NIST GCR 11-941

Continuity of Care (CCD) Suitability Analysis

Lantana Consulting Group 
NIST GCR 11-941

Continuity of Care (CCD) Suitability Analysis

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-CN-0085 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 Document (CCD)

 Suitability Analysis

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

Rick Geimer

Chief Technology Officer

rick.geimer@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

Bob Yencha

Principal Consultant

bob.yencha@lantanagroup.com

Kate Hamilton

Senior Information Analyst

kate.hamilton@lantanagroup.com

Susan Hardy

Senior Technical Editor

susan.hardy@lantangroup.com

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Acknowledgments

This analysis was produced and developed by Lantana Consulting Group for the National

Institute of Standards and Technology (NIST) under contract number SB134110CN0085.

We appreciate the information and insights by several healthcare experts who answered our email questionnaire or took part in phone interviews. To comply with regulations, fewer than 10

private-sector experts took part in discussions about each standard, although the total number of

experts we talked to exceeded 10. They were Anthony LaRocca, Sage Software; Ben Hamlin,

National Committee for Quality Assurance (NCQA); Dave Perry, Lovelace Clinic Foundation;

David Dobbs, Science Applications International Corporation (SAIC)/Biosense; Carl Dvorak,

Epic; George Cole, Allscripts; David Kibbe, American Academy of Family Physicians (AAFP);

Austin Kreisler, SAIC; Mark Stine, Medplus; Paul Klinker, Harris; Dan Pollock, Center for

Disease Control and Prevention (CDC); Rick Moore, NCQA; Tone Southerland, Greenway; Steve

Waldren, AAFP; and Thanos Tsiolis, Epic.

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

CCD Summary of Purpose.......................................................................................................... 7

CCD and Meaningful Use........................................................................................................... 7

Additional Considerations........................................................................................................... 9

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

CCD 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?..........................................12

Does the standard support 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?............................................. 13

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

Are there automated test tools and test suites?.......................................................................... 15

Are there reference implementations?....................................................................................... 15

Is there documented existence of errors, including estimates of the severity?...........................16

Is there a defined and effective process for handling errors?.....................................................16

Do industry associations endorse the standard?.........................................................................16

Has the standard been implemented by a range of vendors?.....................................................17

Is the standard used in more than one country?......................................................................... 17

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

CCD SUITABILITY SUMMARY .................................................................................. 19

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

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

Meaningful Use: Core Set......................................................................................................... 20

Meaningful Use: Menu Set.......................................................................................................22

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CONCLUSIONS..............................................................................................................24

REFERENCES................................................................................................................ 25

ACRONYMS AND ABBREVIATIONS......................................................................... 28

List of Figures

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

List of Tables

TABLE 1: CCD-SPECIFIC INTERVIEW QUESTIONS................................................ 10

TABLE 2: SELECTION OF COUNTRIES USING CDA OR CCD ...............................17

TABLE 3: SELECTION OF COUNTRIES WITH CDA OR CCD EXPERIMENTAL

PROJECTS.............................................................................................................. 18

TABLE 4: CCD CRITERIA RESULTS MATRIX........................................................... 19

TABLE 5: MEANINGFUL USE VOCABULARY SUPPORTED BY CCD...................20

TABLE 6: MEANINGFUL USE CORE SET AND CCD SUPPORT..............................21

TABLE 7: MEANINGFUL USE MENU SET AND CCD SUPPORT.............................22

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Executive Summary

This document analyzes the suitability of the Health Level Seven (HL7) Continuity of Care

Document (CCD) 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).

Lantana Group developed a general methodology to assess the suitability of a standard and has

applied this methodology to CCD. This methodology is described in the “Healthcare Information

Technology Standards: General Suitability Analysis” document, prepared for NIST under this

contract. 

We believe that CCD addresses its intended purpose to provide a snapshot in time of a patient’s

pertinent clinical, demographic, and administrative data. We believe CCD—with its underlying,

stable HL7 Clinical Document Architecture (CDA) standard—supports the overall Meaningful

Use goal of achieving significant improvements in care. We do identify improvements in

testability and testing tools, error handling, and certification that can enhance the adoption of

CCD. In addition, improved documentation will mitigate some of the problems presented by

layered constraints, a problem that is not inherent to CCD but which has developed through the

management of the standard across diverse organizations.

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Introduction

This document presents an analysis of the suitability of the Health Level Seven (HL7) Continuity

of Care Document (CCD) specification to support US Department of Health and Human

Services’ (HHS) Meaningful Use.1 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 assessed four standards for suitability: CCD, ASTM

Continuity of Care Record (CCR), HL7 Quality Reporting Document Architecture (QRDA), and

HL7 V2 Biosurveillance. 

