I am on my way back from two and a half days in Phoenix where approximately 40 SATVA (Software and Technology Vendor Association) member representatives, EMR users, and industry IT experts met to find a way for behavioral healthcare providers to exchange patient information using the electronic Continuity of Care Document (CCD). The CCD is the mechanism specified by current healthcare IT initiatives for the communication of critical patient information between providers. Ideally a care provider could rapidly get up to speed on a patient’s status by requesting and receiving a CCD from another care provider already familiar with the patient.
I first heard the term “continuity of care” in a healthcare seminar I took back in graduate school in the early ‘70s. It was an obvious, common sense concept that patients could receive better care at lower cost if providers were able to continue care already started by another provider, rather than starting over, duplicating care already rendered by the previous provider. Continuity of care requires that meaningful, usable information pass from provider to provider. Almost 30 years later, every patient in the US is familiar with the challenges of getting even simple demographic data, much less meaningful health records, transferred from one doctor to another. Well, the CCD might just be a solution to that problem.
Our meeting started with a demonstration of the creation of a CCD by the system of one SATVA member, and the display and subsequent import of that CCD by the system of another SATVA member. These are the exact capabilities that are mandated by 45 CFR, Part 170, HHS’s recently published Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (Interim Final Rule).
Required or not, systems that are actually doing CCD interchange today are few and far between. To our knowledge, there are NO behavioral health EMR systems that do. Nevertheless, the technical proof of concept was convincingly demonstrated at our meeting — a valid CCD was created, and the generic medical information contained therein was displayed and “consumed” by another system.
In many respects, the technology is the easy part. The challenge that faced our group was to define a standardized way that behavioral health providers can represent their unique domain information within the CCD to allow accurate import by a receiving system. Think, for example, of the five-axis DSM diagnosis — something that exists only in our family of behavioral/mental health specialties. Ultimately, the DSM five axis profile turned out to be the focus of our group’s efforts.
The standard CCD contains sections for identifying information (technically called the Header section), Problems, Procedures, Family History, Social History, Payers, Advance Directives, Alerts, Medications, Immunizations, Medical Equipment, Vital Signs, Results, Encounters, Functional Status, and Plan of Care. A given CCD can contain one or more of these sections, in any order. In this context, the Problems section is normally intended to contain a list of diagnoses, but it is flexible enough to include other information including findings and observations, which means that “problems” in the behavioral health sense could be included when necessary to convey significant information that diagnosis alone could not.
One of the most important aspects of the CCD and related electronic documents is that they must rigidly adhere to standardized sets of coded descriptions that are included in the specification of these documents. For example, when diagnosis codes and descriptions are included in the Problems section, they must be either ICD-9 (until supplanted by ICD-10) or, better, the more universally used SNOMED-CT. The latter includes everything in the ICD, plus a great deal more, and is preferred. Before you get too worried, all the vendors present agreed that it would not be difficult to modify our products to take the sting out of SNOMED for you. Likewise, in Medications, drugs should be listed with their RxNorm codes, and in Results, labs should include LOINC codes. The use of these specific coding systems avoids ambiguity that could potentially result in misunderstandings and serious harm to patients.
The CCD is rendered in XML, a cousin of the HTML code that sits behind the content and presentation of the typical web page. As a result, the CCD can be displayed by any modern web browser. Without getting too technical, the CCD uses a related style sheet that determines the way the CCD data is displayed on screen. As a result, any CCD that you receive can easily be formatted to display in any way you like! Let’s say that you want the Alerts section (which contains important information such as allergies, adverse drug reactions, and perhaps such information as dangerousness) displayed in a bold red font in the top right corner of the page. You can modify your organization’s CCD style sheet to make it so. Thereafter, EVERY CCD you display will have the desired information in the desired font and position. It doesn’t matter who sends it. Compare that to searching through several inches of paper records that bear no resemblance to anything you do in your own organization. See what a breakthrough this would be? Below is the very same CCD, but displayed with two different style sheets. The fancier one is courtesy of Brett Marquard of Alschuler Associates, LLC.
Returning to the meeting, after considerable discussion the group determined that we could, in fact, communicate our beloved DSM axes within the existing CCD specification, with no need for extension or new templates (another component of the document specification). This conclusion was nothing short of huge! The fact that we can get what we need without having to go hat-in-hand to the standards bodies to plead for inclusion of something new means that implementation can go forward on a much faster schedule. Our goal now is much more modest – just an Implementation Guide that describes how and where to put our unique stuff.
If you are still with me, and are curious, we determined that Axes I, II, and III diagnoses will go into Problems, along with additional specific diagnostic criteria (as findings or observations) when necessary. Axis IV will go into Social History, and Axis V will, of course, go into Functional Status.
This initial core group of stakeholders expects to add supporters over the coming months, complete a well-tuned CCD Implementation Guide for Behavioral Healthcare Providers, and put it into use in the field. In the meantime we will move forward, with the expectation of obtaining official adoption by the relevant standards bodies.