What is C-CDA?

Beth Plumptre
April 27, 2023

Health information is perhaps the most valuable resource in modern care delivery. Accurate data collection and documentation have elevated decision-making at the point of care, minimized hospitalizations, and promoted personalized treatment measures. To use patient data, technologies like EHRs are standard features across different health organizations. But, the real magic of data usage sparks when organizations can exchange, retrieve, and update information seamlessly between IT vendors.

To make this possible, organizations like The American Society for Testing and Materials International (ASTM) and Health Level 7 International (HL7) have led the push to promote interoperability between medical facilities. In 2014, a product of these efforts — the Consolidated Clinical Document Architecture (C-CDA) provided a set of rules to achieve easier data exchange between healthcare organizations.

What are the Origins of the C-CDA?

Before FHIR became the go-to standard for health data exchange, the industry went through different phases that encouraged the steady shift and adoption of electronic records across clinical workflows. These phases, developed under the Health Information Technology for Economic and Clinical Health (HITECH Act) — steered the standards for promoting the meaningful use of data to improve the quality of patient care.

The C-CDA emerged from this process, but before exploring its influence on electronic data transfer, a look into what constitutes meaningful use in healthcare IT.

Meaningful Use

EHRs are almost synonymous with patient-record keeping in healthcare — but in the early 2000s, data transfer was powered on manual paper exchange, and snail mail. To encourage the switch to electronic systems, the federal government initiated Meaningful Use (MU), a financial incentive program to push the adoption of EHRs toward patient-centered objectives. Under the American Recovery and Reinvestment Act of 2009, hospitals and physicians received $21 billion to install and use EHRs to meet specified objectives set out in different stages. Two meaningful stages later, and the C-CDA was born.

Meaningful Use Stage 1

Under this stage, eligible professionals (i.e. hospitals and physicians) had one job: demonstrating that they could share and receive electronic health information using EHRs.

This stage permitted two types of document types to carry this out:

  • Continuity of Care Record (CCR)
  • Continuity of Care Document (CCD)

Continuity of Care Record

The CCR was a game changer when a patient was transferred from one medical organization to another. Available in XML standard, this document contained the most vital information in the patient’s medical history to support care continuity. This standard was the joint effort of nine healthcare organizations, including ASTM, The Healthcare Information Management Systems Society, and the American Academy of Family Physicians, who pooled resources to encourage interoperability. Published in 2006, this standard was patronized by small to mid-tier healthcare organizations.

Clinical Document Architecture

While the nine healthcare organizations were hard at work preparing the CCR, HL7, already recognizable for developing HL7 2, was also putting together its standard for electronic record transfer — the Continuity of Care Document.

Unlike the CCR, which was restricted to summary of care records, the CDA applied to different workflows, from discharge summaries, to progress notes, diagnostic reports, and summary of care records.

The CDA adopts a common design structure of six characteristics. These documents must show:

  • Persistence:  capable of use for a long time in its original state without alteration.
  • Stewardship: meaning sustained by a healthcare organization like a clinic.
  • Verifiable: this document must be proven as authentic.
  • Context: the document must hold information on why it was created, and how it is intended to be used.
  • Wholeness: all parts, and not just certain portions of the documents should be verifiable.
  • Human readability: this document should be accessible via the internet using a standard web browser and mobile device.

Continuity of Care Document

The CCD is a compromise ASTM International and HL7 reached to push standardization across patient summary exchange. This document had the same content as the CCR, but with the flexible structure of the CDA (i.e. it is built on CDA elements and XML for easy data exchange).

Its dataset contains valuable administrative, demographic, and clinical information about a patient’s health status. The topic of discussion, the C-CDA, is a type of CCD, and falls under Meaningful Use 2, where eligible players were to demonstrate the maintenance of EHRs to improve patient care.

How is the C-CDA Used?

The C-CDA may walk and talk like a standard of exchange but is instead an implementation guide for the most common CDA documents. This framework became necessary because the CDA’s complex structure required each document type to have its implementation guide. This meant eligible professionals had to sift through a separate implementation guide to gain information from a pathology report, and another direction to access data from consultation reports, and so on.

The C-CDA stands true to its name by consolidating the most common CDA documents into one easier-to-administer implementation guide. This guide contains specifications for the following document types:

  • CCD
  • Consultation Note
  • Diagnostic Imaging Report
  • Discharge Summary
  • History & Physical
  • Operative Note
  • Procedure Note
  • Progress Note
  • Unstructured Documents like images

To comply with the requirements of Meaningful Use Stage 2, this guide was not only accessible but freely available to interested players. Like the CDA, the C-CDA is machine-readable and can be interpreted by EHR systems, HIEs, decision support tools, etc. Eligible providers using the C-CDA standards demonstrate meaningful use by exchanging documents that include information on patient demographics, laboratory tests, vital signs, care plans, medication lists, allergies, and others.

Here's an example of some C-CDA code, sans-PHI:

How did the C-CDA Improve Clinical Data Exchange?

The C-CDA was responsible for shortening the learning gap for electronic document structures. By consolidating data elements into one report, the C-CDA achieved the following benefits for patient care:

  1. This framework streamlined the transfer of care process by gathering relevant patient information into one account. Using the C-CDA, providers were brought up-to-speed on patient challenges, allergies, medications, vital signs, care plans, etc.
  2. This framework can be examined and used by humans and machines alike. EHR systems support care continuity using C-CDA when a CCD is shared, or in cases where referrals are transmitted or received. Likewise, patients benefit from the C-CDA guide when they can view, download, or transfer their patient information from a patient portal.
  3. The C-CDA is capable of supporting different vocabularies like LOINC and SNOMED with newer versions projected to adopt even wider vocabularies.
  4. This template ramped up efficiency in clinical processes by further streamlining access to standardized clinical data. Providers are supported with the right information necessary for furthering the patient care process.

Limitations of the C-CDA

The C-CDA templates may have brought healthcare closer to interoperability, but it is several paces behind modern care delivery needs. For most developers, this format is a complex maze to maneuver, with documents running into hundreds and sometimes thousands of pages. It also doesn’t help that this standard covered several clinical domains. For example, a simple query to discover a patient’s allergies could leave a provider sifting through the entire health record for information.

On the plus side, the C-CDA opened the door to newer formats like FHIR, otherwise considered the future of healthcare interoperability. This newer format simplifies requests for specific records, while maintaining a developer-friendly approach to integrations and real-time data exchange.

This modern, web-based format is on the road to phasing out C–CDA to achieve more efficient interoperability in healthcare. Learn more about FHIR here

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