CCD2 is an implementation guide as defined and developed by HL7. CCD uses the CCR

standardized data set3 to constrain the HL7 Clinical Document Architecture Release 2 (CDA R2)

standard for a patient summary document.

CDA and the data element modeling within CCD are based on the HL7 Reference Information

Model (RIM) within the constraints of the CDA Refined Message Information Model (RMIM).

CCD data elements reuse previously developed domain models and clinical statements also based

on the RIM; many of these data elements and clinical statement models are now defined as

reusable templates.

CCD Summary of Purpose

CCD provides a summary or snapshot of the status of a patient’s health and healthcare in HL7

CDA format. The CCD implementation guide states that CCD inherits the goal of CCR, which is:

...to communicate the most relevant administrative, demographic, and clinical

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. The primary use case for the

CCD is to provide a patient summary containing the pertinent clinical,

demographic, and administrative data for a specific patient. 

Based on this goal, the HHS Office of the National Coordinator (ONC) cites CCD as a means to

achieve Meaningful Use.

CCD and Meaningful Use

1 http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2 (accessed March 2011)

2 HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), April 01, 2007 §; 1.1.

Scope

3 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)

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

improvements in patient care. 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.4 The Meaningful Use and CCD diagram

illustrates the relationship of CCD’s goals with those of Stage 1 Meaningful Use.

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

and reducing health disparities (the first and third goals listed above) through exchange of

reusable standardized templates for clinical, demographic, and administrative data. With

standardized representation of these data elements, the receiving system can understand them

without prior negotiation. Custom interfaces are not required and care providers have instant

access to patient information from disparate systems. With instant access to pertinent patient data,

providers can improve care quality and safety for everyone as well as equality in care for lowincome patients who have no single source of medical care.5

CDA supports adequate privacy and security indirectly. It has a confidentialityCode

element that can be leveraged by a properly designed and implemented privacy and security

system.

Figure 1: Meaningful Use and CCD 

4

 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

5Schwartz and Artiga. Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adult.

http://www.kff.org/uninsured/upload/7651.pdf

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Additional Considerations

We considered three external initiatives related to the CCD during analysis:

1. Healthcare Information Technology Standards Panel HITSP/C32 Summary

Documents Using HL7 Continuity of Care Document (CCD) Component (July 2009).

6

The selection of CCD for exchanging clinical summaries in Meaningful Use is bound by

the constraints and guidance in HITSP’s C32 specification. C32 does not alter the

fundamental function of CCD; it adds US-specific constraints to the exchange of

summary documents. In other words, C32 constrains CCD just as CCD constrains CDA.

C32 also requires many of the IHE constraints described below.

2. Integrating the Healthcare Environment (IHE). The IHE Patient Care Committee

(PCC) developed the PCC Technical Framework7, and created three integration profiles8.

One of these profiles—the Medical Summary Document—identifies the functional

components of a distributed healthcare environment and defines a coordinated set of

transactions for the exchange of CCD/CDA. It is an implementation framework for CCD

and not a standard, but it does constrain CCD. As noted above, C32 requires compliance

with many of the Medical Summary Document constraints.

3. The CDA Consolidation Project. This joint HL7/IHE/Health Story9 project was

launched in December 2010 with support from the ONC as a Standards and

Interoperability Framework Initiative10. It is a US-realm reconciliation of differences

across several CDA-based implementation guides and profiles—including CCD—

developed by HL7, IHE, and the Health Story Project. It will enhance CCD’s suitability

by harmonizing templates, removing discrepancies, and developing simpler, easier-to-use

documentation. The result will improve semantic interoperability in healthcare data

exchanges.

6 http://www.hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=e1b99525-a1a5-48f6-a958-4b2fc6d7a5c7

7

 IHE Technical Framework: http://www.ihe.net/Technical_Framework/index.cfm#pcc

8

IHE Patient Care Coordination (PCC) Technical Framework Volume 2 Revision 6.0, August 2010.

http://www.ihe.net/Technical_Framework/upload/IHE_PCC_TF_Rev6-0_Vol_2_2010-08-30.pdf

9 http://healthstory.com/

10 The S&I Framework Initiative: CDA Consolidation Project.

http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

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Stakeholder Interviews

The “Healthcare Information Technology Standards: General Suitability Analysis”11 describes the

interviews we held with experts in HIT standards development, quality reporting, and standards

implementation to evaluate the maturity, robustness, and suitability of CCD. 

We asked the following questions specific to CCD during these stakeholder interviews.

