HL7 Standards » HL7 Blog



Items available. (2)Not so long ago, CCR and CCD were both common terms used in health IT. In fact, both CCR and CCD were compliant formats for sending patient summary data in the 2011 Edition of EHR certification. But since CCR was left out of the 2014 Edition of EHR certification as a valid way to send summary of care documents, the term has started to fade away.

As a refresher, CCR stands for Continuity of Care Record and it was an electronic document utilized for transferring patients. It started out as a paper document, and had a long history of providing appropriate clinical data so that the patient’s care could continue. CCR was an ASTM standard.

At the same time, HL7 developed their CDA standard that could apply to all types of documents utilized in a healthcare setting. To make a long story short, the content from a CCR was merged into a CDA format and the newly created document was called the Continuity of Care document, or CCD.

Even though CCD was meant to be the harmonization of CCR and CDA, CCR still stuck around for a while and was included in the original rules for Meaningful Use Stage 1. As a vendor testing for the 2011 Edition criteria related to Meaningful Use Stage 1, Corepoint Health had the choice in our test procedures to utilize a CCD or CCR to test for §170.306 (d)(1) Electronic Copy of Health Information. As an integration application, we also had OEM customers who utilized our application to test for this criteria. We would always ask, “Did you chose CCR or CCD for your testing?” Everyone would answer CCR. Why? Their response: “It’s just simpler.”

But now with Meaningful Use Stage 2 and the 2014 Edition of EHR certification there is no choice. Consolidated CDA, which includes CCD as one of its document types, is the standard of choice. To gauge the progress of using Consolidated CDA so far, JAMIA recently published a study. The study found that many EHR systems do not exchange data correctly using Consolidated CDA.

The study sampled 107 healthcare organizations using 21 EHR systems and found 615 errors and data expression variation across 11 key areas. The errors included missing data, incorrect coding terminology, and errors within the XML. The researches commented that “any expectation that Consolidate CDA documents could provide complete and consistently structured patient data is premature.”

With such apparent struggles for vendors and implementers to get the standard correct, you may be wondering, “Why did healthcare IT go the more complex route?” It was already apparent from the 2011 Edition EHR testing that vendors preferred the simplicity of CCR when given the choice. So why then does Consolidated CDA make sense for the path moving forward?

Consolidated CDA is made up of nine document types – including CCD, Discharge Summary, Diagnostic Imaging Report, Consultation Note, and others. And while the schema for CDA is much more complex that CCR, it can be applied to many more use cases. So while the bar is set high to get the summary of care document truly interoperable for Meaningful Use Stage 2, the bar should be much lower to allow for other types of Consolidated CDA documents to be added once interoperability is achieved for summary of care.

Did healthcare IT chose the wrong path by not choosing CCR? It certainly seems so at this point. But one must also step back and ask where the industry should be three to five years from now. Do we want Diagnostic Imaging Reports to be commonly exchanged as electronic documents? How about Consultation Notes?

If we are at the end of the road and in the future we only ever want to exchange documents for transition of care, then I say we definitely should have chosen CCR. It’s just easier. But if we have a longer term vision of interoperability that includes more document types than just for transition of care, then the price paid now to get Consolidated CDA working should speed up the progress of the utilization of all the document types included in the Consolidated CDA family.



As much as I dislike being a patient, I have to admit it’s a good experience for a health care professional to go through. To be on the receiving end of the healthcare system not only helps me develop compassion for patients and families, but it also gives me a clearer vision of what we’re doing right and what we need to work on when delivering care. And it’s also given me some insight into patient satisfaction vs. patient-centered care.

A month or so ago I wrote a post on patient satisfaction scores and how health care providers are focusing on improving those scores, sometimes to the dismay of clinicians. I now have the opportunity to experience the health care system as a patient and be a satisfied or a dissatisfied consumer (or somewhere in between).

Recently, I paid visit to a dietitian and diabetes nurse educator because of a diagnosis of gestational diabetes. I was told to call the hospital’s central scheduling department to make the appointments. When I did, I was given two different dates two weeks apart, the first with the diabetes educator and the second two weeks later with the dietitian. I was given a long explanation about how the hospital was under construction and the bridge to the main hospital was closed, which is why I needed to enter through the medical office building entrance. It was also advised that I come 45 minutes early.

