NIST GCR 11-936

CCR Suitability Analysis

Lantana Consulting Group 
NIST GCR 11-936

CCR Suitability Analysis

Prepared for 

 National Institute of Standards and Technology

Gaithersburg Md 20899-8202

By

Lantana Consulting Group

May 2011 

U.S. Department of Commerce 

John E. Bryson, Secretary

National Institute of Standards and Technology 

Patrick D. Gallagher, Under Secretary for Standards and Technology and Director

This publication was produced as part of contract SB1341-10-SE-0881 with the National Institute of Standards and

Technology. The contents of this publication do not necessarily reflect the views or policies of the National Institute of

Standards and Technology or the US Government.
CCR Suitability Analysis

May 2011

Prepared by Lantana Consulting Group

for

National Institute of Standards and Technology

© 2011 Lantana Consulting Group

All rights reserved.
Lantana Consulting Group

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Bob Dolin, MD, FACP

President and Chief Medical Officer

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Lauren Wood, Ph.D.

Senior Project Manager

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Jingdong Li, MD

Chief Architect

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Yan Heras

Senior Medical Informaticist

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Bob Yencha

Principal Consultant

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Kate Hamilton

Senior Information Analyst

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Susan Hardy

Senior Technical Editor

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Acknowledgments

This analysis was produced and developed by Lantana Consulting Groupfor the National Institute

of Standards and Technology (NIST ), under contract number SB134110SE0881.

We appreciate the information and insights by several healthcare experts who answered our email questionnaire or took part in phone interviews. Those who participated in the Continuity of

Care Record (CCR) phone interviews were Anthony LaRocca, Sage Software; Ben Hamlin,

National Committee for Quality Assurance (NCQA); David Parker, Evolvent; George Cole,

Allscripts; Austin Kreisler, SAIC; Paul Klinker, Harris; Tone Southerland, Greenway; and Steve

Waldren, American Academy of Family Physicians (AAFP).

Any mention of commercial products or organizations in this report is for information only; it

does not imply recommendation or endorsement by Lantana or NIST.

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Table of Contents

EXECUTIVE SUMMARY................................................................................................ 6

INTRODUCTION............................................................................................................. 7

CCR Summary of Purpose.......................................................................................................... 7

CCR and Meaningful Use........................................................................................................... 8

CCR and CCD.............................................................................................................................9

STAKEHOLDER INTERVIEWS.................................................................................... 10

CCR SUITABILITY ANALYSIS.................................................................................... 12

Is the standard based on a stable, well-vetted data model?........................................................ 12

Does the standard have a clear, robust vocabulary binding syntax?..........................................13

Does the standard support the use of reusable modules, such as templates or data types?........13

Does the standard have a well-defined constraint mechanism?................................................. 13

Does the standard have a well-defined extensibility mechanism?............................................. 14

Are there unambiguous definitions of what is testable?............................................................ 14

Are there automated test tools and test suites?.......................................................................... 14

Are there reference implementations for the standard?............................................................. 14

Has the standard been implemented by a range of vendors?.....................................................15

Is there documented existence of errors, including estimates of the severity?...........................17

Is there a defined and effective process for handling errors?.....................................................17

Do industry associations endorse the standard?.........................................................................17

Is the standard used in more than one country?......................................................................... 18

Is certification available for developers and architects?............................................................ 18

CCR SUITABILITY SUMMARY .................................................................................. 19

MEANINGFUL USE ANALYSIS................................................................................... 20

Meaningful Use: Vocabulary Set............................................................................................... 20

Meaningful Use: Core Set......................................................................................................... 21

Meaningful Use: Menu Set........................................................................................................25

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CONCLUSIONS..............................................................................................................27

REFERENCES................................................................................................................ 29

ACRONYMS AND ABBREVIATIONS......................................................................... 31

List of Figures

FIGURE 1: MEANINGFUL USE AND CCR................................................................... 8

FIGURE 2: CCR XML SMOKING STATUS EXAMPLE 1............................................21

FIGURE 3: CCR XML SMOKING STATUS EXAMPLE 2............................................22

FIGURE 4: MEANINGFUL-USE COMPLIANT CCR XML SMOKING STATUS

EXAMPLE.............................................................................................................. 23

List of Tables

 TABLE 1: CCR STANDARD-SPECIFIC INTERVIEW QUESTIONS.........................10

TABLE 2: CCR CRITERIA MATRIX............................................................................. 19

TABLE 3: MEANINGFUL USE VOCABULARY SET SUPPORTED BY CCR...........20

TABLE 4: MEANINGFUL USE CORE SET SUPPORTABLE BY CCR.......................24

TABLE 5: MEANINGFUL USE MENU SET SUPPORTABLE BY CCR......................26

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Executive Summary

This document analyzes the suitability of the ASTM Continuity of Care Record (CCR)

specification to support the US Department of Health and Human Services’ (HHS) Meaningful

Use. It is part of the Healthcare Information Technology (HIT) Standards Analysis Project carried

out by Lantana Consulting Group for The National Institute of Standards and Technology (NIST).

We applied the methodology described in the “Healthcare Information Technology Standards:

General Suitability Analysis” document, also prepared for NIST. The CCR standard meets some

of the defined suitability criteria required . To meet all the criteria, a number of deficiencies

should be corrected. Chief among them are the needs for constraint and extensibility mechanisms

and for a profile of the CCR standard that meets the functionality requirements of Meaningful

Use.

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Introduction

This document analyzes how the ASTM1 Continuity of Care Record (CCR) standard supports the

US Department of Health and Human Services’ (HHS) Meaningful Use. It is part of the

Healthcare Information Technology (HIT) Standards Analysis Project carried out by Lantana

Consulting Group for the National Institute of Standards and Technology (NIST). In this project,

we assessed the suitability of four standards: CCR, Quality Reporting Data Architecture (QRDA),

Continuity of Care Document (CCD), and Health Level Seven (HL7) V2 Biosurveillance. These

findings are reported in separate documents.

CCR documents may be prepared, transmitted, and viewed in multiple ways, including email or

PDF (portable document format) files. This analysis applies only to structured electronic

documents containing Extensible Markup Language (XML) coding. With XML coding, a CCR

may be transmitted and viewed as an element in an HL7 message or a Clinical Document

Architecture (CDA) compliant document. This analysis applies to the former, the non-CDA XML

encoding.

