Information on CCR, CCD and EMR

Dr. Jeff sent me the following summary of quotes he put together about CCR and CCD and how they relate to EMR. I don’t think he meant for it to be published, but the information was too good not to publish it. So, sorry that it’s missing references to where the quotes were made and is a little scattered. With that said, take the following quotes as information purposes and I’d be happy to update the source if someone knows where it’s from. I think Dr. Jeff is going to find some of the sources as well. Enjoy!

“The Continuity of Care Record (CCR) is a patient health summary standard.  It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to the next” – Wikipedia

XML(Extensible Markup Language) is an open standard for structuring information. – the standard data exchange interchange language used by the CCR

PDF and Office Open XML – other formats that the CCR uses

“Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application” – Brian Klepper

CDA(Clinical Document Architecture) stores or moves clinical documents between medical systems. Documents are things like discharge summaries, progress notes, history and physical reports, prior lab results, etc. The CDA uses XML for encoding of the documents and breaks down the document in generic, unnamed, and non-templated sections.

The CCR Standard was developed by a collaborative – the Massachusetts Medical Society (MMS), the HIMSS (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors – under the auspices of ASTM International, a not-for-profit organization that developes standards for many industries, including avionics, petroleum, and air and water quality” – Brian Klepper

“The CCR’s advance will allow patient health data to be easily transported from one platform to another, intact and with integrity, so that better decisions can positively impact care, health, and the costs of achieving them” – Brian Klepper

CCD(Continuity of Care Document) is the result of a collaborative effort between the Health Level Seven and ASTM organizations to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR) and HL7’s Clinical Document Architecture (CDA) specifications. [CORRECTION: See these comments from David C. Kibbe, MD MBA]

HL7(Health Level Seven) is the registered trade mark of the HL7 consortium – an ANSI approved non-profit standards body set up to establish communications protocols for the health industry.

CCD is an attempt to meld  CCR with HL7 standards for data exchange” – jd

“There’s something of a religious war going on here.  BUT many of the more “open” vendors are using both CCR and CCD.  The more “closed” vendors seem to be waiting until CCD “wins” the war” – Matthew Holt

CCD and CCR are often seen as competing standards.  Google Health supports a subset of CCR, while Microsoft HealthVault claims to support a subset of both CCR and CCD” – Mehdi Akiki

IMHO, CCR and CCD are more complimentary than competitive” – Vince Kuraitis

CCD standard is likely to be used by organizations that already use HL7 (large delivery systems), to support existing business models, in non-disruptive applications that achieve cost 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 and where implementers have already incurred significant fixed costs to adapt HL7 as a broad enterprise standard” – Vince Kuraitis

CCR standard is likely to be used by organizations that have not yet adopted any standard (e.g., early stage companies), to support new business models, in disruptive applications that achieve cost 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 and where the implementers are highly sensitive to incremental costs of IT resources and view the CCR as a “better, faster, cheaper” alternative” – Vince Kuraitis

“Most institutions and vendors that have large investments in HL7 are dealing with the “classic” HL7 versions, the 2.x standards” – Margalit Gur-Arie

“For many applications – especially ambulatory and small companies – the CCR is a complete solution.  Hospitals can also deploy CCR for specific applications.  However, hospitals will not view CCR as a complete data exchange solution for all applications.  Hospitals will need to adopt HL7.  The vast majority of hospitals today are on HL7 2.x.  While HL7 3.x is incompatible with 2.x, my assumption is that hospitals view “eventual” migration to 3.x as necessary, albeit dreaded because of the reasons you cite” – Vince Kuraitis

“Forcing vendors and institutions to adopt those standards (CDA and the RIM), if one can call them standards, will result in increased IT spending all over the board.  I don’t think this is something we need right now.  On the other hand, the CCR is almost “simple stupid” which is a compliment when it applies to a standard and could be implemented at very short notice.  I just think we have to start somewhere and CCR is just the easies and simplest way to start the process and achieve meaningful results” – Margalit Gur-Arie

LOINC , SNOMED , RxNORM – other data exchange standards

“The CCR authors recognize the need for our industry to “ease into” structure … the format does a great job of encouraging coding and normalization without creating an unrealistic bar – this is a tough tightrope to walk” – Sean Nolan

“Both formats (CCR and CCD) are important and help move the ball forward.  We come across situations every day where CCD is a better (or sometimes the only) option for some particular problem, so both HealthVault and Amalga are built to embrace them both.  Frankly this isn’t just a CCR/CCD issue – there are a zillion formats out there holding useful information, and the reality is we’re all just going to have to deal with that for some time to come.  The good news is that we do seem to have a little bit of bedrock in the form of XML and XSLT – these help a ton.  The key thing, I believe, is to stay focused on moving data so that it can be reused and shared – not getting dogmatic about how we move it.  Turns out that when we do that … the right things are happening, a little more quickly with every turn of the crank” – Sean Nolan

“Should there be evidence that any proposed approaches to interoperability will actually succeed in the real world before we declare such approaches as required?  Otherwise, who can determine what approaches to interoperability will prove acceptable to the majority of medical practices?” – Randal Oates, MD

CCR is simple and straightforward” – Margalit Gur-Arie

SureScripts is a certified network able to connect one EHR with another EHR.  Mainly used for connecting doctor’s offices to pharmacies.

