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/

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.

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.

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

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