CCR Summary of Purpose

A CCR document is an exchange object between electronic health record (EHR) systems rather

than a clinical document that should be stored. CCR communicates 

... the most relevant administrative, demographic, and clinical information facts

about a patient's healthcare, covering one or more healthcare encounters. It

provides a means for one healthcare practitioner, system, or setting to aggregate

all of the pertinent data about a patient and forward it to another practitioner,

system, or setting to support continuity of care.”

2

The CCR data set includes a summary of the patient’s health status (for example problems,

medications, allergies) and basic information about insurance, advance directives, care

documentation, and the patient’s care plan. 

CCR was not designed to be long-lived. It is a summary of relevant patient data as determined by

the physician based on the expected use of that data. As stated by Peters et al. (2005):

The ASTM CCR is not, however, a ‘clinical document’ – such as a Clinical Note,

Encounter Note, History & Physical, or Discharge Summary, each of which are

medical legal documents, generated and signed by one or more directly

responsible clinical authors. 

The best way to understand a ASTM CCR is as a collection of data from many

clinical documents—documents such as Clinic Notes, H&Ps, Discharge

Summaries, Prescriptions, Orders, Results documents, Operative Reports,

Procedure Notes, etc. The ASTM CCR is what physicians or clinical or

administrative health care providers generate either on scratch paper, in our

heads, or in another document such as an H&P or Discharge Summary when they

1

 Originally called American Society for Testing Materials

2

 ASTM Standard E2369 - 05e1. Standard Specification for Continuity of Care Record (CCR), 2005.

http://www.astm.org/Standards/E2369.htm, Section 1.1 of the Abstract.

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‘review’ the patient chart or charts. The ASTM CCR is an aggregation of all of

the pertinent data from all the documents in the chart(s) and the compilation and

parsing of that data into a uniform and easily interpreted format—the CCR. [...]

To reiterate, the ASTM CCR is not a ‘clinical document;’ the ASTM CCR is an

aggregation of clinical and administrative data from multiple documents from

multiple disparate sources.

CCR and Meaningful Use

The primary objective of Stage 1 Meaningful Use is to leverage technology to achieve significant

improvements in patient care. The Meaningful Use goals are to (1) improve quality, efficiency,

and safety and reduce health disparities; (2) engage patients and families; (3) improve care

coordination; (4) improve population and public health; and (5) ensure adequate privacy and

security protections for personal health information.3

CCR supports the Meaningful Use goals of improving quality, efficiency, safety, and coordination

and reducing health disparities (the first and third goals listed above). CCR helps transmit

automated healthcare information with minimal workflow disruption for practitioners, and allows

data to be exhanged between otherwise incompatible EHR systems, although aggregation of that

data is not feasible without using a profile.

Figure 1: Meaningful Use and CCR

3 Department of Health and Human Services. Medicare and Medicaid Programs; Electronic Health Record

Incentive Program; Final Rule – Stage One Meaningful Use Objectives 42 CFR Parts 412, 413, 422 et al.

http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf

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CCR and CCD

CCR is closely related to HL7’s Continuity of Care Document (CCD). CCD—a collaborative

effort between HL7 and ASTM4,5—is essentially a CDA implementation of the medical

information in a CCR. The major concepts within the two formats are similar and can be mapped

accurately and transformed reliably where the variability in each specification is constrained. A

general mapping is not feasible. 

4 http://www.hl7standards.com/blog/2010/03/10/ccd-and-ccr-the-discussion-continues/

5 http://projectpophealth.org/glossary.html

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Stakeholder Interviews

As described in the “Healthcare Information Technology Standards: General Suitability

Analysis”6 also prepared for NIST, we interviewed experts in HIT standards development, quality

reporting, and standards implementation to supplement our own experience and knowledge of

CCR. The table below lists the questions that guided the discussion on CCR.

We also reviewed material on the web and communicated privately with implementers, members

of the CCR design committee, and the ASTM Staff Liaison for Committee E31.

 Table 1: CCR Standard-Specific Interview Questions

Question block ID Interview Questions

[CCR] • Please briefly describe your experience with CCR to help us understand the

basis for your answers to the following questions. 

• The primary purpose of CCR is to transmit summary data. How well is CCR

meeting its primary purpose?

• Are there errors or ambiguities in CCR that mean it is harder than it should

be to implement and use? Do you have examples?

• Consider the primary purpose of CCR:

o What are some measurable criteria that should be assessed to ensure

it is meeting this purpose?

o In what ways does it not meet its purpose?

o What makes CCR testable?

• Where is “suitability” or “fitness for purpose” lacking or present in CCR?

For instance, here are some potential areas:

o Narrative interoperability or immediate, accurate rendering in a

receiving system

o Data reconciliation

o Data reuse

o Third-party aggregation of data (e.g., ability of disparate systems to

send uniform data to a central repository)

o Others?

• Please discuss the one feature about CCR that most supports the Meaningful

Use ultimate goal of achieving significant improvements in health care.

Senior developers and government-level directors who had some experience with the CCR

standard and its implementation provided insight. Most people with CCR experience also had

6

 Lantana Consulting Group. Healthcare Information Technology Standards: General Suitability Analysis,

May 2011. Related document prepared for NIST.

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experience with the CCD. Thus, many of their comments should be viewed as comparisons of the

two standards. 

CCR is generally seen to be relatively easy to understand and implement. It is defined in one

document and it was designed to meet one specific use case. It is not modular and there are no

related standards using the same model or XML conventions. 

We discussed two issues in some depth. One is that what is rendered to the clinician on screen is

completely up to the receiver of a CCR document. One interviewee thought this allows a system

to render information in a consistent format regardless of where it was sourced or what the source

clinician intended. Other interviewees were concerned that this could create incomplete and

medically dangerous documents. Some providers use free-form text while others provide

structured information. Some style sheets show all information, including what is in free-form

text, but in one case the style sheet worked only when all the structured elements were complete

—without all elements, no information was shown. 

The other issue was that although CCR recommends the use of code sets, it also allows free text.

