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Is There Such a Thing As Stand-Alone Clinical Documentation?

Posted on September 23, 2015 I Written By

Erin Head is the Director of Health Information Management (HIM) and Quality for an acute care hospital in Titusville, FL. She is a renowned speaker on a variety of healthcare and social media topics and currently serves as CCHIIM Commissioner for AHIMA. She is heavily involved in many HIM and HIT initiatives such as information governance, health data analytics, and ICD-10 advocacy. She is active on social media on Twitter @ErinHead_HIM and LinkedIn. Subscribe to Erin's latest HIM Scene posts here.

Imagine if every interested party in healthcare relied on one black and white document to determine a patient’s health care needs, insurance coverage, quality ratings and accreditation, or medical necessity for hospital admissions. This document would have to contain a large amount of information and it would probably end up being very cluttered. Our practices today require creating  an “abstract” of the record consisting of multiple documents and data sources or sometimes requestors want an entire record sent to them which could be hundreds or thousands of pages.

Until we get to the point of easily sharing interoperable data electronically through HIEs, we will continue to rely on release of information practices of fulfilling requests for records by pulling pertinent information from the chart. We find ourselves asking daily, “what is the minimum information we can send that will provide the most information?” We joke about how EHRs have actually increased the amount of paper used to print a chart because of formatting and “note bloat” from trying to cram too many things into each document. Could we ever get to the point of having just one patient summary document that can be shared across providers and levels of care?

I don’t think patient data and information can be summarized into one document in a chart nor should it be. If that were the case, medical records would consist of one source-document instead of the dozens of tabs and modules we have in the EHRs today. Due to the fact that opening up an entire chart to every authorized reviewer is not currently secure or feasible, we are still looking for information sharing solutions involving summarized documentation. That being said, the chart should have key data elements pointed to a destination document where the patient’s course of care would be summarized neatly in one place to prevent the author of the note from having to re-state information repeatedly. I do see some movement toward the single, stand alone document trend but I think there is still quite a bit of work to be done.

The continuity of care document (CCD) was created with the objective of standardizing a single document that could be sent to the next care provider. This document may also be referred to as the After Visit Summary or Discharge Instructions but CCD was coined by HL7 for Meaningful Use electronic exchange initiatives. This template intends to capture important elements from a patient’s clinical data including the problem list, history, vitals, and more pertinent information that would be helpful to the patient’s next provider.

So why does The Joint Commission (TJC) still require so many other documents in the chart if we are able to summarize the care well enough for the next provider with one document? With the focus of health IT professionals being on Meaningful Use and EHR optimization, I see a divide in objectives across departments within healthcare organizations because we are trying to please many different accrediting bodies or payers. I don’t believe there will be a time in the near future when everyone agrees on a standardized record set therefore documentation will continue to evolve with each requirement that comes along. In the meantime, we must ensure the minimum necessary information is shared for continuity of care in a concise and effective manner.

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Contest Offers Prizes For CCD Redesign

Posted on November 19, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

When EMRs are the gossip of the week at TechCrunch (a popular tech startup website), you know our little EMR thang has gone mainstream. And TechCrunch is indeed one of a series of sites trumpeting the news of a design challenge intended to make the Continuity of Care Document more usable.

The White House’s Health Design Challenge, working with a community of philanthropic angels and mentors known as Designer Fund, asks designers to transform the CCD (and by extension the Blue Button output) from a consumer-hostile mess into something easily used by the following groups:

  • An underserved inner-city parent with lower health literacy
  • A senior citizen that has a hard time reading
  • A young adult who is engaged with technology and mobile devices
  • An adult whose first language is not English
  • A patient with breast cancer receiving care from multiple providers
  • A busy mom managing her kids’ health and helping her aging parents

The ONC and VA, which seem to be spearheading the effort, are providing for twelve winners. First place for best overall design gets $16K, second place $6K and third place $4K. They’re also distributing $8K per category across winners for best medical/problem history section, best medication section and best lab summaries.

The design is expected to not only improve the visual layout of the record, it’s also supposed to make it easier for a patient to manage their health, enable medical professionals to digest information more efficiently and help caregivers support patients. Tall order for a messed-up text file?  Well, we’ll see what design superbrains can do.

In part because the VA hopes to use the new designs to support its Blue Button initiative and its MyHealtheVet patient portal, all entries have to be submitted under a Creative Commons license.   Curators will select a final design — which may include elements from various winning entries — and open source the code on code-sharing commuity Github.

Health Information Exchange

Posted on November 2, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In an email response to my EMR and HIPAA post on HIE Waste, Edward Fotsch, M.D. and CEO of PDR Network offered these insights into the state and some history of Health Information Exchanges:

The fundamental question for HIEs is two-fold: 1) what is their purpose and 2) who benefits and will pay for them- the latter is a question of revenue model not grant funding which always runs out sooner or later. Relevant facts include:

1. HIEs are not a new concept. I was around when Community Health Information Networks; or CHINs (The ‘C’ in CHIN stands for communism where we all do the right thing because it’s for the good of the order) came and went. Then RHIOs came and went. Now HIEs. What these have in common is grant funding but generally no business model.