Table 1: CCD-Specific Interview Questions

Question block ID Interview Questions

CCD • Please briefly describe your experience with CCD to help us understand the

basis for your answers to the following questions. 

• The primary purpose of CCD is to transmit summary data; how well is CCD

meeting its primary purpose?

• Are there errors or ambiguities in CCD that mean it’s harder than it should

be to implement and use? Do you have examples?

• Consider the primary purpose of CCD:

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 CCD testable? 

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

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 for disparate systems to

send uniform data to a central repository)

o Others?

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

Use ultimate goal of achieving significant improvements in health care.

The interviews included senior developers experienced with the CCD standard and its

implementation. They provided excellent insights into CCD and its use in a range of clinical data

exchanges. 

Although we were asking about CCD, the HITSP/C32 specification is foremost in the minds of

stakeholders because Meaningful Use mandates its use. Many interviewees mentioned the

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

May 2011. Related document prepared for NIST.

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difficulty of dealing with the constraints layered upon CCD through HITSP/C32 and IHE PCC.

This layering of constraints is not inherent to CCD itself, but it is confusing and a barrier to

adoption of the full C32 specification for Meaningful Use. At the same time, interviewees

appreciated the specificity provided by C32 for the US realm. 

Another general theme was the appreciation of CCD as part of a “family” of clinical document

standards that are derived from a common set of concepts and reusable templates. Once

implementers learn CDA, they know how to implement the related standards with only

incremental effort. This reliance on a foundational architecture is a major “win” within the

implementation community.

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CCD Suitability Analysis

This section applies the questions defined in the “Healthcare Information Technology Standards:

General Suitability Analysis” to CCD.

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

The CCD is an implementation of CDA R2, an American National Standards Institute (ANSI)

approved standard since May 2005. CDA R2 has been widely implemented internationally, and

HITSP selected it as a foundational standard. There are numerous HL7 implementation guides

and IHE profiles that define the use of CDA in healthcare exchange scenarios.

Following HL7 practice, the CCD is defined in an implementation guide that declares constraints

on the CDA base standard for summary reports. Like all CDA documents, CCD documents

derive their machine processable meaning from the HL7 Reference Information Model (RIM) and

use the HL7 Version 3 Data Types. The RIM was developed in a collaborative process engaging a

broad range of experts, both clinical and technical within HL7. The RIM is a robust,

implementable standard (as demonstrated by the many implementation guides and profiles), and

it is applicable to a large number of clinical data exchange use cases within the healthcare

domain. The RIM has demonstrated stability over other models by virtue of its longevity

(approximately 15 years) and ongoing maintenance and evolution.12 The RIM and HL7 Version 3

foundation components, such as data types and vocabulary, are documented in a clear and

understandable way that passes muster with the group of experts that reviewed it. 

Given the global adoption by vendors and healthcare providers of both the RIM and CDA, we

conclude that the CCD is based on a stable, well-vetted data model. 

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

Vocabulary binding is essential to a standard's success. The correct interpretation of an exchanged

message relies upon correct message syntax and correct data semantics. While syntactic

correctness is defined by the standard format, semantics are defined by vocabulary binding. Clear,

robust vocabulary binding defines unambiguous links between a data field and medical

vocabulary systems. A data field can be valued only with one specific code or one selected from a

“value set” of codes in the specified vocabulary system.

CCD has a clear, robust vocabulary binding syntax as it uses HL7 vocabulary binding syntax and

the HL7 RIM. The HL7 RIM is more expressive than other current and emerging models with

respect to semantics and vocabulary critical to healthcare interoperability. The vocabulary binding

syntax defined by the HL7 Vocabulary Work Group has been extensively reviewed and improved

through numerous rounds of balloting, and is in wide use in the HL7 RIM and CDA

implementations throughout the world, including CCD. 

12 CBIIT SAIF Implementation Guide, March 30, 2011.

https://wiki.nci.nih.gov/display/SAIF/CBIIT+SAIF+Implementation+Guide

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

The CCD implementation guide was the prototype implementation of a concept called Templated

CDA. This concept defines sets of uniquely identified conformance statements that can apply to a

document, a section, or a clinical statement. Section and clinical statement templates by their

nature are reusable; multiple documents can reuse section templates and multiple sections can

reuse clinical statement templates. Once someone can understand and support a given template,

they can understand and process that template no matter where they encounter it. 

As vendors of electronic health records (EHR) become familiar with structured documents and

the CCD as part of the ONC certification process, they can reuse CDA and CCD templates for

rapid implementation of solutions to exchange clinical information with consistent representation.

Does the standard have a well-defined constraint mechanism?