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CCR Suitability Analysis

This section applies to CCR the suitability criteria defined in the “Healthcare Information

Technology Standards: General Suitability Analysis”. 

Is the standard based on a stable, well-vetted data model?

CCR was developed by ASTM International Technical Committee E31 on Healthcare Informatics

in Subcommittee 31.25 on Healthcare Data Management, Security, Confidentiality, and Privacy7.

ASTM is a recognized international standards developing organization (SDO) with a consensusdriven approach. Membership is open to all who can pay the membership fee. This SDO structure

typically makes it possible for any interested experts to take part in the development of a standard

to ensure it meets the needs of the community. In this case, ASTM E31 did have a large number

of healthcare experts working on the design of CCR. As of March 2011, CCR is listed as an

ACTIVE standard under the jurisdiction of E31.25 (although the latest version was published in

2005). 

CCR has a data model insofar as an XML document with a structure that conforms to a specific

schema has a data model. Using the World Wide Web Consortium Document Object Model (W3C

DOM), all information units within an XML document can be represented by data objects within

a software application. Annex A2.2 of the CCR standard refers to this:

(2) The CCR Document Object is constructed from a set of discrete XML

building blocks, which are defined as Data Objects.

(3) The Data Objects are contained within Sections, such as Medications,

Immunizations, Problems, and Procedures, in the CCR Document Object.

(4) Each discrete Medication, Immunization, Problem, Procedure represents a

discrete data object within the CCR.

The CCR XML object model could be applied to use cases within a restricted area, where such

use cases are essentially variations on a theme of CCR. Application to other, more extensive use

cases would require significant work to develop a consistent underlying conceptual model, if the

resulting standards were to be properly compatible with each other. Such a conceptual model

would also make it easier to relate the XML data model to the models required for healthcare IT

implementations. The XML schema for CCR can represent some of object relationships, but

cannot represent all of the constraints required. Other, more formal ways of describing the data

model, such as the Unified Modeling Language (UML)8 in combination with the Object

Constraint Language (OCL), can represent additional relationships and constraints. Even this

method, however, does not represent all constraints; the rest must be expressed in natural

language. 

A number of experts participated in the development of CCR and it did go through more than one

cycle of ANSI ballot, so the XML data model was well vetted, but it remains limited. It does not

7 http://www.astm.org/COMMIT/SUBCOMMIT/E3125.htm

8

 http://www.uml.org

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have an underlying conceptual model and does not cover all the necessary relationships and

constraints. 

There is currently no active development of CCR. Although the standard could therefore be

described as “stable” (or more precisely, unchanging), we believe that true stability results from

ongoing testing against the applicable use cases to ensure that a standard continues to meet those

defined needs. 

Thus we conclude that the CCR standard is not based on a stable, well-vetted data model, since

the standard is not being monitored in case it needs to be updated.

Does the standard have a clear, robust vocabulary binding syntax?

Although the CCR standard recommends the use of controlled vocabularies, it does not mandate

them. Information can be coded using SNOMED CT, ICD-9 CM, ICD-10, CPT, LOINC, and

RxNorm, or described using simple natural-language text strings. 

The standard contains the phrase “using the most recent codes at the time CCR is generated” for

many of the coding recommendations. This increases the variability among different

implementations. Even if the same coding system is used, the different implementations may

update their codes at different rates. The standard recommends that problems, procedures,

products, and agents be coded “to as granular a level as possible”, which can also create

mismatches through different interpretations of what is, or should, be possible.

In addition, the standard does not completely describe how code systems should be represented.

The definition of the XML element <CodingSystem> allows many choices in the way the content

can be encoded (e.g., "SNOMED CT", "SCT", or "SNOMEDCT" would each be a valid CCR

representation of the SNOMED CT code system). This makes it difficult to validate, compare, or

aggregate the data encoded in a CCR.

In conclusion, while CCR does offer some support for the use of vocabularies and code sets, this

support is minimal and without sufficient guidance to be maintained and relied upon.

Does the standard support the use of reusable modules, such as templates or data types?

CCR was designed to meet a single use case and does not support the concept or use of reusable

modules. The CCR standard contains XML elements that could be used as “building blocks” for

other standards, but this is not defined in the CCR standard. Many of these structures are reused

within the CCR standard itself (e.g., the Immunization section reuses structures defined in the

Medications section), but the use of these elements in any other standard would have to be

considered carefully to avoid unintended consequences. 

Thus, the CCR standard does not support the use of reusable modules. Implementers are faced

with implementing CCR as a stand-alone interchange format. 

Does the standard have a well-defined constraint mechanism?

A constraint mechanism restricts the original standard to meet specific business and content

needs, such as for specific use cases or geographic locations. 

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CCR data elements and structures are optional. It does not have a defined mechanism to constrain

optionality or create agreement on profiles between users. 

The CCR standard does not have a well-defined constraint mechanism.

Does the standard have a well-defined extensibility mechanism?

The CCR disallows end-user or vendor configurable fields and thus all customization and

variation is forbidden. This does increase interoperability (the given reason for not allowing any

customizable fields), but at the cost of excluding related use cases that were not considered when

the standard was developed, such as use in international locales. 

The CCR standard does not have a well-defined extensibility mechanism and does not provide a

method for localization.

Are there unambiguous definitions of what is testable?

The CCR defines both required and optional items, as well as many recommended items with

“either/or” optionality. As an example of the latter, the <Code> element may contain code

systems (recommended), simple text strings, or a combination of both.

The CCR states that “Adherence only to the CCR XML schema is necessary, but not sufficient to

support interoperability.” XML schema validation is a necessary baseline test but it is not a

sufficient test mechanism. XML schema can test for the correct spelling of element and attribute

names, the presence of required XML elements or attributes, and basic XML well-formedness.

XML schema testing is limited for those items that are optional or have alternatives. For example,

XML schema validators cannot test that the code system being referenced has the correct name,

or that the various values used within an element of type CodedDescriptionType are consistent. 

The CCR standard does not have unambiguous definitions of what is testable.

Are there automated test tools and test suites?

