Workshop: CCR-DE - A Medical Data Set Supporting Continuity of

Care

München April 28 - 29, 2008

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Clinical Design of the CCR

Problem:

We need to extract the key clinical data we need from the patient and the medical record to make clinical decisions.

Design:

The CCR Dataset is a summary of all the key current and historical data that defines that patient’s current clinical status…

– How well or sick are they?

– What individual, hereditary, and environmental health risk factors do they have?

– What is their pertinent clinical history?

Technical Design of the CCR

Comprehensive Security, Confidentiality, and Privacy– Support for compete dis-identification of data from patient and provider(s).

– Support for static encryption and encryption in transport (IETF/W3C Compliant).

– Support for blinded patient, provider, and data identifiers.

XML– IETF/W3C Compliant - all content tagged, all formatting supported through external .xslt(s).

– Maximized for parsing efficiency and system scalability.

– Language (tag and content) independence.

– Human readability.

– Ease of implementation.

Data Model– XML-based object-relational data model.

– De-normalized for processing (processor) efficiency.

– UML object data model representation.

Implementation Support– Designed to map seamlessly with PHR and EHR architectures.

– Support for 100% open-source implementation if desired.

– Implemented using widely supported machine-readable (XML) and display/print output (PDF/H) formats.

Clinical/Technical Goals of the CCR

• Human and machine-based decision support.

• Clinical workflow efficiency.

• Clinician-to-clinician and setting-to-setting data exchange.– Continuity of care.

– Emergency dataset.

– Referral and second opinion.

– Discharge, transfer of care, and follow-up.

– Teaching/clinical training (including ‘hand-off’ and dis-identified teaching files).

– Telemedicine.

– Tumor Board/Referral Rounds

– Public health surveillance.

– Clinical research.

– Patient safety.

– Quality of care management.

– Real-time and retrospective clinical decision support.

The CCR is designed to provide critically fast real-time access to aggregated and extracted data to bring productivity to the tasks that really affect workflow, health care quality, and cost control.

CCR

Problems 3/11/04 Myocardial Infarction – Anterior Septal 9/18/92 CVA – Right Middle Cerebral Artery Infarct

Medications Atenolol 25mg po bid (3/12/04) Last Fill 3/1/05 Coumadin 5mg qd M/W/F (3/1/05) Last Fill 3/1/05 Coumadin 7.5mg T/Th/Sat/Sun (3/1/05) Last Fill 3/1/05

Inpatient Chart

Clinic Chart

Consult Note

PHR/Patient

11/09/2005

Doe, John Quincy

Medical Record # 0005769896

Date of Birth 01/09/1965

Problems 3/11/04 Myocardial Infarction – Anterior Septal 9/18/92 CVA – Right Middle Cerebral Artery Infarct

Medications Atenolol 25mg po bid (3/12/04) Last Fill 3/1/05 Coumadin 5mg qd M/W/F (3/1/05) Last Fill 3/1/05 Coumadin 7.5mg T/Th/Sat/Sun (3/1/05) Last Fill 3/1/05