Then over the next few days I received follow-up calls from the scheduling department regarding the two appointments. When I returned the calls, a different employee took my call and wasn’t sure what the follow-up was regarding. I had assumed it was just to verify the times two weeks apart.

When I showed up for my appointment I followed the instructions then realized I was never given a suite number for the visit. I did my best to guess which one it was, but they were all closed. Why did I need to be there 45 minutes in advance? Perhaps I needed to stop in main hospital’s registration department first, after all they did mention something about the bridge being closed. So I got in my car and drove over to registration where I sat for 15 minutes before they called me over to discover that I had been in the right spot in the first place and I should go back. As I readied to get back into my car I asked what the suite number was. The registration employee had no idea and had to call the educator’s office to find out.

Once I settled in for my appointment, the educator asked about the instructions I was given and I told her I wasn’t given a suite number and was told to come 45 minutes early. She was none too pleased to hear that. Then she informed me that my appointment with the dietitian was immediately following my appointment with her. So that’s what the scheduling department was calling about! I told her that was great but I had no idea. She also told me that the employees in central scheduling could not see the same scheduling screen as the folks in the diabetes center and often did not know that earlier appointments were available.

Was this a satisfying experience? Not really. But the clinical care from the educator and dietitian was very good. They really listened when I explained how I felt about being there (annoyed at the diagnosis) and worked to try to come up with an eating and glucose testing schedule that fit my night shift job. After seeing them I knew what to do, when to do it, and who to call if something was off. With their focus on my needs, they were providing patient-centered care.

If asked if I was satisfied with my experience how would I respond? The scheduling process could have used some work but the clinical care was quite good.

This experience got me thinking about patient satisfaction and patient-centered care and how there is a distinct difference between the two. The writers of a July 2012 JAMA article Patient Satisfaction and Patient-Centered Care Necessary but Not Equal share my opinion.

Patient-centered care, as defined by the Institute of Medicine in its 2001 report Crossing the Quality Chasm, is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,” whereas the JAMA authors explain, patient satisfaction is based on consumer marketing and measures the quality of the service against the consumer’s expectations.

As pointed out in the 2011 article The Values and Value of Patient-Centered Care in the Annals of Family Medicine, what some hospitals have been calling patient-centered care is “superficial and unconvincing.” Things like greeters and hotel-like decor “might enhance the patient’s experience, they do not necessarily achieve the goals of patient-centered care.”

When looking at my experience, the scheduling department did not meet my expectations — to give the appropriate information like suite number and arrival time. Yes, I was not satisfied with the scheduling experience but not getting the correct information did not harm me in any way. However, if the diabetes center had not taken my unique situation into account and given me a health regime that fit my night shift schedule, then my health outcomes could have been compromised. Had I gotten the correct scheduling information but not appropriate clinical care, in theory I could have been happy but not as healthy.

In an opinion piece in Circulation: Cardiovascular Quality and Outcomes, the author writes that satisfied patients can still have poor clinical results, though more research on the correlation between patient-satisfaction, patient-centered care and patient outcomes needs to be done.

I agree and would also argue that when health care providers focus on patient-centered — because patients feel heard and valued with this type of care — high satisfaction scores will follow. Plus, there will be better patient outcomes when patients are participating in their care. If you had to pick one area to focus on, patient satisfaction vs. patient-centered care, I’d focus on patient-centered care.

Two resources to help providers achieve patient-centered care are The Journal of General Internal Medicine‘s A 2020 Vision of Patient-Centered Primary Care and Plantree’s Patient-Centered Care Improvement Guide. Both help providers assess their implementation of patient-centered care and give pointers on how to improve care delivery.

Perhaps it’s because I have always worked in the clinical setting that I believe good clinical care can trump, or at least balance, parts of an experience that are less satisfying. Healthy patients equal happy patients and I feel they, like me, would be more willing to compartmentalize different aspects of the care experience. Because they are treated like individuals and listened to by their clinicians, they’ll be less likely to give an overall poor satisfaction score if something, like scheduling, goes amiss. And let’s not forget that despite how health care has changed over the years, good health outcomes are really what it is all about.



