Policy Statement of the American Academy of Family Physicians Regarding Electronic Health Record (EHR) Interoperability and the ASTM Continuity of Care Record (CCR) Standard

Monday, April 4, 2005

In 2002-2004 the Family Medicine community engaged in a collaborative project which examined the future of family medicine as a discipline and medical specialty. As part of the Future of Family Medicine report, a New Model of Care was designed to meet the needs of patients in the future. This model necessitates the use of health information technology (HIT) to improve quality, enhance patient safety, and increase efficiency. Electronic health record (EHR) software is viewed as the “central nervous system” of this New Model family practice. The American Academy of Family Physicians (AAFP) is joined in this belief that the future of the health care system depends on physician EHR adoption by many other physician membership organizations, the federal government, and a broad coalition of US industries.

However, and surprising as it sounds, most EHRs available today cannot exchange patient data. It is very important that EHRs used in doctors’ offices become capable of “talking to one another” and of sharing important clinical information: otherwise each office or clinic is simply an island of data without the means of networking the stored patient information it contains. Benefits to patients from the use of EHRs will be optimal only if their personal health information can travel with them from care setting to care setting. Further, doctors will be able to justify the expense of EHRs only if these proprietary software applications can seamlessly read, interpret, and manage each other’s exported patient health information summaries in much the same way that word processing software programs can open and read each other’s files.

This background formed a compelling rationale for the American Academy of Family Physicians’ involvement as a sponsor of the ASTM Continuity of Care Record (CCR), in collaboration with sister associations, including the American Medical Association (AMA), the American Academy of Pediatrics (AAP), the Massachusetts Medical Society, (MSS) and other ASTM CCR co-sponsors including the Health Information Management Systems Society (HIMSS), the Patient Safety Institute (PSI), the National Association for the Support of Long Term Care, the American Health Care Association (AHCA), and the Mobile Healthcare Alliance (MoHCA). It also led to our decision to contribute clinical and technical expertise to the development of this new standard.

The ASTM CCR is a patient health summary standard, a way to create flexible documents that contain the most relevant and timely core clinical information about a patient, and to send these electronically from one care giver to another or to provide them directly to patients. It contains various sections -- such as patient demographics, insurance information, diagnosis and problem list, medications, allergies, advance directives, and care plan, etc. – that represent a “snap shot” of a patient’s health that can be useful, even life-saving, if available when patients have their next clinical encounter.

It is important to understand that the ASTM CCR standard has been designed by practicing physicians, nurses, and technologists to permit easy creation by a clinician using an electronic health record software program (EHR) at the end of an encounter, and also to be created using simple Web-based tools. That is, its usefulness does not require that either patient or caregiver have an EHR, but its usefulness is expanded if they do. Because it is expressed in the World Wide Web standard language known as XML, the ASTM CCR can be created, read and interpreted by various EHRs from various software companies. Being “built to run on the Web” means that the CCR can also be viewed within any of the popular Web browsers, eg Internet Explorer or Foxfire, and printed out in user-friendly paper formats, such as pdf and as a Microsoft Word document.

The AAFP believes the ASTM CCR standard is a clinically sophisticated and technically robust solution to the need for both portability and interoperability of patient health information stored in physicians’ EHRs. We believe the ASTM CCR will provide a near term benefit by making those products and services which are compliant with it more desirable to new purchasers of EHRs, thus making it possible for the New Model of family practice to go from concept to reality at an accelerated pace. The AAFP recommends to its members that they select EHR products, services, and vendors of HIT that are ASTM CCR compliant or in the process of adopting the ASTM CCR. Vendor recognition and acceptance of the value to be gained by complying with the ASTM CCR is borne out by the fact that over twenty-five vendors of HIT software have been involved in its ongoing development and have participated in two demonstrations of ASTM CCR interoperability in 2004 and 2005.

The AAFP also understands and appreciates the requirements for interoperability standards to address the issues associated with legacy systems in place in large institutions, such as hospitals and integrated health delivery networks, and the need to “harmonize” the content and structure of the ASTM CCR standard with other developing standards that are intended to serve some of the same, or complementary, purposes. These standards include HL7, NCPDP, DICOM, and HIPAA, among others.

The AAFP supports, therefore, the Memorandum of Understanding signed between the boards of ASTM and HL7 that pledges both organizations to work together to harmonize the ASTM CCR with the HL7 CDA. Such efforts are only now beginning to take place, and, although perhaps long overdue, are an important step in the right direction, one that should proceed with deliberation and be given adequate time for all parties to fully understand and digest the relevant differences and similarities between the ASTM CCR and the HL7 CDA document templates. Both sets of standards appear to offer value in circumstances that are similar but not identical, and, since both are in the process of standard development organization (SDO) balloting, we strongly recommend that a period of product use and testing in real clinical situations be allowed to occur before any decision is made by the federal government or any IT certifying entities as to the inclusion or exclusion of either the ASTM CCR or the CDA in its formal certification criteria.

The ASTM CCR is not a panacea for all of the problems of fragmentation of health data within the health care system. But the AAFP believes it is a worthy beginning that can be implemented now. It is worth emphasizing that the main benefit of the widespread use of the ASTM CCR will be the improvement in the clinical quality of care of our patients that can result from more, and more accurate, summary patient health information being accessible when treatment and diagnostic decisions need to be made. Safety of care will also be improved, as patients and doctors benefit from immediate access to patients’ lists of medications and dosages, allowing all parties to avoid the sometimes very dangerous duplication of medications and other kinds of errors associated with illegible or incomplete drug information. Finally, the AAFP believes that the ASTM CCR standard can have a noticeable impact on efficiency, as errors and duplications due to missing or incomplete health information is one of the components contributing to the unnecessarily high costs of care that must be paid by patients, insurance companies, and other payers of medical care in the U.S.