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Developing a Continuity of Care Document

Important for Transitions of Care


Developing a Continuity of Care Document

The move to EHR and ultimately the CCD is great for patients but not without its growing pains in your IT infrastructure.

Harry Briggs

The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the "meaningful use" of certified Electronic Health Record (EHR) technology to improve patient care. To receive an EHR incentive payment, providers have to show that they are "meaningfully using" their EHRs by meeting certain thresholds. The continuity of care document - CCD - -is considered an important step for the next phase of meaningful use.

Transitions of care are so important and becoming more so. Whether moving someone from hospital to assisted living, skilled nursing, even into the ambulance that transports the person to providers, it is important that each team hand off a set of information that can be used by the next provider in understanding the care plan.

Essentially, a CCD is a Health Level Seven International (HL7) XML standard that serves as a summary of core patient data. Got that? Well that is half the issue for senior living providers. The CCD is an industry-accepted standard that provides a "human-readable" and an "EHR-readable" summary of patient data that can be shared electronically. Problem is that the long-term care industry is not necessarily there yet. Nonetheless this article should at least serve as part information and part warning.

The best accountable care partners will be the ones who can communicate best with their hospital partners.

The information in the CCD includes: administrative, demographic, and basic clinical facts about a patient's health covering one or more healthcare encounters. It provides a method for one healthcare organization to aggregate all pertinent data about a patient and forward it to another practitioner, system, or setting to support continuity of care.

Experts agree that the CCD is the element that sets the stage for the next phase of meaningful use. A number of document implementation guides, including those for history and physicals, consultation and operative notes, and diagnostic imaging reports, have been developed using this framework.

The CCD provides a basis to reuse data in a way that will create efficiencies for quality, reimbursement, and data exchange with groups outside of a hospital's EHR framework. The document can also be imported into other applications for decision support.

A better resident/patient experience can result from this as caregivers and patient alike do not have to repeat information and risk it not matching the record. The foundational elements of patient encounters are already captured through templates.

The CCD should not to be confused with a full HER. A CCD works well in situations where data must be transferred to meet basic healthcare needs - exchanging information in the context of Personal Health Record (PHR), triage, administrative functions, and decision support.

A CCD could be used to provide a summary to be kept within a PHR, data that may be used for personal health advocacy and management or direct exchange of information from a nursing home into a PHR.

A CCD supplies an effective initial summary for triaging patients in a number of settings, including home health, nursing homes, acute care, and assisted living.

The CCD will be a moving target going forward and experts believe it will always be in an evolution phase.

It will be important to have a narrative of why clinicians made the decisions they did while caring for a particular patient. This capability makes it clear why certain treatment methods and strategies have been chosen for the resident/patient. That in turn helps everyone's' understanding.

Here are some templates found in a CCD to communicate patient data:

  • header
  • purpose
  • problems
  • procedures
  • family history
  • social history
  • payers
  • advance directives
  • alerts
  • medications
  • immunizations
  • medical equipment
  • vital signs
  • functional stats
  • results
  • encounters
  • plan of care

Given the range of care settings and the number of healthcare providers, it is not surprising that communication problems and other errors in treatment persist as patients move across the continuum of care. Adverse events often occur during care transitions, most often with complex, chronically ill, and vulnerable patients. Failure to communicate critical information related to a person's medical care, safety, medications, advance directives, in-home support services and social situation can result in adverse events.

Failure to identify issues such as health literacy, cultural barriers, and educational issues may also lead to higher rates of hospitalization, particularly in vulnerable populations at a time when hospital re-admissions are being penalized.

The result is not just higher costs but also unnecessary procedures and testing. And ultimately what results is a dissatisfied resident/patient/person who has to bare the brunt of a dysfunctional health care system. In other words, we all can gain when transitions of care are smooth and that can happen when a CCD is in place.

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