CCD, CDA, C-CDA and their evolution

CCD, CDA, C-CDA and their evolution

Health Technology

Standardizing data for seamless information exchange in Healthcare

Clinicians across the country gather patient data using a wide spectrum of digital interfaces. These user interfaces are adapted to suit their local preferences for sequence and naming conventions and include fields for standard elements. As a result, the captured data from one system couldn’t be understood by other systems thus making it difficult to share with other clinicians or measure the quality of care.

The ability to create a document that embraces semantic interoperability and supports seamless information exchange is critical to overcoming this problem. Health Level Seven (HL7) and American Standards for Testing and Materials (ASTM) – international standards developing organizations developed two different frameworks (CDA and CCR) for the exchange, integration, sharing and retrieval of patient data to manage, deliver and evaluate health services.

Clinical Document Architecture (CDA) by HL7

First released by HL7 in 1999, CDA is not a document but a framework/templates that specifies the structure and semantics of “clinical documents” for the purpose of information exchange between providers. The most recent version of CDA is Release 2 while CDA Release 3 is currently under development. CDA uses a concept of incremental semantic interoperability allowing users to set their own level of compliance. A minimal CDA consists of XML-encoded metadata fields (such as provider name, document type, document identifier, and so on) and a body (commonly-used attachments such as pdf, .doc, .jpg, .mp3, and so on). Standard metadata set and display characteristics allow this document to be filed, searched, categorized and retrieved along with more richly-encoded documents.

Sample CCD File

Continuity of Care Record (CCR) by ASTM

Released in 2004, the CCR is a document created by health care practitioners based on their perceptions of the data they wish to share in a given circumstance. Clinicians were actively involved in the creation of the CCR and were integral to defining its form and content. It is patient-focused and emphasizes the data directly related to a patient’s current medical problems but is not a complete health record of a patient’s lifelong care.

Continuity of Care Document (CCD) – a harmonization of CCR and CDA

CDA is conceived and built to represent virtually any type of medical document and adds complexity to cover this generality. On the other hand, CCR is conceived and built to quickly showcase a snapshot of a patient’s case for the current time. A complete CCR “summary document” could be expressed as a CDA document template. Since the CCR has clear and immediate clinical utility and CDA provides a strong structural backbone, it naturally seemed that harmonization of these technologies is the best solution.

Standards organizations and developers realized this and came together to create Continuity of Care Document (CCD). Released in 2007 and endorsed by the Certification Commission for Health Information Technology (CCHIT) in 2008, the CCD was created through a joint collaboration between HL7 and ASTM as a way to address the divide between those who adopted HL7 CDA and those who had adopted ASTM CCR with a goal to drive the meaningful use of clinical data. CCD is built using the HL7 Clinical Document Architecture (CDA) elements and contains data that is defined by the ASTM Continuity of Care Record (CCR). It is used to share summary information about the patient within the broader context of the personal health record.

CCD sections

Consolidated Clinical Document Architecture (C-CDA) – a library of CDA templates

Released in 2011, the Consolidated CDA (C-CDA) is a master implementation guide that provides a single source to find CDA templates for twelve different document types, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP).

To conclude, CDA, CCR, CCD, C-CDA are all evolving standards developed to achieve seamless information exchange and meaningful use of healthcare data. In order to stay relevant and useful, these standards are evolving. HL7 has released Fast Healthcare Interoperability Resources (FHIR) Release 4 is a next-generation standards framework that leverages the latest web standards and applies a tight focus on implementation published in 2019 for Trial Use.

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