Procedures Echocardiogram (3/12/03) Normal Holter Monitor (310/03) Normal

Results CBC (3/12/03) WBC 7.4; Hct 31.6; Hgb 9.7

Inpatient Chart

Clinic Chart

Consult Note

EHR or RHIO or HIS Database

DATA DOCUMENTS

EHR RHIO HIS Lab Rx Image Claims PHR

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

BIRTH_GIVEN_NAME

BIRTH_MIDDLE_NAME

BIRTH_FAMILY_NAME

BIRTH_SUFFIX

BIRTH_TITLE

CURRENT_GIVEN_NAME

CURRENT_MIDDLE_NAME

CURRENT_FAMILY_NAME

CURRENT_SUFFIX

ID MAP

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

SOURCE

SOURCE_XML

EXTERNAL_ID

ID_TYPE

ISSUED_BY

LOCATION

DATE_ISSUED

EXPIRATION_DATE

XML_STRING

ADDRESS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

TYPE

LINE1

LINE2

CITY

COUNTY

STATE

COUNTRY

POSTAL_CODE

PRIORITY

RESULTS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PROCEDURE_TYPE

PROCEDURE

SUBSTANCE

RESULT_TYPE

TEST_VALUE

TEST_UNITS

TEST_DATE

REFERENCE

XML_STRING

PROBLEMS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PROBLEM_TYPE

PROBLEM

REFERENCE

XML_STRING

EMAIL

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

VALUE

TYPE

PRIORITY

XML_STRING

PHONE

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

VALUE

TYPE

PRIORITY

AVAILABLE

XML_STRING

SUPPORT

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

UNID_B

ROLE

RELATION

AVAILABLE

XML_STRING

INSURANCE

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

INSURANCE_TYPE

INSURER

INSURER_UNID

SUBSCRIBER_RELATION

SUBSCRIBER_UNID

EFFECTIVE_DATE

EXPIRATION_DATE

SUBCRIBER_NUMBER

PLAN_NUMBER

GROUP_NUMBER

XML_STRING

ALERTS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

ALERT_TYPE

AGENT

REACTION

REFERENCE

XML_STRING

ENCOUNTERS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

ENCOUNTER_TYPE

ENCOUNTER

PROVIDER

PROVIDER_UNID

ENCOUNTER_DATE

REFERENCE

XML_STRING

PROCEDURES

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PROCEDURE_TYPE

PROCEDURE

SUBSTANCE

ANATOMIC_LOCATION

PROCEDURE_DATE

REFERENCE

XML_STRING

MEDICATIONS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

MEDICATION_TYPE

PRODUCT_NAME

START_DATE

STOP_DATE

REFERENCE

XML_STRING

PLAN OF CARE

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PLAN_TYPE

ORDERRX_TYPE

ORDERRX

PROVIDER

PROVIDER_UNID

ORDERRX_FULFILLMENT_DATE

REFERENCE

XML_STRING

PROVIDERS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PROVIDER_TYPE

PROVIDER

PROVIDER_UNID

ROLE

RELATION

START_DATE

END_DATE

XML_STRING

ADVANCE DIRECTIVES

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

DIRECTIVE_TYPE

DIRECTIVE

PATIENT_KNOWLEDGE

REASON

EFFECTIVE_DATE

END_DATE

REFERENCE

XML_STRING

FUNCTIONAL STATUS

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

FUNCTION_TYPE

PROBLEM

REFERENCE

XML_STRING

FAMILY HISTORY

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

PROBLEM_TYPE

PROBLEM

RELATIONSHIP

RELATIONSHIP_UNID

REFERENCE

XML_STRING

SOCIAL HISTORY

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

RISK_TYPE

RISK_FACTOR

REFERENCE

XML_STRING

MEDICAL EQUIPMENT

UNID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

EQUIPMENT_TYPE

PRODUCT_NAME

DATE_TIME

REFERENCE

XML_STRING

SIGNATURES

UNID

CCR_ID

DOCUMENT_ID

OBJECT_ID

DATE_TIME

DATA_STATUS

STATUS

XML_STRING

CCR

UNID

CCR_ID

DOCUMENT_ID

DOCUMENT_TYPE

DATE_TIME

DATA_STATUS

STATUS

SOURCE

SOURCE_XML

TO

PURPOSE

SECTIONS

XML_STRING

DOCUMENT

UNID

RELATION

DATE_TIME

DATA_STATUS

STATUS

XML_STRING

About Graphics in Presentation

Generated from

NetBeans

www.netbeans.org)Open Source Java Development Environment with Enterprise Expansion Pack for XML development

Primitive Type

Complex Type

Type Name

Type Name

Cardinality

Element

Arrow means

there are child nodes

Schema Structure Info

Global Element

Components of the CCR Standard

Implementation GuideDiscusses the appropriate use of the standard and its semantics

XML Schema DefinitionDefines the formal constraints on an XML instance of the standard

Element SpreadsheetProvides guidance

and examples for each of the data elements that make up the standard

Essence of the CCR

• Think of the CCR standard as a way to collect personal summary health information from one or more sources - such as diagnoses, medications, allergies, and insurance info -organize this in a single patient-centric XML file that permits: �Expression of the information as a web page, a Microsoft Word document, or an Adobe pdf

document for viewing on a computer screen or printed out on paper

�Secure carriage and transmission of the electronic file via physical transport media, e.g. USB thumb drive, cell phone, CD ROM, or smart card

�Secure transmission of the electronic file via a network, e.g. LAN, T1 line, or the Internet

�Creation, editing, management, and reporting of the data using both proprietary electronic health records (EHRs) and (nearly) free desktop computing software, e.g. web forms, pdf forms, Firefox plug-in, and other familiar applications, as well as commercial PHRs

Body (clinical data) of the CCR

–Insurers/Payers

–Advance Directives

–Support

–Functional Status

–Problems

–Family History

–Social History

–Alerts

–Medications

–Medical Equipment

– Immunizations

–Vital Signs

–Results

–Procedures

–Encounters

–Plan of Care

–Healthcare

–Providers

Flexible Data Representation

Free Text

Structured

Text

CodedDescriptionType

Free Text & must be semantically equivalent to

code(s) used

Codified Data using a pre-coordinated controlled vocabulary

Codified Data using a post-

coordinated controlled vocabulary

List of coded

terms

“Axis” or

“Perspective”

Properties of all CCR Clinical Data

• Unique Identifier in the CCR

• List of Important Dates

• List of External Identifiers

• Source(s) of the Data

• Reference(s) to External Documents or Images

• List of Relationships to other CCR Clinical Data

(InternalCCRLink)

• Digital Signature

DateTimeType

Used for vague dates

As a , “in the s”)

String in ISO 8601 format (allows partial dates)

SourceType

References an Actor’s ActorObjectID

SignatureType

xmldsig-core:Signature

ProcedureType

PlanOfCareType

ActorType

CCR V2.0

• Activity is underway to develop the next version of the CCR standard

• Focus of the new version will be– XML structural improvements and bug fixes

– Increased clarity and capabilities related to security

– Expansion of the clinical and administrative content expressible in a CCR

– Tackle issues around controlled vocabularies and code sets

• Backwards compatibility is critically important

Implementation in the USA

• Over 100 vendors including EHR vendors, health

information exchange networks, telecommunication,

and security

• MinuteClinic creating and sharing ~ 10,000 CCR per

day

• Google Health and Microsoft HealthVault support the

CCR standard

• The CCR standard has been proven to work in the

USA and its adoption it growing quickly

Questions

Additional Resourceshttp://www.centerforhit.org/x201.xml

http://www.ccrstandard.com/

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