NIST GCR 11-937

Continuity of Care Record (CCR) Action Plan

Lantana Consulting Group 
NIST GCR 11-937

Continuity of Care Record (CCR) Action Plan

Prepared for 

 National Institute of Standards and Technology

Gaithersburg Md 20899-8202

By

Lantana Consulting Group

June 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.
Continuity of Care Record (CCR)

 Action Plan

June 2011

Prepared by Lantana Consulting Group

for

National Institute of Standards and Technology

© 2011 Lantana Consulting Group

All rights reserved.
Lantana Consulting Group

PO Box 177

East Thetford, VT 05043

www.lantanagroup.com

Liora Alschuler

Chief Executive Officer

liora.alschuler@lantanagroup.com

Bob Dolin, MD, FACP

President and Chief Medical Officer

bob.dolin@lantanagroup.com

Lauren Wood, Ph.D.

Senior Project Manager

lauren.wood@lantanagroup.com

Gaye Dolin, RN, MSN

Senior Nurse Informaticist

gaye.dolin@lantanagroup.com

Jingdong Li, MD

Chief Architect

jingdong.li@lantanagroup.com

Yan Heras

Senior Medical Informaticist

yan.heras@lantanagroup.com

Susan Hardy

Senior Technical Editor

susan.hardy@lantangroup.com

Lantana Consulting Group CCR Standard Action Plan June 2011

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Table of Contents

EXECUTIVE SUMMARY................................................................................................ 4

INTRODUCTION............................................................................................................. 5

RECOMMENDED ACTIONS.......................................................................................... 6

Refining the Standard ................................................................................................................. 6

Profiling the Standard..................................................................................................................7

Testing and Validation................................................................................................................. 7

Error Handling............................................................................................................................ 8

Certifying Developers and Architects..........................................................................................8

Creating Additional Documentation............................................................................................ 8

CONCLUSIONS............................................................................................................... 9

REFERENCES................................................................................................................ 10

ACRONYMS AND ABBREVIATIONS..........................................................................11

Lantana Consulting Group CCR Standard Action Plan June 2011

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Executive Summary

This document is the action plan to improve the suitability of ASTM Continuity of Care Record

(CCR) to support the Department of Health and Human Services’ Stage 1 Meaningful Use.

Lantana Consulting Group prepared this report for the National Institute of Standards and

Technology (NIST) to accompany the related “CCR Suitability Analysis”.

Based on our analysis, we believe that the CCR can be made suitable for Meaningful Use if these

actions are carried out. We recommend six categories of actions that correspond to the issues

identified in the Suitability Analysis.

• 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.

• 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.

Lantana Consulting Group CCR Standard Action Plan June 2011

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Introduction

This document is the action plan to improve the suitability of ASTM Continuity of Care Record

(CCR) to support the Department of Health and Human Services’ Stage 1 Meaningful Use.

Lantana Consulting Group prepared this report for the National Institute of Standards and

Technology (NIST) to accompany the related “CCR Suitability Analysis”1.

This plan recommends actions for all issues identified in the “CCR Suitability Analysis”. We also

consider the interdependence between the recommended actions. Resolution of these issues may

encourage more widespread adoption of the CCR standard. 

We do not duplicate our analysis in this document, but do refer to it wherever applicable. This

report does not discuss assignment of responsibility for management of the change process. 

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.

1

 Both CCR reports were prepared under contract SB134110SE0881.

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Recommended Actions

We recommend six categories of actions: refining the standard, profiling the standard, testing and

validation, error handling, certifying developers and architects, and creating additional

documentation.

Refining the Standard 

The CCR standard contains useful information and concepts. We believe the standard would be

more flexible and easier to implement, and could more fully support the Meaningful Use

requirements if the following modifications were made: 

• Add a constraint mechanism to meet specific use cases, such as a Meaningful Use profile

of CCR, as described in “Profiling the Standard”. A constraint mechanism restricts the

original standard to meet specific business and content needs.

• Develop templates from the data objects, fields, types, and groups that are frequently

reused. The definition of each template should include what is allowed within it, the

precise meaning of allowed sub-elements, and any constraints on its use. Developers

could use these templates to create profiles of the CCR to meet different use cases; they

could also reuse them in different document types.

• Add an extensibility mechanism to meet specific use cases. The extensibility mechanism

defines a process for adding certain elements or structures. Implementers could use an

extensibility mechanism to create a localized version of the CCR for a jurisdiction that

requires information not currently allowed by the CCR standard. 

• Define a vocabulary binding method. Vocabulary binding defines code and value sets for

specified elements within the standard. Vocabulary binding method can be used in

constraint definitions, in localization, and during validation. 