The HL7 V3 standard has a well-defined constraint mechanism to be applied to the RIM, data

types, and vocabulary supported by CDA, and thus by the CCD. This constraint mechanism

provides the International Committee a clear set of rules for producing local variants on the HL7

V3 standard. This meets realm-specific localization requirements but preserves the global

applicability of the V3 standard.13

The CCD is a US realm implementation guide based on the CDA R2 base standard and was

developed following the HL7 V3 standard constraint mechanism. CCD meets the needs of patient

summary documents requirements in the US while allowing for localization and preserving the

global applicability of the V3 standard.

Does the standard have a well-defined extensibility mechanism?

The CCD is derived from the base CDA R2 standard, which has a well-defined extensibility

mechanism. As clearly stated in the CDA standard, it is permissible to use namespace extensions

to include additional XML elements and attributes that are not included in the CDA schema.

These extensions cannot change the meaning of any of the standardized data elements, and

document recipients must be able to render the CDA document faithfully while ignoring

extensions.14

For vocabulary binding to a domain, the HL7 V3 standard allows an extensibility qualifier to be

associated with the coded entry. The extensibility qualifier has two possible values: CNE (coded

no extensions), and CWE (coded with extensions). The CWE extensibility qualifier expands the

code set to meet local implementation needs: when a coded attribute is sent in a message, local

concepts or free text may be sent in place of a standard code if the desired concept is not

represented in the standard vocabulary domain. 

An additional extensibility feature of the CDA standard is the inclusion of generic classes such as

act and participant. The act class can be used if no more specific class is available for the use

case. “Teach cast care” is an example. While “teach cast care” is defined in some code systems

13 HL7 International Localization Report. http://www.docstoc.com/docs/57624000/HL7-V3-Localization

14 CDA Normative Web Edition. § 1.4 CDA Extensibility.

http://www.hl7.org/documentcenter/private/standards/cda/r2/cda_r2_normativewebedition.zip

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as a procedure, it does not fit the HL7 definition of procedure: “an Act whose immediate and

primary outcome (post-condition) is the alteration of the physical condition of the subject”;15 nor

is teaching an observation. The act class can represent this in CDA such that is semantically

interpretable across systems. The generic participant can represent any participants not explicitly

mentioned by other classes that were involved with the patient or the situation being documented.

For example, there is no “Next of Kin” participant, but the generic participant can use standard

modeling and codes to represent detailed information about such a participant.

These namespace extensions, code extensibility qualifiers, and generic classes provide much

flexibility in the standard until the use case is brought to the HL7 and incorporated into a future

release if appropriate. These well-documented extensibility mechanisms support unanticipated

use cases as well as local exchange requirements. 

Are there unambiguous definitions of what is testable?

The methods for declaring conformance to the CCD and the obligations of the instance creator

and receiver are stated within the CCD implementation guide16 and the base CDA R2

specification. The implementation guide explains the use of conformance statements. 

Conformance statements are constructed from common language statements and keywords

adopted across the HL7 community to ensure semantic interoperability across standards and wire

formats. These statements provide detailed guidance for the coding and information content of a

given template.

The CCD was one of the earliest guides (2007) to use these techniques; it is in the midst of a

revision to harmonize the format and intent of the conformance statements. Some of the current

statements are not enforceable by a machine-based validation approach; they require a juried

review or are more appropriately included as guidance. The ONC’s Standards and Interoperability

(S&I) CDA Consolidation project17 will further clarify and document those conformance

statements that are fully machine testable; those that require human intervention; and those that

cannot be evaluated by a machine-driven process. The project will provide the desired crisp

definitions (with examples) for each of these categories.

The “CCD Coverage Report”18, also prepared by Lantana for NIST, analyzes the CCD

specification from the perspective of validation, looking at the limits of automated testing and

assessing various approaches to it. The conclusions and recommendations in that report provide

valuable information to develop strategies that will improve testability of CCD and other CDA

standards.

15 HL7 V3 RIM Definitions http://www.hl7.org/v3ballot/html/welcome/environment/index.html Normative

Vocabulary for the RIM, actClass, Procedure (PROC). Note: Access Requires download of the V3 Ballot

16 HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), §1.4 Asserting

Conformance to this Guide

17 http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

18 Lantana Consulting Group. CCD Coverage Report, May 2011. Related document prepared for NIST. 

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Are there automated test tools and test suites?

CCD is supported by a number of testing venues (Certification Commission for Health

Information Technology [CCHIT]19, Project Laika20, Lantana Consulting Group21, NIST22) that

provide a range of interfaces for developers to validate CCD and other CDA document instances.

These venues offer both interactive web pages for manual submission of an instance and web

services interfaces for programmatic access.