Open Health Data provides an open source ASTM CCR validation tool, available at

https://github.com/openhealthdata/CCR-Validator. It was most recently updated in February 2011

and appears to have two regular developers. It was developed to meet the NIST conformance test

procedure for electronic information.9 The tool includes validation rules for the use of CCR

within the federal regulations for Meaningful Use.

There was a web interface to this tool at http://chit.dyndns.org/ValidationService/ for testing

purposes, but when last checked in April 2011, the site was not available.

The CCR standard does have a validation tool.

Are there reference implementations for the standard?

There are currently no reference implementations of CCR EHR or personal health record (PHR)

applications created during the development of the CCR standard. 

9 http://healthcare.nist.gov/docs/170.304.f_ElectronicCopyOfHealthInformation_v1.0.pdf

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Has the standard been implemented by a range of vendors?

CCR is based on a simple XML data model, with an XML schema. Several tools are available

that will automatically take XML schemas and produce data objects for software development,

thus making the process of exporting a CCR document from an EHR or PHR relatively easy. 

According to the e-CareManagement blog10:

The ASTM CCR standard is more likely to be used in ambulatory settings:

• By organizations that have not yet adopted any standard (e.g., early stage

companies)

• To support new business models

• In disruptive applications [...]

• Where the implementers are highly sensitive to incremental costs of IT resources

and view the CCR as a “better, faster, cheaper” alternative.

The ONC Certified Health IT Product List11 includes over 250 vendors that can create and/or

display CCR documents. The commercial implementations of CCR include:

GoogleHealth supports a subset of CCR, detailed at

https://code.google.com/apis/health/ccrg_reference.html. Google has a number of partners who

integrate their solutions with Google Health listed at http://www.google.com/intl/enUS/health/about/profiles.html.

Microsoft HealthVault can transform HealthVault information items into and out of CCR

documents (http://msdn.microsoft.com/en-us/healthvault/dd797577). Microsoft Amalga is an

enterprise data aggregation system that can transfer information to a patient’s HealthVault record.

This is implemented at New York Presbyterian Hospital.

Allscripts Enterprise EHR (formerly TouchWorks EHR) exports CCR.

(http://www.allscripts.com/resources/docs/stimulusPackage/CriteriaforSelectinganEHR.pdf)

eClinicalWorks (http://www.eclinicalworks.com/products-technology.htm) is implemented at

Children’s National Medical Center of Washington D.C.

Solventus (http://www.solventus.com)

NextGen (http://www.nextgen.com/index.asp)

Allutia from Doctor–Patient Health Records (DHRPHR) (http://allutia.com/)

Chartware (http://www.chartware.com)

Good Health Network (http://www.ghnetwork.com/index.html)

Records For Living (http://www.recordsforliving.com/)

10 http://e-caremanagement.com/the-third-rail-in-hitech-implementation-please-dont-make-us-all-speaklatin/

11 http://onc-chpl.force.com/ehrcert/ehrproductcriteriasearch Click on “Inpatient Practice Type” or

“Ambulatory Practice Type”. Click on “Search by Criteria Met”. Scroll down and select “) Exchange

clinical information and patient summary record”. Click on “Search Matching Products”. Scroll down to

view results.

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Digital Clinic from Medico System Inc (http://www.medicosystem.com)

MedCommons (http://home.medcommons.net/index.html)

Clinical Portal from Lawson (http://www.lawson.com)

CareProfile from Availity (http://www.availity.com) is used by many Blue Cross and Blue Shield

providers

Google and Microsoft are household names, though not (until recently) big players in health care.

Allscripts, on the other hand, is well known in the HIT world. However, the information that one

of their products exports CCR documents came from private communication with a senior

developer; it is not listed on the Allscripts web site. This is not exceptional because HIT vendors

seldom mention the standards that are implemented in their systems or give any details on the

extent to which those standards are used. It is therefore difficult to definitively answer the

question of commercial vendor implementation.

The public domain Veterans Health Information Systems and Technology Architecture (VistA)

also supports CCR, using the tools for CCR/CCD support to communicate with other EHRs.12

There are also a number of open source implementations—many related to VistA: 

VistA-Edge Practice Management System (http://sourceforge.net/projects/vista-edgepms/)

vxVista (http://www.docstorsys.com/dss-vxOpenSource.html)

popHealth (http://projectpophealth.org/)

OpenVista (https://medsphere.org/index.jspa)

Indivo (http://indivohealth.org/)

WorldVistA (http://worldvista.org/)

PatientOS (http://www.patientos.org/)

ClearHealth (http://www.clear-health.com/)

Two viewing implementations are Android Continuity of Care Record Viewer, ACCReV, and a

free stylesheet for transforming a CCR XML document to HTML (hypertext markup language),

available at http://sourceforge.net/projects/ccr-resources/files/.

A 2008 list of implementations at

http://www.ccrstandard.com/ccrstandardimplementationsanddeployments, includes some that no

longer exist. However, the CCR standard has been implemented by a range of vendors, small and

large, open source and commercial.

12 "Opensource CCR and CCD support for VistA based systems Project Update (Powerpoint slideshow)" -

http://groups.google.com/group/ccd-ccr-project/web/CCR-CCD-Update-090219.ppt (Information from

https://secure.wikimedia.org/wikipedia/en/wiki/VistA, last accessed March 17, 2011.)

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Is there documented existence of errors, including estimates of the severity?

There are implementation-specific discussion lists for Google Health13 and open-source VistA

CCD/CCR tools14, but we were unable to find any general error or discussion lists for CCR

implementers available to the public. Email requesting a subscription to the CCR Acceleration

Group15 went unanswered for a month before being acknowledged.

We don’t know of any specific errors in the CCR standard; however we also don’t know if this is

because there are no errors, or because the implementers have not reported them, or because

reports of any errors are not made public.

Is there a defined and effective process for handling errors?

We are not members of ASTM. As non-members, we were unable to discover what formal

process exists, if any, for notifying ASTM International Technical Committee E31 of any errors

in the CCR standard. The ASTM web site gives no obvious process. Private communication

indicates that emails to ASTM are routed to technical contacts with no tracking.

The CCR standard does not have a well-described process for handling errors.

Do industry associations endorse the standard?

