How the Continuity of Care Document Can Advance Medical Research and Public Health

John D. D'Amore, MS; Dean F. Sittig, PhD; Roberta B. Ness, MD, MPH


Am J Public Health. 2012;102(5):e1-e4. 

In This Article

Abstract and Introduction


Electronic health records in the United States currently isolate digital information in proprietary, institutional databases. Experts have identified inadequate data exchange as a leading challenge to advancements in care quality and efficiency.
Recent federal health information technology incentives adopt an extensible standard, called the Continuity of Care Document (CCD), as a new basis for digital interoperability. Although this instrument was designed for individual provider communications, the CCD can be effectively reused for population-based research and public health.
Three examples in this commentary demonstrate the potential of CCD aggregation and highlight required changes to existing public health and research practices. Transitioning to the use of this new interoperability standard should be a priority for public health investment, research, and development.


The adoption of electronic health records (EHRs) has focused on enhancing the delivery of individual care, but the application of digital medical data to widespread population health analysis is critically lacking. Population analysis empowers public health agencies, disease registries, medical researchers, and practicing clinicians to monitor care quality and improve disease management beyond face-to-face patient encounters. Potential applications of EHR technology to population analysis are straightforward. Health surveillance should rely on automated detection rather than manual inspection. Quality measures should be calculated and streamed directly to agencies for quality improvement. Comparative effectiveness should leverage the emerging wealth of digital data to inform decisions on care appropriateness and provide feedback to clinicians. What limits these applications is the divergence of how EHRs capture and record medical data without a standard method to exchange information between these systems. This observation led the President's Council of Advisors on Science and Technology[1] and the Institute of Medicine[2] to recently identify interoperability as the major deficit of current health information technology. From their perspectives, fluid and secure data exchange has the most immediate potential to improve care quality and efficiency nationwide.

Achieving robust interoperability requires common language and structures to medical data so communication is seamless to care providers. This contrasts with current practice. Today, implementations of medical data exchange force both senders and recipients of medical data to plan in advance the content and format of exchange. This is akin to installing a unique web browser for each Web site on the Internet; the complexity and burden of such networking effectively isolates medical data at the point of care. Health information exchanges confront this same obstacle, where even successful networks note the challenge of normalizing heterogeneous EHR data.[3] Information exchange is consequently the exception rather than the norm. Recent federal initiatives, however, are beginning to dismantle these barriers.

In the American Recovery and Reinvestment Act of 2009,[4] Congress approved $27 billion in health information technology stimulus and placed standardized information exchange as a leading policy objective. Specific objectives for this program were released in July 2010, a majority of which focus on data structure and interoperability.[5] One requirement for all providers is that an EHR must be able to create, transmit, and receive an electronic document containing key clinical information using standard terminologies. The 2 standards that may be used for this objective are the Continuity of Care Document (CCD) and the Continuity of Care Record (CCR). Although both the CCD and CCR are acceptable in federal regulation, EHR vendors have focused on the CCD because it is the newer format developed through the harmonization of the CCR with other past standards.[6]


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