The most common means to date for the automated testing of CCD instances is through the use of

the International Organization for Standardization (ISO) Schematron. This method was first used

for CDA instances in an application developed in 2006 by Alschuler Associates, LLC (now

Lantana Consulting Group) in response to a request from the Electronic Health Record Vendors

Association (EHRVA, now the EHRA). 

NIST has further refined and expanded this schematron approach to support implementation

testing in support of HITSP’s selection of CDA and CDA-based implementation guides. Today,

the NIST validation suite is the “gold standard” used by the implementation community, despite

the lack of a governance process to vet all rules and resulting validation tests for completeness

and accuracy. This “not for production use” is clearly identified on the NIST and other

organizations’ web pages. 

There is no detailed peer review of the Schematron statements used to enforce the concepts of a

conformance statement. Detailed peer review of Schematron statements would improve accuracy

of these valuable tools.

Additionally, the CDA Consolidation project has an ancillary goal of creating a new, modeldriven approach to testing. While this technique holds promise, it has yet to be proven and widely

implemented. See the “CCD Coverage Report” for a full review of CCD test options.23

Are there reference implementations?

To date, reference implementations have not been developed concurrently with the development

of CDA based standards. Pilots may be planned and identified when the scope of the standard is

defined and approved; however, they may be in proprietary systems and thus are not publicly

available. There is currently no publicly available reference implementation of a CDA/CCD in an

EHR. 

We believe, however, that the existing proprietary implementations coupled with the current

industry demonstration projects and certification processes serve as hardy evidence of

implementations of CCD that could be used as reference for implementers should they become

accessible.

19 Certification Commission for Health Information Technology: http://www.cchit.org/

20 Project Laika: http://laika.sourceforge.net/

21 Lantana Consulting Group Validator: https://www.lantanagroup.com/validator/

22 National Institute for Standards and Technology Validator: http://xreg2.nist.gov/cdavalidation/validation.html

23 Lantana Consulting Group. CCD Coverage Report, May 2011. Related document prepared for NIST.

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

HL7 has a well-defined error reporting process. The organizations that contributed to C32 host

different processes. 

HITSP Public Comment tracking system captures issues related to all HITSP artifacts. It reports

issues that relate to the C32 and CCD as well as other CDA-based profiles selected by HITSP

(QRDA, etc.). 

The HL7 Structured Documents Working Group has maintenance responsibility for the CCD

implementation guide and maintains a publicly accessible CCD errata wiki24.

Both HL7 and IHE host mailing lists where suspected errors and proposed solutions can be

discussed.

IHE captures Change Proposals for IHE specifications that are evaluated by their technical

communities.

Errors on the lists mentioned above that cannot be resolved are recorded either on the HL7 wiki

or in the IHE change control process. 

Is there a defined and effective process for handling errors?

The CDA Consolidation project is addressing many of the issues recorded through forums

described in the previous section, focusing first on those items that will affect the support of

Meaningful Use.

The HL7 processes deal with CCD and CDA and are well-defined. C32 and ONC resolution

processes have not yet been fully defined. The multi-organization CDA Consolidation project

may set a precedent for cross-organization collaboration in development of a formal process for

error handling and maintenance, however, this is yet to be confirmed.

Do industry associations endorse the standard?

The CDA and CCD have been endorsed and adopted by many industry associations. The

following are a selection of organizations known to endorse and/or implement CDA:

ONC HHS via the Meaningful Use Final Rule

EHRA

Health Story Project

HITSP

24 HL7 Wiki CCD Errata page. http://wiki.hl7.org/index.php?title=CCD_Errata

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Has the standard been implemented by a range of vendors?

As demonstrated at the HIMSS Interoperability Showcase over the past five years, all major

vendors have implemented the CDA and CCD standards. Many medium and small vendors are

now implementing CDA and CCD to prepare for Meaningful Use certification. The ONCcertified Health IT Product List site provides a list of vendors that can create and/or display

CCDs25.

Is the standard used in more than one country?

CCD was developed to meet the needs of the US realm, but CCD or its base standard CDA has

also been cited as the basis for the exchange of clinical data in a number of countries. The next

two tables list some of the countries with existing or experimental CDA or CCD projects. A

Google map, “Where in the World is CDA and XDS”26, shows some of the CDA implementations

around the world.

Table 2: Selection of Countries Using CDA or CCD 

Country Organization or Product

Germany SCIPHOX

Finland Aluetietojärjestelmä

Greece HYGEIAnet/WebOnColl

Japan MERIT-9 (MML)

Canada e-MS

France Dossier Médical Personnel

Italy TeleMed Escape

Argentina Hosp. Italiano de Buenos Aires

England National Program for HIT

Turkey Ministry of Health - Saglik-Net network

25 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.