“But consider that CVS MinuteClinic is already sending many thousands of CCR xml files from its EHR via SureScripts network, where they are either routed electronically to practices in thexml format (not many yet) or transformed into PDF and sent electronically or faxed.  There is no reason that existing national network operators (e.g. NaviMedix, Zix and Quest, just to name a few that easily come to mind) couldn’t do the same job.  It’s really simply an electronic post office.  There is growing real world experience.  It’s just not coming very often from incumbent health care organizations and vendors” – David C. Kibbe, MD MBA

“Consider this a model (SureScripts, Prescriptions, CVS MinuteClinic) for health network exchange of data like that which is in the CCR standard XML file format supported by Google Health, limited to demographics, insurance info, problem list/diagnoses, medications, allergy and alerts, vital signs, and lab results [I would add consultation reports, hospital discharge and operative reports and test results (ie.  stress test, cardiac catheterization].  Not a lot of data, but meaningful data much of the time.  Kept current and accurate by a person’s healthcare team (nurses, doctors and pharmacists) which includes the patient” – David Kibble, MD MPH

“My argument is that it is much more efficient, and in the long run much easier to implement, a system that pays for the data to be transmitted in CCR format among providers, and between care systems;  and to trust that the market will come up with innovative tools and technologies for helping doctors and patients do this; than it is for government, or anyone else, to pay for complicated “EHRs” that create new silos of data and which force physicians to click dozens or hundreds of times to document a “visit”, while not creating the data set that could be useful in so many ways outside the four walls of the practice to help managed care!  I don’t think this is as complicated as we’re made to think this is, and I know that the tools are available now to get it done.” – David C. Kibbe, MD MPH

“I do agree that the HITECH money would be better spent on facilitating simple data transfer, as opposed to complex data entry” – Margalit Gur-Arie

I have to agree with MD regarding the reality of office and hospital computer systems.  It seems there is a disconnect between the people talking abut all the wonderful things these systems do, and we physicians whose experience with the things in the real world is almost uniformly negative, to neutral at best.  Some of the people with big visions need to visit a hospital or large doctor’s office sometime and see how these things actually work (or don’t)” – Bev M.D.

This summary compiled by Jeffrey E. Epstein, MD

About the author

John Lynn

John Lynn

John Lynn is the Founder of, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Nice set of quotes. I do want to correct some misinformation. The CDA CCD was NOT a joint effort of ASTM CCR developers and HL7’s group working on the CDA CCD. There was never any “harmonization” of the two standards, and they remain quite distinct. HL7 did utilize much of the data content and its organization of the CCR standard in its CDA CCD, and they claimed that his was a combined effort, a “better” and compromised result. However, that’s more a political wish than a reality. These are still very different standards, one about data (the CCR) and the other about documents (the CDA CCD). Both are needed by different entities to do different tasks.
    Kind regards, DCK

  • Thanks for the clarification Dr. Kibbe. I added a correction note on the post with a link to your comment. I appreciate the extra information.

  • This “document motif” for patient data exchange sounds nice (and for the non-technical, mention XML and it even seems ‘sophisticated’) but in essence, it’s a database dump.

    A patient has a primary care provider with all her information. Then she moves. And the old provider dumps her data on the new provider. Too big? Maybe there’s a magic way to scrub the dumps so only “current” or “relevant” data is sent. Really? Who or what decides relevance?

    So let the patient own the record! On Google et al. But what about redaction? Don’t like something there. Go to Google and remove it. It’s medically relevant? Oh. Oops.

    There is another model – replicate the VA (with or without DOD). Hospitals/clinics federate. There must be national IDs – the VA gives Integration Control Numbers to every Vet. National ID? No way.

    Unmaintainable, self-contained dump or national ID? Um.

  • hoot72cpd,
    Now add in the complexities of when and what parts you’re allowed to share based on the laws/releases that have been signed. It gets pretty ugly.

  • True though some of the cries of “security” are really just calls for the status quo.

    A (opt in?) Health Care ID avoids some of the security concerns too. No Social Security # needed (or even allowed maybe). No address or credit card (all this is billing stuff).

    Make your identity for health distinct. Detach it from your other identifiers and you remove much identity theft. Does it ensure privacy? Well, nothing will ever be perfect but it should remove the silly “free credit report for one year” stuff promised to anyone whose records get into the wild.

  • I’m not so much worried about “security” as I am for litigation liability for doctors. This lawsuit happy society makes it hard to do the right thing sometimes.

    Of course, that doesn’t mean we shouldn’t try and break down those barriers. It’s an important goal that needs to be reached.

  • If you think about medicine as an enormous number of individual contractors, all wanting bits of a patient’s data, then “leaks” are inevitable. The best course – and the only one to get this stuff going quickly – would be to make the leaks as harmless as possible. Oh look, I have patient (22233355666)’s data. So what! Who’s that anyway.

    Billing’s the real problem. Who you are outside health-care only matters here. Focus should be on locking down billing (which does need to link into the Patient Data but not vica-versa) and let the de-identified patient data free.

  • I am confused by Dr Kibbe’s comments about CCD not being a collaboration. The following quote is from a press release dated 2/12/2007 regarding the endorsement of CCD by HITSP: “The collaboration between HL7 and ASTM reflects the integration of two complementary
    specifications [ASTM’s E2369-05, Continuity of Care Record (CCR), and HL7’s Clinical Document
    Architecture (CDA)] developed by separate standards development organizations, and
    demonstrates what can be achieved when patient care is the driving priority,” said Robert Dolin,
    MD, co-editor of the CCD specification and board member of HL7.
    “It has been a pleasure to work with Bob Dolin and the HL7 team on the harmonization of
    ASTM’s Continuity of Care Record (CCR) and the HL7 Clinical Document Architecture (CDA). The
    Continuity of Care Document (CCD), resulting from the representation and mapping of CCR data
    within the CDA, will help drive the use of structured XML standards for clinical information
    exchange and the improvement of patient safety, quality, and efficiency,” said Richard Peters, MD,
    chair, ASTM International Committee E31 on Healthcare Informatics.

Click here to post a comment