Healthcare organizations have been bi-directionally sharing information for several years using a variety of formats and systems. To achieve true interoperability among organizations, standards must be put into place regarding how this information is to be shared.
A key step in standardizing the information exchange process can be found in the recently proposed CMS rules released in February that build and expand on Meaningful Use Stage 2, especially concerning interoperability.
The Centers for Medicare and Medicaid (CMS) have identified Continuity of Care Documents (CCD) as the standard format to be used within these exchanges. CCDs are a part of the Clinical Document Architecture standards initiated by the healthcare IT organization HL7. According to the HL7 website, a CCD “fosters interoperability of clinical data by allowing physicians to send electronic medical information to other providers without loss of meaning and enabling improvement of patient care.”
For healthcare professionals to transmit universally understood CCDs, they must adhere to a common structure. The new rules will modify the current CCD structure, which is primarily an XML-based file with different 32 data elements as necessitated by CMS. These documents, which can be read by both people and computers, are the red blood cells coursing through the veins and arteries of a Health Information Exchange (HIE).
John Kravitz is the associate vice president of IT at Geisinger Health System, a healthcare system that includes four hospitals, several clinics, and a handful of community outreach centers in eastern and central Pennsylvania. At the recent HIMSS12 conference in Las Vegas, Kravitz was quoted as saying that sending a CCD is not exactly a “piece of cake.”
Several problems exist when using CCDs in their current state and CMS has looked to address these issues with the newly proposed rules.
One problem concerns the exchange of CCDs. Different providers use different EHR systems and getting these systems to communicate with each other is one of the major stumbling blocks for information exchange.
This issue has been addressed extensively by the Direct Project program, a year-old public-private partnership dedicated to facilitating HIEs. The project has developed a series of protocols for exchanging information over the internet using CCDs. These protocols are now being implemented in pilot programs in both Rhode Island and Minnesota. The programs began in February and will be followed by similar ones in New York, Connecticut, Tennessee, Texas, Oklahoma and California.
In addition to how the CCDs are being exchanged, the CMS rules also address some of the content of the documents themselves. Currently, the information found within a CCD can vary depending on where it was generated and for what purpose.
The new CMS rules suggest the standardization of medical terminology used in creating and maintaining a CCD. SNOMED CT, LOINC, and RxNORM are being suggested as the primary terminology in writing CCDs for health problems (SNOMED CT), lab results (LOINC), and e-prescriptions (RxNORM).
Once the proposed rules have been modified and codified into law, they will establish the rules of the road for exchanging health information.