26 http://www.google.com/maps/ms?

ie=UTF8&oe=UTF8&source=embed&msa=0&msid=110535847732151766411.00047b0b46314e91435c9

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Table 3: Selection of Countries with CDA or CCD Experimental Projects

Country Organization or Product

Korea Kyungpook National University

Israel IBM Haifa Research Lab

New Zealand GP2GP Patient Records Transfer

Australia The Royal Marsden NHS

Wales Wales' National Architecture Design Board

Switzerland IHE Suisse' initiative

Is certification available for developers and architects?

While not focused narrowly on the CCD itself, HL7 offers certification in CDA through a testing

process. The certification makes no distinction among different roles within an implementing

organization.

HL7 provides training for CDA at its worldwide working group meetings and educational

summits; these are primarily one-to-two day lecture-based classes aimed at a high level

understanding of CDA.

The CDA Academy27 offers hands-on, weeklong training in the US.

27

 http://www.cdaacademy.com

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CCD Suitability Summary 

The following matrix summarizes the results of applying suitability criteria to the CCD standard.

All findings were positive with caveats in testability, test tools, C32 error handling, and

certification.

Table 4: CCD Criteria Results Matrix

Criteria Results Notes

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

model?

Yes

Does the standard have a clear, robust vocabulary

binding syntax?

Yes

Does the standard support reusable modules, such

as templates or data types?

Yes

Does the standard have a well-defined constraint

mechanism?

Yes

Does the standard have a well-defined

extensibility mechanism?

Yes

Are there unambiguous definitions of what is

testable?

Yes Improvement is needed in the creation of testable

conformance statements. Current projects are

working to further clarify and document what is

fully machine testable.

Are there automated test tools and test suites? Yes Schematron rules underlying these test tools need

public vetting for accuracy.

Are there reference implementations? No Existing implementations coupled with the

current industry demonstration projects and

certification processes could serve as references

for CCD implementers

Is there documented existence of errors, including

estimates of the severity?

Yes

Is there a defined and effective process for

handling errors?

Yes HL7 has a well-defined process. The errorhandling process for C32 was defined by HITSP

but has not been maintained by the current ONC.

Do industry assosciations endorse the standard? Yes

Has the standard been implemented by a range of

vendors?

Yes

Is the standard used in more than one country? Yes

Is certification available for developers and

architects?

Partial There is certification for CDA, but not for CCD

specifically. Training should be available at

multiple levels. There should be distinct

certification for developers vs. architects.

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Meaningful Use Analysis

Here we evaluate CCD based on specific Stage 1 Meaningful Use criteria. 

Meaningful Use: Vocabulary Set

CCD specifies coding systems in some instances and recommends optional coding systems in

others. Users can also use plain text. Meaningful Use requires use of the coding systems listed in

the table below28. The table compares vocabulary requirements for CCD and Meaningful Use.

Table 5: Meaningful Use Vocabulary Supported by CCD

Item Vocabulary Supported by CCD?

Problem List ICD9-CM, SNOMED CT Yes

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

(allowed)

Labs LOINC Yes

Medications RxNorm Yes 

Immunizations HL7 CVX - Vaccines Administered Yes

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

Meaningful Use: Core Set

Every certified EHR system must provide a Core Set of functionality. Stage 1 Meaningful Use

provides no guidance as to how the Core Set criteria are to be supported, so flexibility is allowed

in Stage 1. The table below shows the Core Set criteria and whether CCD can meet the criteria or

provide or receive information in support of the EHR function

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

Standards for Electronic Transactions. http://edocket.access.gpo.gov/2010/pdf/2010-17210.pdf

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Table 6: Meaningful Use Core Set and CCD Support

Core Set Criteria Supported by CCD?

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.)

Yes, supported per C32 guidance

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.) 

Yes, supported per C32 guidance

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. 

Yes, supported per C32 guidance

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, supported per C32 guidance 

Hospitals must provide patients with an electronic copy of their

discharge instructions at time of discharge, upon request.

Not applicable. A CCD is not a discharge

summary, but applicable CCD entry templates

could be used with a discharge summary.

Provide patients with an electronic copy of their health

information (including diagnostics test results, problem list,

medication lists, medication allergies) upon request.

Yes, supported per C32 guidance

Generate and transmit permissible prescriptions electronically

(does not apply to hospitals). 

Yes, supported per C32 guidance

Computerized Provider Order Entry for Medication Orders. Not applicable

Implement drug-drug and drug-allergy interaction checks.

Functionality must be enabled for these checks for the entire

reporting period.

This functionality is supported by CCD when

Level 3 coding is available

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. 

