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Chilmark Needs to Chill Out on CCR/CCD Findings
John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.
However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” in The Health Care Blog. He writes:
In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future. The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.
I have four beefs with John’s essay:
- It’s no news that HIEs prefer CCD.
- HIEs are not representative of the broader health IT market.
- The narrow findings don’t justify the broad conclusion.
- The CCD and CCR standards are more complementary than competitive
Let’s look at these one at a time.
1) It’s no news that HIEs prefer CCD.
First, let’s separate findings from inferences.I don’t dispute John’s findings that HIEs prefer the CCD standard.
My reaction to this finding is: “duh”.
Asking HIEs whether they prefer CCR or CCD is akin to asking Bill Gates whether he thinks Windows or Linux is the better operating system.
The CCD is a standard designed and created for heavy duty health care institutional use — exactly what HIEs are created to do.
Here’s another metaphor: asking a HIE whether they prefer CCR or CCD is like asking an ancient Roman whether they would prefer to converse in Latin or Swahili. The obvious answer will be “Latin” — not because Latin is a better language, but because they already have sunk costs into learning Latin. If you already speak Latin, it won’t bother you that Latin is complex, archaic and difficult to learn.
2) HIEs are not representative of the broader health IT market.
HIEs have struggled to create a sustainable business model. John, as you yourself wrote less than two weeks ago:
As we have seen in a number of failed HIEs to date, stating in writing a sustainable business plan and actually having one that works are two very different things…While the funding [HITECH] is welcomed by many in the industry, creating regional and statewide HIEs will prove challenging as to date, there are still no demonstrable and repeatable business models to create such exchanges that are truly self-sustaining.
In that same essay, you also noted that most HIEs today are not capable of the type of interoperability envisioned by the HITECH legislation:
Sure, there are countless HIEs today, but the vast majority of these are within a given Integrated Delivery Network (IDN), but these are closed systems.
…and the recent KLAS report on HIEs points out that vendor hype does not always match reality:
Though marketing by some vendors would suggest that many examples of successful health information exchanges (HIEs) have been built on their solutions, the reality of HIE adoption is quite different. According to a new report from KLAS, only a relatively small number of vendors have risen to the challenge enough times to claim a proven, repeatable model.
3) The narrow findings don’t justify the broad conclusion.
The fact that HIEs prefer CCD says nothing about adoption patterns in the broader market. John broad conclusion “CCD Standard Gaining Traction, CCR Fading” isn’t justified by the narrow findings.
4) The CCD and CCR standards are more complementary than competitive.
As my colleague Steven Waldren MD and I have written:
We see at least two different HIT “nations”.
- One is populated by large institutions that are comfortable speaking Latin (i.e. HL7 CDA, UCUM)
- One populated by ambulatory tribes — small to medium size physician practices, clinics, patients with PHRs, and innovative early stage companies with limited health IT budgets – that prefer multiple less sophisticated, yet effective dialects.
Let’s consider one example: the differing use of summary care record standards in institutional and ambulatory settings.
The HL7 CCD standard is more likely to be used in institutional settings:
- By organizations that have already adopted HL7 (e.g., large delivery systems)
- To support existing business models
- In non-disruptive applications that achieve costs savings and/or quality improvements by automating EXISTING processes that are INTERNAL TO THE ORGANIZATION (or with existing trading partners), e.g., hospitals sending test result information to doctors.
- Where implementers have already incurred significant fixed costs to adopt HL7 as a broader enterprise standard
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 that achieve costs savings and/or quality improvements by creating NEW PROCESSES, often involving parties that are not currently exchanging information, e.g., improving patient chronic care management with the goal of avoiding ER visits and hospitalizations.
- Where the implementers are highly sensitive to incremental costs of IT resources and view the CCR as a “better, faster, cheaper” alternative.
John, referencing a recent movie — “I Love You, Man”…but I can’t agree with you on this one.
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RT @VinceKuraitis: "Chilmark Needs to Chill Out on CCR/CCD Findings" http://bit.ly/a00KrW #hitpol #healthit #hie
RT @VinceKuraitis "Chilmark Needs to Chill on CCR/CCD Findings" My rebuttal to @john_chilmark http://bit.ly/a00KrW #hitpol /via @HITpol
Vince: Thanks for clearing the air in your blog post. What I say is “hurray, we’re actually using health data exchange standards that structure the data in XML!” which is what the CCR standard is all about. Which led to the CDA CCD. Let’s let the companies in the various sectors of the health IT industry tell us what standards work for them over the next 2-3 years, and not talk about “dominating,” shall we? Certainly, the HIEs should not be the ones to “dominate” the rest of the industry. Regards, DCK
RT @healthsystemCIO: RT @VinceKuraitis "Chilmark Needs to Chill on CCR/CCD Findings" My rebuttal http://bit.ly/a00KrW #hitpol /via @HITpol
Great discussion. I agree that CCDs are designed to interact with what for lack of a better term is a long-term model that places all providers, doctors and hospitals under one big tent capable of connecting any patient to any doctor. It is as though they all work in a single building.
I think this is another clear example of the fact that we have two business models in conflict; a provider model and a national delivery model.
It think it remains to be seen if the HIE model has the legs to sustain it in the long term. I do not think it does.
My best – Paul
Vince: this is what I wrote as commentary on Johh’s THCB blog post:
Hurray! We’re discussing the actual use of health data exchange standards that use XML (extensible markup language, the lingua franca of the Web). This was a major purpose of creating the CCR standard in 2004-05, as a means of enabling movement of health data over the Web and Internet, you know, as other industries have done to share data and make it computable using web services. So, simply having the choice of two XML clinical summary standards that can be computably exchanged is real progress.