• Refine the definitions, explanations, descriptions, requirements, and restrictions in the

CCR standard to increase the testability of CCR documents. Each requirement and

restriction should be written using a consistent style, and each should be individually

testable, unless it is based on an untestable real-world condition. Improved testability

makes it easier to create test suites and testing tools. It also decreases any ambiguity in

the CCR standard, making it easier to understand and ultimately easier to implement

correctly. We discuss this further in the Testing and Validation section.

Several of these recommendations are needed for the creation of a CCR profile for Meaningful

use described in the next section. 

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Profiling the Standard

A CCR profile is required to meet the Meaningful Use requirements. Using the above

recommended refinements to the standard, this profile would do the following:

• Define the elements that are required for Meaningful Use and use the constraint

mechanism to require them in the profile. Validation and test suites will then be able to

test for the presence or absence of the required elements.

• Use the extensibility mechanism to add selected Meaningful Use items. The definition of

specific elements, such as the smoking status, makes it easier to aggregate information

from different sources.

• Use the vocabulary binding method to constrain the vocabularies for Meaningful Use.

Specified how to reference the relevant vocabularies, such as SNOMED CT, LOINC,

RxNorm, and the National Health Interview Survey (NHIS) vocabulary for smoking

status.

• Define how CCR Meaningful Use documents should be rendered (“rendering

expectations”). A clear definition of what is expected when a CCR document is rendered

ensures that information encoded by the originating clinician is shown to the reader.

Because of the large variability in systems that could use the CCR, the defined

expectations must be simple (for example “this information, if present, must be shown,

and if not present, the words ‘IS NOT DEFINED’ must be shown”).

Testing and Validation

A validator exists for the CCR standard, written as a J2EE servlet; it implements a large amount

of the functionality expected in a test suite. The following actions would provide additional

functionality:

• Add a test for rendering expectations, including any that may be part of a Meaningful Use

profile. A minimum test would be to create sample files that trigger defined expectations

and then examine the files visually to ensure all required information is rendered

appropriately.

• Provide schematron test files as well as the schema files for general automated testing.

• If a Meaningful Use profile is developed, create schematron files to test compliance with

that profile.

• Provide sample files that exercise various parts of the standard. Include samples for

Meaningful Use and “bad” sample files that trigger defined schematron warnings and

errors.

• Create a thorough, documented reference implementation. The reference implementation

can be used for to test and validate instances and to show developers how to implement

each feature. It can test profiles and constraint mechanisms where edge cases may be

important. 

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Error Handling

Any standard has errors and ambiguity. In all cases, readily available, vendor-independent

information on errata will improve applications and implementations of CCR. Currently there

does not appear to be a publicly available archive of errors apart from some vendor-specific

forums. We recommend the following actions:

• Create a vendor-independent process for handling errors that is readily available to

developers and implementers.

• Create a vendor-independent, publicly available forum or archive system for reported

errors or ambiguities. 

• Create a reference implementation to test for potential errors and to clarify the intent of

the CCR standard in cases where the standard is ambiguous (see also “Testing and

Validation”). 

Certifying Developers and Architects

We recommend the creation of a certification program for developers and architects that

motivates them to gain in-depth proficiency in the CCR standard and its implementation. 

Creating Additional Documentation

CCR documentation exists for both the standard itself and vendor-specific implementations. The

CCR standard is relatively simple for those who understand the concepts and as such does not

require much extra documentation. Our recommendations for this category overlap with

recommendations for other categories:

• Create forums where developers or implementers can discuss the standard, issues they

have with it, or potential improvements. This could be located with a forum for

discussing errors.

• Create a reference implementation. 

• If a Meaningful Use profile of the CCR is created, create documentation specific to that

profile.

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Conclusions

The CCR standard is widely implemented and is generally considered sufficient for ambulatory

settings and to give patients access to their health information. We found, however, that the CCR

standard does not satisfy many suitability requirements, including some required for Meaningful

Use. We recommend a number of actions that, if implemented, will ensure the CCR standard

meets all criteria.

Chief among these actions are refining the standard to make it both extensible and subject to

constraint to meet particular use cases. We recommend that a profile be created to meet the

Meaningful Use requirements. The standard should be refined to increase its testability, which

will also make it easier to understand and implement. Aids to testing, including schematron files

and a reference implementation, should be created to help clarify the intent of the standard. A

certification program for developers and implementers would also be advantageous. Finally, there

should be a publicly available, vendor-independent way for developers and implementers to find,

report and review known errors and ambiguities.

A CCR standard that includes the results of these action items will be more suitable for its stated

purpose as well as for Stage 1 Meaningful Use.

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References

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

Lantana Consulting Group. CCR Suitability Analysis, May 2011. Related document prepared for

NIST.

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Acronyms and Abbreviations

ASTM Originally called the American Society for Testing and Materials

CCR Continuity of Care Record 

LOINC Logical Observation Identifiers Names and Codes

NHIS National Health Interview Survey

NIST National Institute of Standards and Technology

SNOMED CT Systematized Nomenclature of Medicine, Clinical Terms

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