In various conversations on how to improve patient care, the importance of health literacy is often raised. Health literacy is needed as it relates to effective patient engagement and healthy habits. Information and knowledge create greater awareness of how to live healthier and interact with doctors in a more meaningful way.

Another element of health literacy needs to include health IT literacy. With about 78% of care providers now using electronic health records (EHR) and wearable technology gaining momentum, healthcare is moving into the digital age. Patients will not need go deep into the technology, but a base understanding will be required.

Although this is not a complete list, we need to begin somewhere. Highlighted below are some basic health IT elements to raise the literacy levels of patients.

Key Health Laws

Affordable Care Act: This law generates intense feelings and debate. The Medicaid.gov site defines the Affordable Care Act in this way:

“…provides Americans with better health security by putting in place comprehensive health insurance reforms that will:

Expand coverage,

Hold insurance companies accountable,

Lower health care costs,

Guarantee more choice, and

Enhance the quality of care for all Americans.”

Essentially, the Affordable Care Act expands Medicaid coverage to low-income individuals and works toward adding improvements to our healthcare system. Read more about your healthcare rights here.

HITECH / Meaningful Use: In health IT circles, most will know what Meaningful Use is and where it came from. Move outside this circle and most will just think the drive to electronic health record adoption is a part of the Affordable Care Act (Obamacare). Meaningful Use was born out of the American Recovery and Reinvestment Act of 2009 (aka Stimulus bill) in which the Health Information Technology for Economic and Clinical Health (HITECH) was buried. Meaningful Use is a part of HITECH and, together, they seek:

“…to improve American health care delivery and patient care through an unprecedented investment in health information technology. The provisions of the HITECH Act are specifically designed to work together to provide the necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.”

Simply stated, HITECH/Meaningful Use is an incentive program to move patient records from paper to an electronic format, which will then enable secure, efficient exchange of patient data, and provide patients easier access to their records.

Key Applications

EHR – Electronic Health Record: According to the HealthIT.gov website:

“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.”

An important element to an EHR is it contains all relevant patient information from different clinicians involved in a patient’s care.

PHR – Personal Health Record: According to American Health Information Management Association (AHIMA),

“The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.”

Patients own and manage their health data – you own it, you maintain it. Having the ability to electronically receive relevant data from care providers in a usable, efficient way is very helpful.

Key Privacy and Security Elements

HIPAA – Health Insurance Portability and Accountability Act: Finding a concise definition for HIPAA is challenging. On HHS.gov, the following explanation is good:

“Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.”

Even better, watch this quick video:

Your rights include saying who can see your data from clinical visits, and providers are responsible for securing your data collected during these visits.

PHI – Protected Health Information: Since protected health information was used in the HIPAA definition, we should address it. The National Institutes of Health highlights PHI as “individually identifiable health information that is transmitted or maintained in any form or medium (electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records.”

Essentially, PHI is your health data.

Key Health Actions

Quantified Self: There is much more health data available because there are more tracking devices to use. Quantified Self, or wearable tech, are interchangeable terms and what it means you are proactively tracking (quantifying) your health metrics. Watches, mobile phones, apps, and other devices make the recording of your daily health information easy.

By tracking your health status, the objective is to understand your healthy habits and their impact as well as keep chronic conditions monitored and stable.

With better and timelier data, your health patterns are recognized and can be adjusted more effectively, as needed. Think diet, exercise, blood sugar, heart rate, and much more… recorded, tracked, and shared as you define.

Interoperability: Inevitably in health IT conversations, the lack or challenge of sharing patient data between providers, applications, and devices will arise. Healthcare has many data standards (e.g., HL7, X12) and different communication protocols (e.g., TCP/IP, Direct Project, Web Services).

For data to flow, each application vendor needs to open up their application or device to send and receive data. After this, the data differences need to be understood and then mapped. Integration solutions exist to orchestrate this patient data flow, but the considerations are many: application perimeters, privacy and security requirements, data specifications, workflow necessities, and more.