2. The idea of providers paying for the opportunity to share their patient (‘read “Client”) information with competitors is novel I must admit. But in the old days when I was seeing patients, when you sold your practice you largely sold your charts. It was the charts as much as anything else that kept patients coming to the new doctor after the sale- ‘it still works this way for many dentists. Now docs are supposed to pay for the privilege of having their charts opened to competitors? Now I know that the hospital execs all salute this flag when the discussion of HIEs occurs at the rubber chicken dinners. But when I was on the exec committee at a community based hospital we spent time trying to compete with, not empower, competing hospitals. You may say that is not right- but that’s a fact.

3. HIEs I’ve seen that have any hope serve a specific business purpose and often exist within an economic entity. Kaiser has a large HIE- they just don’t call it that.

4. Data exchange between competitors has worked in many venues- the obvious example is ATMs where competing banks collaborate. BUT this occurs because customers demand it. Unless or until patients/consumers begin to select healthcare providers who participate in some level (i.e. CCD-level sharing at least) of basic patient information exchange (i.e. refusing to go to providers who hand them a clipboard), the HIE concept is massively challenged. ‘Though it’s always fun right up until the grant funding runs out.

The Depressing State Of HIEs

Posted on May 3, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

Ladies and gentlemen, I’ve been following the progress of HIEs since the mid-2000s, and the story has always seemed to be the same.  HIE gets sparked by a grant or some entrepreneurial thinking, gets to rolling, looks promising, then dies because there’s not enough cash to keep things working.

Seven or eight years later, I’d love to be telling y’all that the HIE has magically matured, and that regional HIEs are taking off rapidly now that it’s clear everyone will need to be part of one at some point.  Well, I’m afraid that even that modest hope — let’s forget the National Health Information Network — doesn’t look like it’ll be fulfilled soon.

The latest downer came from the National eHealth Collaborative (NeHC), a public-private partnership funded by ONCHIT.   While the report was apparently intended to help HIEs grow, it also did much to remind us of the obstacles facing most public HIEs.

As Chris Muir, state HIE project manager for ONC recently told a press conference, the $564 million in federal funds that have been laid out to date to jumpstart HIEs haven’t gotten the job done.  He noted that in many regions, infrastructure doesn’t exist to support HIEs, but even if it does, few providers sign up. Then, even if they sign up, most participants don’t take full advantage of the network.

And wouldn’t you know it, the growth of ACOs has ended up spiking some HIE projects. For example, a successful HIE noted in the NeHC report told the conference that ACO growth is hampering his organizations operations. Some ACO providers are now blocking access to their data so competitors can’t get to it, said CEO Tom Fritz.

There’s also some technical obstacles faced by the HIEs, but those, I must say, seem solvable in an era when people are already making determined strides to allow interoperability between HIEs and outpatient EMRs. One group of federally funded HIEs, the Beacon Communities, is developing a continuity of care document that can be automatically exported to an exchange via a pre-arranged trigger, said Jason Kunzman, Beacon Community senior project manager for ONC.

Well, this is all well and good. But I still think I’ll be keeping my basic medical info on a thumb drive for now.

Will Epic Interoperate With Other EMRs? Doesn’t Look Likely

Posted on March 2, 2012 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

Epic president Judith Faulkner has suggested more than once that her company’s system can interoperate with virtually every other system out there, including your grandmothers Pentium 286 with Windows 3.0 on it.  How?  Through the magic of the continuity of care document.

But what’s the real story?  If the informed commentary among a group of IT insiders on Google Plus is correct, Faulkner’s claims are, uh, exaggerated at best. Epic’s EpicCare Everywhere isn’t quite what it seems, the group concludes.

Vince Kuraitis noted that per Epic’s own technical manual, non-Epic institutions get an XML file containing the CCD, but the Epic institutions get an XML file containing Epic proprietary extensions to the CCD.  “This is consistent with Epic’s proprietary, one-vendor-shop,non-interoperability stance,” Kuraitis noted. “The statement that “any hospital can interoperate with EpicCare Everywhere – just so long as they are an Epic institution aptly summarizes this”

My colleague John Lynn notes that Epic says it will offer richer data exchange between two Epic hospitals, but will only interoperate with other EMRs that comply with industry standards. As John appropriately asks, which standards does Epic support?

Epic may get away with these ambiguities for now, but it may not do so for long, argued Dave Chase.  For one thing, he notes, even IBM was forced to embrace the open source gospel once it began to lose market share, and to some extent Microsoft.

Perhaps more significantly, some observers are beginning to question whether Epic’s locking up interoperability options could constitute a restraint of trade, putting them in the sights of not only the Federal Trade Commission but also the ONC. “To the extent that patients are being harmed, I would think that the ONC would have something to say,” Chase wrote. (I would tend to agree with him.

As is often the case where Epic is concerned, we’re left with a cloud of smoke even when smart people have smart discussions on the topic of the feckless Wisconsin giant. I sure hope someone holds them accountable, and soon.