The Clinical Document Architecture and Continuity of Care Record

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The Clinical Document Architecture and Continuity of Care Record

The Clinical Document Architecture (CDA), Continuity of Care Document (CCD), and Continuity of Care Record (CCR) are standards that are designed for medical data organization and sharing. Thus, the three formats are used in the field of healthcare for the documentation of relevant information about the patient, conditions, and treatments. However, there are certain differences that highlight the various characteristics of the three standards, where they are utilized, and their overall purpose. The CDA is the markup architecture of all the clinical documents that illustrate a medical history. It is mainly used for document exchange, which is why international standards are to be followed. Thus, the common format of the document allows different hospitals to exchange data regarding relevant information while providing comprehensive, accurate, and readable overviews on a subject. The information, however, does not necessarily only have to include the medical history or discharge summary. Instead, images and other relevant data that are to be included in the medical record can become a part of the Clinical Document Architecture (Ji et al., 2020). This is especially useful when a patient is to be transferred to a different institution or chooses to continue treatment in a different hospital without having to go through the process of documentation restoration. CDA has been developed by HL7 and is used internationally, including by entities such as doctors offices, clinics, hospitals, and authorities within the medical field.

On the other hand, the Continuity of Care Record (CCR) is not a representation of a full medical record but a summary of the individuals health. The main purpose of the standard is to ensure the healthcare providers do not make medical errors and avoid mistakes by having specific guidelines when it comes to providing the best care possible based on the patients medical history. Thus, information about medications, possible allergies, demographics, the patients insurance, and the medical procedures is well organized and easily accessed by the physician. It, however, does not contain all the information but only the data that is the most relevant (Papers, 2021). At the same time, similarly to the previously mentioned CDA, it is used for data transferring, reducing the risks of mistakes when patients change facilities. It is mainly used by physicians and practitioners instead of having a broader scope since it is relatively constraint and allows the healthcare provider to access the most useful information without having to look through data unrelated to the concern that is to be addressed.

Continuity of Care Document (CCD) is a complete version of the previously illustrated CCR. It is a combination of CDA and CCR since it contains the summary of the health record while still remaining fairly complete as the architecture intends. A similar characteristic is its use for document exchange, which means minimization of risks when it comes to a change in medical facilities of care providers for patients (Srivastava et al., 2017). At the same time, it contains both person-readable textual information as well as encoded data processed by software. This standard is, arguably, a mix of the benefits correlating with the CDA and the CCR, which implies that it can be successfully implemented and used by multiple entities and for various reasons. It is also essential to point out that the CCD is intended to be used based on US standard requirements, making it a national format that is not intended to be used in terms of information exchange between facilities in different countries. Thus, this may be a limitation due to the possibility only to apply it in the US.

Based on the analysis of all the three standards and the examination of characteristics specific to CDA, CCD, and CCR, evidence shows that CCD may be an effective measure for implementation when it comes to data organization and exchange. There is a limitation when it comes to this particular format, which is its appliance to the US due to the fact that it does not fit international standards. However, it is a more advanced version of CCR containing more information and being a mix between CDA in terms of the amount of information and CCR in regards to its practical usefulness. Moreover, it is essential to point out that it fits the agenda of Integrating The Health Enterprise (IHE) in terms of systems that make data exchange and information access easier (About IHE, 2018). Thus, CDA can be used in multiple settings in which the patients information is to be shared and understood to avoid mistakes and medical errors and mitigate risks. CDA can be favorably implemented in the IHE environment since it follows the standards of ensuring safe and comprehensive exchange of data, giving physicians an overview on which treatment is to be implemented or avoided while being readable through the system in terms of the more extensive information that still holds importance under certain circumstances. While the three standards have all been practically applied in medical settings, the contrasting characteristics highlight that applying CDA in an IHE environment is the ideal option.

References

About IHE. IHE International. (2018). Web.

Ji, H., Kim, S., Yi, S., Hwang, H., Kim, J.-W., & Yoo, S. (2020). Converting clinical document architecture documents to the common data model for incorporating health information exchange data in Observational Health Studies: CDA to CDM. Journal of Biomedical Informatics, 107, 103459. Web.

Papers, W. (2021). Understanding the continuity of care record. Lyniate. Web.

Srivastava, S., Soman, S., Rai, A., Cheema, A., & Srivastava, P. K. (2017). Continuity of Care Document for Hospital Management Systems. Proceedings of the 10th International Conference on Theory and Practice of Electronic Governance. Web.

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