But there’s still a long way to go until any EHR technology can reliably and consistently exchange structured summary health data with any other EHR technology using one or both of these standards. As Google Health, CVS MinuteClinic, Microsoft HealthVault, and a growing ecosystem that includes all the major pharmacies, a number of clinical decision support and pharma decision support firms, several Apple iPhone apps companies, a couple of EHR vendors, and others have shown, the CCR standard is quite serviceable for the purpose of secure and structured health data exchange in XML. What hasn’t occurred is for the broader health IT industry to work out the details — and there are quite a few — of this kind of useful, practical exchange over the Web.
This isn’t really a standards problem at all. It’s a business model problem. Businesses that want to exchange data have always found a means of doing so, and now, in health care, it’s gotten much, much easier to do so. It helps that the feds are behind this movement.
Beware of the complex solutions that must be “perfect” and agreed upon by all the incumbents before they can be deployed. Respect the choice made by those who accept loose consensus and working code. They usually win the race in the end.
Regards, and thanks. DCK
Great post, thank you.
I agree completely with many of your assertions, especially:
– The fact that HIEs prefer CCD says nothing about adoption patterns in the broader market –
In my view, HIE’s are not where innovation is occurring in healthcare. The HIEs are part of the provider-payer-government triumvirate of healthcare that is focused on how providers and payers will share information ABOUT patients, while the connected and mobile health markets are already moving at light-speed helping consumers get access to and control over their own health, wellness, and fitness information — today.
As a founder of an early-stage connected-health company, I can say that we do not look at the CCD as the future. In fact, most entrepreneurs involved in early stage connected-health companies that I talk with just shake their heads when the topic of HL7 and the CCD come up. Given the technologies and approaches available today, HL7 and the CCD seem like antiquated, over-engineered, and overly-complex techniques that hurt more than help.
I know there are some compelling use cases for these technologies, but in consumer-centric, connected health where I believe the future is, I wouldn’t bet on the CCD, especially given the more intuitive CCR as well as other approaches.
Hi Vince,
Thanks for stirring the pot.
Now on to some follow-on comments:
1) There currently is a need for both CCR and CCD and in the future there will likely be a greater convergence towards something like Green CDA, which may ultimately provide the best of both world’s – the flexibility of CCD with the ease of use of CCR.
The issue is not Linux or .Net, Latin or Swahli, that is too simplistic. What is at issue is what standard will help an organization do the work they need to do. CCR may be fine in a small ambulatory practice with limited IT resources and simple data mgmt requirements/workflow. CCR though is not flexible enough to allow larger practices, clinics and hospitals to create document structures, add data types, etc. to meet their internal operational needs. As David rightly pointed out, it is a business issue.
2) I said RHIOs have struggled and will continue to struggle to have some relevance in the market. RHIOs are actually a very small part of the total HIE pie. Our estimates put about 80% of the entire HIE market in private exchanges within IDNs and the like. These private exchanges/HIEs are thriving – it is a very hot market and no, that is not because of Stimulus funding, though it sure doesn’t hurt.
3) CCR will have its place, but it will be a smaller presence than what many proponents of this standard are assuming, it just does no have enough “muscle” to meet many of the broad market needs.
4) Yes, CCD and CCR are complimentary – heck they better be as CCD was created to bridge the gap between CDA and CCR.
I applaud those that created the CCR as it got the folks at HL7 to actually get off their duff and start thinking about truely flexible XML standards. Standards are never clean cut in the IT world, always messy and oft-times, the standards that win out in the end are those that create value for their users.
I’m not trying to pick sides in this debate, but through our research at Chilmark, we are attempting to inform the market as to what some of the broad trends are today. Today, we are seeing some significant movement to CCD, thus the origin of the post. And it is important to note that the HIE market is going to be quite influential in all of this going forward as this will be the enabling tech for care coordination.
@VinceKuraitis "Chilmark Needs to Chill Out on CCR/CCD Findings" My 4 point rebuttal to @john_chilmark http://bit.ly/a00KrW #hitpol
The CCD gaining popularity? That’s not the way it seems to me. The term “CCD” is more widely used than the term “CCR”, especially among people who are only mildly familiar with what it means. But I wouldn’t judge success of the standard by how many people use the word. In the end the functionality is all that really counts, and what is being used is XML and the CCR.
Hi…just joining. fyi, see recent discussion re: CCR/CCD on my blog. Both standards are needed. http://bit.ly/a00KrW
Hi…just joining. fyi, see recent discussion re: CCR/CCD on my blog. Both standards are needed. http://bit.ly/a00KrW #dataflow
Kuraitis sets the record straight in CCR/CCD dust-up … http://tinyurl.com/ykweorv
@VinceKuraitis responds to Chilmark CCR v. CCD debate. https://e-caremanagement.com/chilmark-needs-to-chill-out-on-ccrccd-findings
Thanks all for a great discussion.
This essay is also posted on The Health Care Blog…and there are many other insightful and provocative comments:
http://www.thehealthcareblog.com/the_health_care_blog/2010/02/chilmark-needs-to-chill-out-on-ccrccd-findings.html#comments
You should also read Jon Mert’z blog post: CCD and CCR – The Discussion Continues
http://www.hl7standards.com/blog/2010/03/10/ccd-and-ccr-the-discussion-continues/