The description of CCR (dated 2005) lists a number of organizations as co-leaders with ASTM in

the standard’s development and adoption. They are the Massachusetts Medical Society, HIMSS,

the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics, the

American Medical Association (AMA), the Patient Safety Institute, the American Health Care

Association, the National Association for the Support of Long Term Care, the Mobile Healthcare

Alliance (MoHCA), the Medical Group Management Association (MGMA) and the American

College of Osteopathic Family Physicians (ACOFP). 

We were unable to find a current list of industry associations endorsing CCR. However, the fact

that the CCR standard is listed as a component of the Meaningful Use Final Rule is an

endorsement by the Department of Health and Human Services.

Of the industry associations that endorsed the CCR in 2005, a number of them have references to

CCR on their web sites indicating continued interest. Chief among these are the Massachusetts

Medical Society, HIMSS, the American Academy of Pediatrics, and AAFP (which hosts the

“Unofficial FAQs About the ASTM CCR Standard”16 although it appears the FAQs—frequently

asked questions—had not been updated for some time when we checked in March 2011).

Thus, the CCR standard was endorsed at its creation by industry associations, some of whom still

appear to endorse it, and has since been endorsed by a US Federal department as part of Stage 1

Meaningful Use.

13 https://groups.google.com/group/googlehealthdevelopers

14 https://groups.google.com/group/ccd-ccr-project

15 http://www.centerforhit.org/online/chit/home/project-ctr/astm/ccraccel.html

16 http://www.centerforhit.org/online/chit/home/project-ctr/astm/unofficialfaq.html

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Is the standard used in more than one country?

We found two descriptions of non-US CCR implementations. One is a press release from a

Bangkok hospital that implemented CCR to allow US patients to connect to their personal

Microsoft HealthVault accounts.17

The other is the Singapore General Hospital piloting the use of the CCR standard for continuity in

care transfers. The current status of the pilot project is unknown.18

We also found a research pilot project undertaken by the Helmholtz Institute in Bavaria,

Germany, where they are mapping the CCR to ISO EN 13606 for trial in a healthcare network. 19

There are some university courses in informatics and research institute papers that cite the CCR

as a standard to watch, but we were not able to find concrete evidence for actual implementations.

While there is some indication of implementations outside the US, it was not sufficient for us to

conclude that the CCR standard is in widespread use in more than one country or endorsed as a

local, regional, or national standard in any country outside the US.

Is certification available for developers and architects?

We have not found any professional certification programs for developers or software architects

with expertise in the CCR standard. We followed our standard research procedures, including

asking members of the ASTM E31 committee and the ASTM staff liaison for E31 if they knew of

any certification programs. 

There is a CCR workshop listed on the ASTM web site, but there are no dates listed and the

description has not been updated for some time. The workshop can only be found by searching

the web site; it is not in the current course listing.

We conclude that no professional certification program for developers or software architects is

available for the CCR standard.

17 http://7thspace.com/headlines/323806/global_leaders_team_up_to_give_portable_health_information_to

_medical_travelers.html

18 http://www.ccrstandard.com/ccrstandardimplementationsanddeployments

19 http://www.helmholtz-muenchen.de/en/bymedconnect/home/index.html

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CCR Suitability Summary 

This following matrix summarizes how the suitability criteria can be applied to the CCR standard.

Table 2: CCR Criteria Matrix

Criteria Results Notes

Is the standard based on a stable, well-vetted data model? Partial The XML schema is a simple

data model. The model is

unchanging rather than stable,

as it is not maintained.

Does the standard have a clear, robust vocabulary binding

syntax?

No

Does the standard support use of reusable modules, such as

templates or data types?

No

Does the standard have a well-defined constraint mechanism? No

Does the standard have a well-defined extensibility

mechanism?

No

Are there unambiguous definitions of what is testable? No

Are there automated test tools and test suites? Yes

Are there reference implementations for the standard? No

Has the standard been implemented by a range of vendors? Yes

Is there documented existence of errors, including estimates of

the severity?

No

Is there a defined and effective process for handling errors? No

Do industry associations endorse the standard Yes

Is the standard used in more than one country? Partial Some pilot projects have been

announced

Is certification available for developers and architects? No

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Meaningful Use Analysis

This section analyzes CCR based on the stricter requirements for Stage 1 Meaningful Use. These

criteria “establish the required capabilities and related standards and implementation

specifications that certified electronic health record (EHR) technology will need to include”

20

.

Systems must implement the specifications and functionality in a secure way to satisfy the Final

Rule for Stage 1 Meaningful Use. 

Meaningful Use: Vocabulary Set

In the CCR standard, the choice of coding system is optional. This is not the case for Meaningful

Use; the coding systems listed in the table below must be used by health plans and healthcare

clearinghouses, as well as any healthcare provider transmitting an electronic transaction21. The

CCR supports most of the Meaningful Use coding systems as well as plain text. 

In addition, the CCR standard does not completely describe how code systems should be

represented. The XML element <CodingSystem> allows many choices in the way the content can

be encoded. For example, the string “SNOMED CT” could be used, or the string “SNMD”. The

former is recommended, but not required.

Table 3: Meaningful Use Vocabulary Set Supported by CCR

Item Vocabulary Supported by CCR?

Problem List ICD9-CM, SNOMED CT Yes, with no guidance on how to represent

specific code systems

Procedures CPT-4, ICD-9-CM: Procedures, HCPCS SNOMED CT, LOINC (preferred); recent

CPT (allowed), with no guidance on how

to represent specific code systems

Labs LOINC Yes, with no guidance on how to represent

specific code systems

Medications RxNorm Yes, with no guidance on how to represent

specific code systems 

Immunizations HL7 CVX - Vaccines Administered Yes, with no guidance since you can put in

anything you want. You’re supposed to put

in the type and then the value.

RACE/Ethnicity The Office of Management and Budget

Standards for Maintaining, Collecting, and

Presenting Federal Data on Race and Ethnicity,

Statistical Policy Directive No. 15, October 30,

1997

Yes, with no guidance since you can put in

anything you want.