Interoperability is achievable and, as a patient, requesting your data in an electronic, secure way will help facilitate this requirement.

What Does Health IT Literacy Look Like?

When health IT literacy works, it looks like a more fully engaged patient. The flow of health IT literacy may look like the illustration below. Pieces of the healthcare puzzle begin to fit together and patients have a broader perspective of how it all fits together, along with their important role within the healthy flow.

Health IT Literacy

The Flow of Health IT Literacy

Raising Health IT Literacy

Healthcare has many components and, ultimately, the most essential elements are delivering high quality care in a timely and efficient manner. In the middle of this is you – the patient. Understanding what is healthy is core to health literacy. Understanding how your data is collected, stored, used, and exchanged is central to health IT literacy. We need to raise our health standards for both healthcare and health IT literacy, and this will take a community and your active participation.

What other key elements are required to raise health IT literacy? Add your thoughts and let’s expand this list to what is important for patients to grasp and use.



I’m a big fan of the online world. I love the ease of online banking, the efficiency of Zappos shoe shopping, and the simplicity of reading The Drudge Report for all the latest news. Someday I may also be a huge enthusiast for online patient portals, but that’s not quite the case today.

During the workday I rarely think about mundane tasks such as scheduling physicals or calling the eye doctor to order new contacts. I am more likely to recall that my daughter needs a follow-up appointment with the ENT when I notice her taking off her hearing aid for the night. Or, I’ll remember it’s time for a mammogram while sharing a bottle of wine with girlfriends and someone mentions the joys of her most recent scan. That last one happens a lot, actually.

I’d like to think I am the quintessential candidate for online patient portals: busy single mom who works full-time and is tech-savvy. I have little patience for being placed on hold for 10 minutes while listening to an endlessly looping recording about the importance of my call. I’d much rather schedule a doctor’s appointment with a few clicks on my keyboard while sipping my first cup of coffee. I get annoyed when my only communication option is to wait until the office opens at 9:00 a.m., navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.

Recently I had a very positive experience using my primary care physician’s patient portal. One of my specialists requested a copy of my PCP’s referral form in order to schedule a new appointment. I accessed the PCP’s patient portal and in about two minutes found the referral and requested a copy to be forwarded to the specialist. The next day the specialist’s office called to say they had the referral in hand.

Other recent patient portal attempts have been a bit less successful. Typically if I need to schedule any type of medical appointment, I first go to the practice’s website and determine if they have an online scheduling option. That’s what I did a couple of months ago to schedule an appointment for my daughter and the whole process worked beautifully: the system asked for my preferred days and times; the next day I had an email informing me to check to practice’s portal for a message; the message informed me of the appointment time, which I then confirmed.

Unfortunately, a couple of days later my daughter reminded me of a conflict. So, back to the portal I went to send a new message requesting a reschedule. After several days I realized no one had responded to my message. I sent a second message. Again, no response. I ended up having to call the office, navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.

Another one of my physicians uses a patient portal but its functionality is limited. For example, I am able to request an appointment with preferred dates and times, but rather than having an automated response, someone calls me back to finalize the appointment time. It beats having to call the office and being placed on hold, but if I miss the call or am driving, it’s back to the old-fashioned telephone method.

I often hear providers complain about the Stage 2 Meaningful Use requirement that at least five percent of patients view or download their personal health information via an online portal. Many argue the threshold is too high because many patients lack Internet access or computer expertise, or simply prefer communicating with a live person. However, I’d contend that providers are not doing themselves any favors by implementing poorly designed portals with limited functionality. As a patient, I wonder why I should use a portal if it doesn’t eliminate having to call the practice. I worry that my messages are getting “lost” – either due to technical glitches or office workflow issues. I get frustrated with confusing navigation and functionality that can’t hold a candle to what my veterinarian offers.

In a world where we can spend 10 minutes online and pay a month’s worth of bills, buy a pair of shoes, and read the day’s headlines, why is the healthcare industry so far behind in its efforts to provide patients with a consistently efficient online experience?