Yes, supported by CCD when Level 3 coding is

available

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Core Set Criteria Supported by CCD?

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.

Not applicable

Report clinical quality measures to Centers for Medicare and

Medicaid Services (CMS) or states. 

For 2011, provide aggregate numerator and denominator through

attestation. 

For 2012, electronically submit measures.

Yes, supported by CCD when Level 3 coding is

available

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). The current expectation is that Stage 2 Meaningful Use will require certified systems to

have all of the items in the Menu Set.

The table below shows whether CCD could meet the Menu Set criteria or provide or receive

information in support of the EHR function.

Table 7: Meaningful Use Menu Set and CCD Support

Menu Set Criteria Supported by CCD?

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.

Yes, supported by CCD when Level 3 coding is

available

Incorporate clinical laboratory test results into EHRs as

structured data. 

Yes, supported by CCD when Level 3 coding is

available

Generate lists of patients by specific conditions for use for

quality improvement, reduction of disparities, research or

outreach. 

Yes, supported by CCD when Level 3 coding is

available

Use EHR technology to identify patient-specific education

resources and provide those to the patient as appropriate. 

Not applicable

Perform Medication reconciliation between care settings. Yes, supported by CCD when Level 3 coding is

available

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

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Menu Set Criteria Supported by CCD?

Submission of electronic immunization data to immunization

registries or immunization information systems. 

Yes

Submission of electronic syndromic surveillance data to

public health agencies. 

Yes, supported by CCD when Level 3 coding is

available

For hospitals - record advanced directives for patients 65

years or older. 

Yes, supported by CCD when Level 3 coding is

available

For hospitals - submission of electronic data on reportable

laboratory results to public health agencies. 

Not applicable

For professionals - Send reminders to patients (per patient

preference) for preventative and follow-up care. 

Not applicable

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

CCD's purpose is to provide a snapshot in time of the pertinent clinical, demographic, and

administrative summary data for a specific patient. Unambiguous communication of summary

data is achieved through the use of a stable well-vetted data model coupled with a formal

vocabulary binding syntax. Data elements are modeled as templates, which are modular reusable

constraints applied against the base CDA model. CDA templates are computable artifacts, from

which schematron validation rules can be generated. As a result, CCD instances can be tested not

only for conformance to the base CDA standard, but also for conformance against the invoked

templates. CCD has been widely adopted, and is widely supported across the United States. The

base CDA standard is widely used across the globe.

We identified areas in which CCD can be improved to further ease its adoption for Meaningful

Use; these are testability, testing and validation, error handling for C32, certification, and

documentation. Testability will be improved as model-driven CDA development techniques such

as those described in “Templated CDA: Key Concept for Interoperability,”

29 evolve. Modeldriven development will improve our ability to generate schematron and other testing and

validation artefacts. Improved error handling processes for C32 will help ensure that errors are

corrected at the source, such that revisions cascade to all down-stream artefacts. Certifying

individuals not only in CDA, but also in CCD, will improve the consistency of technical

implementations. Improved documentation, particularly the creation of an implementation guide

that flattens the multiple layers of indirection across multiple documents, can dramatically lower

the learning curve. The accompanying “CCD Standards Action Plan”30 provides our

recommendations in each of these areas.

We conclude that CCD fulfills its intended purpose, and that it can be improved. It also supports a

broader set of requirements because it is built upon the base standard, the CDA. CCD supports

the Meaningful Use goal of achieving significant improvements in care.

29 Lantana Consulting Group. Templated CDA: Key Concept for Interoperability, May 2011. Related

document prepared for NIST.

30 Lantana Consulting Group. CCD Standards Action Plan, June 2011. Related document prepared for

NIST. 

Lantana Consulting Group CCD Suitability Analysis June 2011

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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

CBIIT SAIF Implementation Guide, March 30, 2011.

https://wiki.nci.nih.gov/display/SAIF/CBIIT+SAIF+Implementation+Guide

CDA Consolidation Project.

http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

CDA Normative Web Edition. § 1.4 CDA Extensibility.

http://www.hl7.org/documentcenter/private/standards/cda/r2/cda_r2_normativewebedition.zip

Curran, Patrick. Conformance Testing An Industry Perspective, Sun Microsystems. 2003.

Available from: http://www.nist.gov/itl/vote/upload/6-Curran.pdf

Department of Health and Human Services, Health Insurance Reform: Standards for Electronic

Transactions. 45 CFR Parts 160 and 162.