20 http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_ifr/1195, accessed

March 2011

21 Department of Health and Human Services, 45 CFR Parts 160 and 162, Health Insurance Reform:

Standards for Electronic Transactions

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Meaningful Use: Core Set

The Core Set of functionality is defined as that which every certified EHR system must provide

for Meaningful Use. The CCR standard does provide a way to encode much of the data to be

transmitted, though not all. It is important to remember that the scope for CCR is a transitory

document for transferring information from one system to another. Some of the Meaningful Use

criteria are outside the CCR scope.

Where our notes in the Meaningful Use Core Set table state “can be stored as free-form

information”, this means that although there is a recommended place—and perhaps a specific

XML element—for some of the Meaningful Use information within the CCR document, the

content of each of those elements is generic, not specific. The CCR specification has 17 sections

at the body level, each designed for a particular type of information. Many of those sections

contain generic elements and attributes with names such as <Text> or <Type> or

<CodedDescriptionType> that are used to encode the information. Thus the items required, in

particular for demographic information, can be represented in several ways. The standard states,

for example, that “5.1.2.7 Social History contains data defining the patient’s occupational,

personal (for example, lifestyle), social, and environmental history and health risk factors, as well

as administrative data (ADT) such as marital status, race, ethnicity, and religious affiliation”22 but

does not specify any more details on how the marital status and risk factors should be

represented.

To illustrate this, the following two figures provide alternate methods, each of which could be

used to represent a patient’s smoking status.

22 ASTM Standard E 2369 – 05 Standard Specification for Continuity of Care Record (CCR)

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Figure 2: CCR XML smoking status example 1

<SocialHistory>

 <SocialHistoryElement>

 <CCRDataObjectID>abc</CCRDataObjectID>

 <Type>

 <Text>Smoking</Text>

 <Code>

 <!-- code for Cigarette consumption (observable entity) -->

 <Value>230056004</Value>

 <CodingSystem>SNOMED CT</CodingSystem>

 </Code>

 </Type>

 <Source><Actor><ActorID>xyz</ActorID></Actor></Source>

 <Episodes>

 ...

 </Episodes>

 </SocialHistoryElement>

...

</SocialHistory>

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Figure 3: CCR XML smoking status example 2

<SocialHistory>

 <SocialHistoryElement>

 <CCRDataObjectID>abc</CCRDataObjectID>

 <Type>

 <Text>Smokes</Text>

 </Type>

 <Source><Actor><ActorID>xyz</ActorID></Actor></Source>

 <Episodes>

 ...

 </Episodes>

 </SocialHistoryElement>

...

</SocialHistory>

Since there are different ways to represent the same information, combining information from

multiple CCR documents is difficult unless the systems creating those documents all make the

same coding style choices. 

The CCR can satisfy the Stage 1 Meaningful Use requirement of using the Center for Disease

Prevention and Control (CDC) National Health Interview Survey (NHIS) codes for the smoking

status23 by making use of two features. Information can be encoded with a generic element if

there is no specific element available for it, and coding systems other than the recommended ones

can be used. The next figure shows a version of the above example that is closer to the intent of

Meaningful Use.

23 Available at http://www.cdc.gov/nchs/nhis/tobacco/tobacco_recodes.htm

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Figure 4: Meaningful-Use compliant CCR XML smoking status example

<SocialHistory>

 <SocialHistoryElement>

 <CCRDataObjectID>abc</CCRDataObjectID>

 <Type>

 <Text>Smoking Status</Text>

 <Code>

 <!-- code for Current some day smoker -->

 <Value>2</Value>

 <CodingSystem>SMKSTAT2</CodingSystem>

 </Code>

 </Type>

 <Source><Actor><ActorID>xyz</ActorID></Actor></Source>

 <Episodes>

 ...

 </Episodes>

 </SocialHistoryElement>

...

</SocialHistory>

Thus CCR’s method of encoding much of the information in a relatively free-form manner makes

it difficult to aggregate the information and lowers the interoperability between systems (the

implementers of the systems need to agree on details that aren’t specified in the standard), but

allows unforeseen use cases. 

In conclusion, the CCR supports the Meaningful Use data set, though not necessarily in a form

that makes aggregation of the data easy. In the table below we list the Core Set criteria and

whether they are supportable by the CCR. If CCR were profiled so that the many choices and

options were reduced to a set that matches the Meaningful Use requirements, it would have a

wider range of applicability.

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Table 4: Meaningful Use Core Set Supportable by CCR

Core Set Criteria Supportable by CCR?

Record patient demographics (preferred language, insurance type,

gender, race and ethnicity, date of birth, and date and cause of

death in the event of mortality.)

Except for date and cause of death, which have

specific elements, all can be stored as free-form

information within <SocialHistoryElement>

elements in the <SocialHistory> element.

Record vital signs and chart changes (height, weight and blood

pressure and calculate and display body mass index (BMI) for

ages 2 and over; plot and display growth charts for children 2–20

years, including BMI.) 

All except the growth charts can be stored as freeform information within <Results> elements in

the <VitalSigns> element. The growth charts

could be put in as images, but there is no specific

support for them.

Maintain up-to-date problem list of current and active diagnoses. 

Maintain an active medication list. 

Maintain an active medication allergy list. 

Record smoking status for patients 13 and older. 

Diagnoses: Yes, in the <Problem> element.

Medications: Yes, in the <Medications> element,

including the allergies.

Smoking status: Yes, in the <SocialHistory>

element.

Provide patients with clinical summaries for each office visit:

clinical summary is an after-visit summary that provides a patient

with relevant and actionable information and instructions

containing, but not limited to, the patient name, provider’s office

contact information, date and location of visit, an updated

medication list and summary of current medications, updated

vitals, reason(s) for visit, procedures and other instructions based

on clinical discussions that took place during the office visit, any

updates to a problem list, immunizations or medications

administered during visit, summary of topics covered/considered

during visit, time and location of next appointment/ testing if

scheduled, or a recommended appointment time if not scheduled,

list of other appointments and testing patient needs to schedule

with contact information, recommended patient decision aids,

laboratory and other diagnostic test orders, test/laboratory results

(if received before 24 hours after visit), and symptoms. 

Yes. 

Provide patients with an electronic copy of their discharge

instructions at time of discharge from the hospital, upon request.

