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.
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.
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.
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:
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.
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:
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.
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:
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:
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:
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.