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. Electronic Health Records and Meaningful Use (web

site). http://healthit.hhs.gov/portal/server.pt?open=512&objID=2996&mode=2

Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo A, (Editors). HL7

Clinical Document Architecture, Release 2.0. ANSI-approved HL7 Standard; May 2005. Ann

Arbor, Mich.: Health Level Seven, Inc. Available through HL7 http://www.hl7.org or if an HL7

member with the following link:

http://www.hl7.org/documentcenter/private/standards/cda/r2/cda_r2_normativewebedition.zip.

Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo A., HL7 Clinical

Document Architecture, Release 2. J Am Med Inform Assoc. 2006;13:3039. Available at:

http://www.jamia.org/cgi/reprint/13/1/30.

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

HITSP/C32 Summary Documents Using HL7 Continuity of Care Document (CCD Component,

Version 2.5, July 2009. http://www.hitsp.org/Handlers/HitspFileServer.aspx?FileGuid=e1b99525-

a1a5-48f6-a958-4b2fc6d7a5c7

HL7 Implementation Guide for CDA Release 2 CDA for Public Health Case Reports (PHCR)

Informative Standard, October 2009. Available through HL7: http://www.hl7.org

Lantana Consulting Group CCD Suitability Analysis June 2011

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HL7 Implementation Guide for CDA Release 2 Quality Reporting Document Architecture

(QRDA) Draft Standard for Trial Use, March 2009. Available at:

http://www.hl7.org/documentcenter/ballots/2008sep/downloads/CDAR2_QRDA_R1_DSTU_200

9APR.zip

HL7 Implementation Guide for CDA Release 2: NHSN Healthcare Associated Infection (HAI)

Reports, Release 2 Draft Standard for Trial Use, January 2009. Available at:

http://www.hl7.org/documentcenter/ballots/2009JAN/downloads/CDAR2L3_IG_HAIRPT_R2_D

STU_2009MAR.zip

HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD): A CDA

implementation of ASTM E2369-05 Standard Specification for Continuity of Care Record©

(CCR) April 01, 2007 available through HL7: http://www.hl7.org

HL7 International Localization Report: Report from the International Task Force Committee.

http://www.docstoc.com/docs/57624000/HL7-V3-Localization

IHE Patient Care Coordination (PCC) Technical Framework Volume 2 Revision 6.0, August

2010. http://www.ihe.net/Technical_Framework/upload/IHE_PCC_TF_Rev6-0_Vol_2_2010-08-

30.pdf

IHE Technical Framework: http://www.ihe.net/Technical_Framework/index.cfm#pcc

Lantana Consulting Group. CCD Standards Action Plan, June 2011. Related document prepared

for NIST.

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NIST.

Lantana Consulting Group. Healthcare Information Technology Standards: General Suitability

Analysis, May 2011. Related document prepared for NIST.

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Related document prepared for NIST.

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SNOMED CT®: SNOMED Clinical Terms SNOMED International Organization.

http://www.ihtsdo.org/

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patient’s complete health story. http://healthstory.com/

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http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

Lantana Consulting Group CCD Suitability Analysis June 2011

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Using SNOMED CT in HL7 Version 3; Implementation Guide, Release 1.5. Available through

HL7 http://www.hl7.org or if an HL7 member with the following link:

http://www.hl7.org/v3ballot/html/infrastructure/terminfo/terminfo.htm

Where in the World is XDS and CDA. http://www.google.com/maps/ms?

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e91435c9

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Acronyms and Abbreviations

AAFP American Academy of Family Physicians

ANSI American National Standards Institute

ASTM originally American Society for Testing and Materials

CBIIT Center for Bioinformatics and Information Technology

CCD Continuity of Care Document

CCHIT Certification Commission for Health Information Technology

CCR Continuity of Care Record

CDA Clinical Document Architecture

CDC Center for Disease Control and Prevention

CMS Centers for Medicare and Medicaid Services

CNE Coded No Exceptions

CWE Coded With Exceptions

EHR Electronic Health Records

EHRA Electronic Health Records Association

FR Final Rule

HHS US Department of Health and Human Services

HIMSS Healthcare Information and Management Systems Society

HIT Healthcare Information Technology 

HITSP Healthcare Information Technology Standards Panel

HL7 Health Level Seven

IG implementation guide

IHE Integrating the Healthcare Environment

IHE PCC Integrating the Healthcare Environment – Patient Care Committee

ISO International Organization for Standardization

IT Information Technology

NCQA National Committee for Quality Assurance

NIST National Institute of Standards and Technology

ONC The Office of the National Coordinator

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QRDA Quality Reporting Document Architecture

R2 Release 2

RIM Reference Information Model

S&I Standards and Interoperability

SAIC Science Applications International Corporation

SAIF Service-Aware Interoperability Framework (SAIF)

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