No. “Since the CCR is a core data set of selected,

relevant information, it is not a discharge

summary”24

Provide patients with an electronic copy of their health

information (including diagnostics test results, problem list,

medication lists, medication allergies) upon request.

Yes.

Generate and transmit permissible prescriptions electronically

(does not apply to hospitals). 

Yes.

Provide Computerized Provider Order Entry for Medication

Orders. 

No.

Implement drug-drug and drug-allergy interaction checks.

Functionality must be enabled for these checks for the entire

reporting period.

No. It has the drug data, but not the decision

support.

24 ASTM Standard E 2369 – 05 Standard Specification for Continuity of Care Record (CCR), page 1

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Core Set Criteria Supportable by CCR?

Implement capability to electronically exchange key clinical

information among providers and patient-authorized entities.

Must perform at least one test of the EHR’s capacity to

electronically exchange information.

Yes.

Implement one clinical decision support rule and track

compliance with that rule. One rule must be implemented. 

No.

Protect electronic health information created or maintained by the

certified EHR technology through the implementation of

appropriate technical capabilities. Conduct or review a security

risk analysis in accordance with the requirements under 45 CFR

164.308(a)(1) and implement security updates as necessary and

correct identified security deficiencies as part of its risk

management process.

Yes, where relevant. The CCR specification

includes security and privacy considerations as

requirements, but does not discuss what would be

entailed in a security risk analysis.

Report clinical quality measures to CMS or states. 

For 2011, provide aggregate numerator and denominator through

attestation. 

For 2012, electronically submit measures.

Some25. Pophealth imports CCR documents and

then uses that data to compute the numerator and

denominator. Some quality measures require data

that isn’t in the CCR ( e.g., discharge medication).

Meaningful Use: Menu Set

The Meaningful Use Menu Set lists additional criteria for certified EHR systems. These systems

must provide a specified percentage of the functionality listed in the Menu Set (see the table

below on Mean in gful Use Menu Set Supported by CCR). The current expectation is that Stage 2

Meaningful Use will require certified systems to have all of the items in the Menu Set. 

For many of these items, the EHR system could use data encoded in the CCR as input to the

required functionality, but in many cases that use is not directly supported by the standard. The

CCR can encode information for six of the twelve Menu Set items, with some caveats. The

recording physician must be aware of the proposed use of the information to ensure that all

relevant information is included. The relevant information can be coded within a CCR document

in more than one way, so that the CCR must be profiled to support data aggregation and

secondary use.

25 For an example, see http://projectpophealth.org/faq.html - standards

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Table 5: Meaningful Use Menu Set Supportable by CCR

Menu Set Criteria Supportable by CCR?

Implement drug formulary checks. Drug formulary check

system must be implemented and access at least one internal

or external drug formulary during the reporting period.

No.

Incorporate clinical laboratory test results into EHRs as

structured data. 

Yes.

Generate lists of patients by specific conditions for use for

quality improvement, reduction of disparities, research or

outreach. 

The CCR could supply data to an EHR for this

calculation if it were appropriately profiled. 

Use EHR technology to identify patient-specific education

resources and provide those to the patient as appropriate. 

No.

Perform Medication reconciliation between care settings. Yes. The definitions used for medication

reconciliation are not precise, so the CCR can supply

data. A profiled CCR would, of course, be better.

Provide summary of care record for patients referred or

transitioned to another provider or setting. Transition of care

means the movement of a patient from one setting of care

(hospital, ambulatory primary care practice, ambulatory,

specialty care practice, long-term care, home health,

rehabilitation facility) to another.

Yes (this was the original intent for the CCR).

Submit electronic immunization data to immunization

registries or immunization information systems. 

Not applicable, since MU requires HL7 V2

messaging.

Submit electronic syndromic surveillance data to public health

agencies. 

Not applicable, since MU requires HL7 V2

messaging.

For hospitals, record advanced directives for patients 65 years

or older. 

Yes.

For hospitals, submit electronic data on reportable laboratory

results to public health agencies. 

Not applicable, since MU requires HL7 V2 messaging

For professionals, send reminders to patients (per patient

preference) for preventative and follow-up care. 

No.

For professionals, provide patients with an electronic copy of

their health information (including diagnostics test results,

problem list, medication lists, medication allergies) upon

request. 

Yes.

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Conclusions

The CCR standard is well known in HIT. It was designed to transfer of relevant records when a

patient moves from one provider to another. CCR is a relatively simple standard to understand.

The number of implementations show that it is considered suitable for HIT use. It is generally

considered sufficient for ambulatory settings26 and for giving patients access to their health

information27. 

We found, however, that the CCR standard does not satisfy many of our suitability requirements,

and some that it does satisfy come with caveats. There are indeed implementations by a range of

large and small vendors, and open-source implementations are also available. Many industry

organizations endorsed CCR in 2005 and contributed to its development, but the ASTM stopped

seeking official sponsors after the standard was published28. The validation suite, although open

source and regularly updated, appears to have only two regular contributors. We could find no

error lists or process for reporting errors available to non-members. In private communications,

E31 members said that emails to ASTM with questions are typically passed on to technical

contacts and not tracked. There is a CCR Acceleration Group29 that we subscribed to, but there

was no email traffic in two months, making it difficult to judge how active the group is. 

The CCR satisfies some of the Meaningful Use criteria, again with caveats. In many cases CCRrecommended code systems would satisfy the Stage 1 Meaningful Use criteria, but CCR also

allows plain text, which falls short of the Meaningful Use standards. In other cases, such as for

demographics, there are no dedicated elements or attributes in the CCR XML schema. Thus, there

could be confusion over how to code those items defined by Meaningful Use, leading to a

decrease in interoperability at best, and the potential of improper processing of important

information. The lack of a well-defined constraint mechanism in the CCR becomes apparent here,

since there is no defined process for creating a profile of the CCR for Meaningful Use.

CCR was designed for one purpose and is specific to that use case. It is not extensible, so cannot

easily satisfy variations of that use case or be localized where constraints or extensions are

required. As CCR is a stand-alone standard, implementers of CCR or CCR data objects cannot

apply that experience to implementing other potentially related clinical-care document formats.