Any dancer or doctor knows full well what an incredibly expressive device your body is. 300 joints! 600 muscles! Hundreds of degrees of freedom!

The next time you make breakfast, pay attention to the exquisitely intricate choreography of opening cupboards and pouring the milk — notice how your limbs move in space, how effortlessly you use your weight and balance. The only reason your mind doesn’t explode every morning from the sheer awesomeness of your balletic achievement is that everyone else in the world can do this as well.

With an entire body at your command, do you seriously think the future of interaction should be a single finger? – Bret Victor

MultiSense ICTThe Future will be Virtual, Augmented, and Wearable

The USC Institute for Creative Technologies is a pioneer in Virtual Human (VH) technology. ICT’s work with virtual humans creates digital characters that look, sound, and behave like real people.

Understanding the human face is an especially complex process. The face contains 43 muscles, and it takes five muscles to display whether we are happy, sad, afraid, angry, disgusted or surprised.  But understanding and sensing emotions in real humans is key to making virtual characters more realistic.

VH technology is currently being used to help clinicians better interact with patients.

MultiSense and SimSensei in Healthcare 2014

ICT developed MultiSense as a way to quantify facial expressions, body posture, and speech patterns. Algorithms combine this data to create a complete picture of a user’s emotional state in real time, and with a profile that recognizes changes over time. MultiSense drives SimSensei – a next generation Virtual Human platform designed to improve healthcare decision-making and delivery.

Virtual Humans USC ICT

Learn more about MultiSense and SimSensei in healthcare.

Patients More Honest with Virtual Humans

Virtual Human technology is used in role-playing and training to help clinicians improve their interactions with patients. But new research by ICT has netted some surprising results.

New research finds patients are more likely to respond honestly to personal questions when talking to a Virtual Human.

Originally, ICT began training clinicians by having them interact with a Virtual Human patient. In the new research, the tables were turned – patients interacted with Virtual Human interviewees asking questions a physician might normally ask. The process started with general getting-to-know-you types of questions gradually leading to more personal and revealing questions like, “How close are you to your family?”

“Half of the participants were told that their conversation was entirely computer-driven and not being observed. The others were informed they were being watched by a person in another room who was also manipulating the machine to ask certain questions. In all cases, video images of their faces were recorded and later analyzed to gauge their level of emotional expression.” – Tom Jacobs, “I’ll Never Admit that to My Doctor

Surprisingly, Virtual Humans were able to extract better patient data. In discussing private matters with the computer-generated entities, patients disclosed more information. Why? According to Gale Lucas, who led the study for ICT, participants did not feel like they were being observed or judged. They also reported “significantly lower fear of self-disclosure.”

You can read more about the study in the journal Computers in Human Behavior.

Virtual Humans Will Help Predict Treatment

Across the pond, researchers in England are using Virtual Physiological Humans “to engineer a simulation of the body so true to life, any data could be potentially input to create a personalized health plan, and predictions for any future patient.”

According to Marco Viceconti, Director of the Insigneo Institute at the University of Sheffield,

“If I now feed to my simulations the data related to a particular individual, that simulation will make health predictions about the status of that individual. This is not personalized medicine, this is individualized medicine, we can finally say something about you not because you are about the same age and sex and disease as another thousand people, but because you are you with your condition and your history.”

Virtual Human Insight for Wearable Technologies

In a recent opinion piece for CIO,  Brian Eastwood writes that wearable tech’s dilemma is too much data, and not enough insight. He explains that even though he runs marathons and writes about healthcare IT, he still does not have a fitness tracker.

I started thinking about how Virtual Human technology could combine with wearable devices. Although speech recognition technology is already used with Google Glass, it is not at the level of sophistication of VH. Imagine your own Virtual Human personal trainer who would have an understanding of your emotions and behaviors, and your personal weaknesses and motivators. Interacting with your VH through speech-recognition technology would minimize the need to display lots of data on a small screen. Your VH-enabled wearable device could know just the right words and cues to promote healthy behaviors, and maximize your personal wellness.

There will be no distinction, post-Singularity, between human and machine and between physical and virtual reality. – Ray Kurzweil

Additional Viewing


Blog url: 

Follow Us: