the standard is coming out with a wide base of support and that the CCR will have little difficulty establishing a foothold in healthcare as the norm for information sharing.

The standard has three annexes under development. What do they cover?

Annex A will provide a detailed list of the CCR data elements, including the element’s definition, comments about it, examples, whether it is required or optional, and the XML code for the element. Annex B will provide the XML schema definition, or .xsd, which is a way to describe and validate data in the XML environment. When the CCR is prepared in structured electronic format, the .xsd must be used to assure interoperability. Finally, Annex C will be an implementation guide, providing instructions for using the XML .xsd for the generation of a standard-compliant, interoperable CCR.

Is there any international interest in the CCR standard?

We have seen interest from individual countries in Europe, Asia, the Middle East, and South America, to name a few. Committee E31 plans to explore the possibilities of helping ministries of health around the world, the European Commission, and the World Health Organization in adapting or adopting the standards and in creating electronic translation of core data elements. //

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