The concepts within CCR are useful, however, and map to many of the Stage 1 Meaningful Use

criteria. The concepts underlying CCR (which are the same as those in CCD) are important as

illustrated by its use in PHR systems. The issues and problems documented in this analysis fall

into six categories, for which specific actions are defined in the related “CCR Action Plan”30. 

• Refine the standard to add constraint and extensibility mechanisms, develop templates,

add a vocabulary binding syntax, and define testability

• Profile the standard to define elements and vocabularies that are needed for Meaningful

Use.

26 http://www.hl7standards.com/blog/2010/03/10/ccd-and-ccr-the-discussion-continues/

27 http://jamia.bmj.com/content/18/2/118.full.html

28 Dan Smith, ASTM Staff Liaison for Committee E31, private communication

29 http://www.centerforhit.org/online/chit/home/project-ctr/astm/ccraccel.html

30 Lantana Consulting Group. CCR Action Plan, June 2011. Related document prepared for NIST.

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• Create more testing tools and a reference implementation to improve testing and

validation.

• Improve the process for error handling. 

• Create a certification program for developers and architects.

• Create additional documentation.

If these are resolved, CCR could be considered for implementation in clinical healthcare systems

to support Meaningful Use.

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References

An Analysis of the Final Standards Rule. http://geekdoctor.blogspot.com/2010/07/analysis-offinal-standards-rule.html

ASTM Standard E2369 - 05e1. Standard Specification for Continuity of Care Record (CCR).

DOI: 10.1520/E2369-05E01. 2005. http://www.astm.org/Standards/E2369.htm

Department of Health and Human Services, 45 CFR Parts 160 and 162, Health Insurance

Reform: Standards for Electronic Transactions

Department of Health and Human Services. Health Information Technology: Initial Set of

Standards, Implementation Specifications, and Certification Criteria for Electronic Health

Record Technology; Final Rule, 45 CFR Part 170. http://edocket.access.gpo.gov/2010/pdf/2010-

17210.pdf

Department of Health and Human Services. Medicare and Medicaid Programs; Electronic

Health Record Incentive Program; Final rule – Stage 1 Meaningful Use Objectives, 42 CFR Parts

412, 413, 422 et al. http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf

Department of Health and Human Services. Standards & Certification Criteria Final Rule (web

site). http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_ifr/1195

Extensible Markup Language, www.w3.org/XML.

HL7 Health Standards Blog: CCD and CCR—the Discussion Continues.

http://www.hl7standards.com/blog/2010/03/10/ccd-and-ccr-the-discussion-continues/

Kuraitis, V and Waldren, S. e-CareManagement Blog. The Third Rail in HITECH

Implementation: “Please Don’t Make Us All Speak Latin”, posted September 2009. http://ecaremanagement.com/the-third-rail-in-hitech-implementation-please-dont-make-us-all-speaklatin/

Lantana Consulting Group. Healthcare Information Technology Standards: General Suitability

Analysis, May 2011. Related document prepared for NIST.

Lantana Consulting Group. CCR Action Plan, June 2011. Related document prepared for NIST.

 LOINC® : Logical Observation Identifiers Names and Codes, Regenstrief Institute.

http://www.regenstrief.org/loinc

National Institue of Standards and Technology. Test Procedure for §170.304 (f) Electronic Copy

of Health Information. Version 1.0, August 13, 2010.

http://healthcare.nist.gov/docs/170.304.f_ElectronicCopyOfHealthInformation_v1.0.pdf

Office of the National Coordinator for Health Information Technology. Certified Health IT

Product List. http://onc-chpl.force.com/ehrcert/ehrproductcriteriasearch

Peters, RM, Jr., Kibbe, DC, Sullivan, T, Tessier, C, and Zuckerman, A. A Rebuttal to Wes Rishel’s

Gartner Report ‘Two Versions of Continuity of Care Record Offer Different Approaches to

Interoperability’ – and a Proposal for Rapid Progress on Interoperability.” April 6, 2005.

Lantana Consulting Group CCR Suitability Analysis May 2011

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http://www.centerforhit.org/online/etc/medialib/chit/documents/proj-ctr/rebuttal-wes-rishelrep.Par.0001.File.tmp/chit_CCRCDARebuttal.pdf

popHealth Glossary. http://projectpophealth.org/glossary.html

SNOMED CT®: SNOMED Clinical Terms SNOMED International Organization.

http://www.ihtsdo.org/

The Clinical Document Architecture and the Continuity of Care Record: A Critical Analysis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513652/

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Acronyms and Abbreviations

AAFP American Academy of Family Physicians

ACOFPAmerican College of Osteopathic Family Physicians

ADT administrative data

AMA American Medical Association

ARRA American Recovery and Reinvestment Act

ASTM originally called the American Society for Testing and Materials

BMI Body Mass Index

CCD Continuity of Care Document

CCR Continuity of Care Record 

CDA Clinical Document Architecture

CDC Center for Disease Prevention and Control (CDC)

CFR Code of Federal Regulations

CPT Current Procedural Terminology

DHRPHR Doctor-Patient Health Records

DOM Document Object Model

EHR Electronic Health Record

FAQs frequently asked questions

H&P History and Physical

HHS Department of Health and Human Services

HIMSS Health Information Management and Systems Society)

HIT Healthcare Information Technology 

HL7 Health Level Seven

HTML hypertext markup language

ICD International Classification of Diseases

IETF Internet Engineering Task Force

IHE Integrating the Healthcare Environment

ISO International Organization for Standardization

IT Information Technology

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LOINC Logical Observation Identifiers Names and Codes

MGMAMedical Group Management Association

MoHCA Mobile Healthcare Alliance

MU Meaningful Use

NIH National Institutes of Health

NHIS National Health Interview Survey

NIST National Institute of Standards and Technology

OCL Object Constraint Language

ONC Office of the National Coordinator

PDF portable document format)

PHR Personal Health Record

QRDA Quality Reporting Document Architecture

SDO standards developing organization

SNOMED CT Systematized Nomenclature of Medicine, Clinical Terms

UML Unified Modeling Language

VistA Veterans Health Information Systems and Technology Architecture 

W3C World Wide Web Consortium

XML Extensible Markup Language

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