Continuity of care documents bridge gaps

In Portland, Ore., behavioral health provider LifeWorks NW and Virginia Garcia Memorial Health Center, a federally qualified health center, have long worked to coordinate care, which involved lots of document scanning, phone calls and transferring of paperwork. Clinicians were unable to electronically access patient records from their counterparts, even though they had many patients in common. 

But now after considerable retooling of their electronic health records (EHR), the two organizations are exchanging distilled information in what are known as continuity of care documents (CCDs).

“Mental health is such a big part of care that to not have that information easily available is silly,” says Laura Byerly, MD, medical director at Virginia Garcia. “But even this close relationship with Lifeworks does not mean that it has been easy to get information to flow both ways.”

So what is a CCD and how are providers starting to use them to build interconnectivity? 

Created by a standards development organization, the CCD is a standardized document template for transferring patient information between care settings. In theory, the same information could be transferred by paper documents. But in the digital infrastructure, modern EHRs are designed to generate CCDs that compile an agreed-upon core data set of relevant administrative, demographic and clinical information in a patient’s record for transmission.

They can be used for transitions of care from one setting to another as well as for referrals. Once established, the standard data set does not change regardless of the type of provider. A behavioral provider would include patient demographics, the presenting problem, current medications, a brief summary of assessment results and the plan for care.

Like most providers exchanging CCDs, the Oregon partners create a secure e-mail message using a protocol called “Direct” and send it to the partner provider through a certified health-information exchange. The partners’ EHRs can ingest the incoming information in the CCD to populate their own records.

Slowly but surely

Byerly says that while progress has been made in Oregon, there are still many limitations to the CCD approach.

“The data set is narrow, and the richness of the information coming across still isn’t where it needs to be,” she says. “I want to know whether the patient’s depression is getting better or not, but what I get to know is that they have increased their medication to a certain dose or they were seen for a certain type of visit. I don’t get to know much about what the content of the visit was. I do know they were talking to someone. So we are not where we need to be.”

Byerly says another issue for her organization is that the Direct secure messages from LifeWorks get mixed in with the slew of messages the clinic receives from all the local hospitals.

“There are lots of these messages, and they are indiscriminate,” she adds. “The utility of the LifeWorks messages are decreased because of this other noise coming to the same place. We have to keep working on this.”

Because CCDs do not contain any fields specific to behavioral health, some behavioral providers assume they are irrelevant to their work, says Colleen O'Donnell, policy and practice improvement specialist for the National Council for Behavioral Health.

“Behavioral health providers can go one of two ways: They can integrate with the larger healthcare system, or they can go in a direction that is isolating and creates barriers to exchanging patient health information,” she says. “When a behavioral provider looks at a CCD for the first or second time, they almost invariably say, ‘this doesn’t have anything to do with behavioral health.’ But that is not the truth,” she says. “That is an artifact of a mindset about treating patients.”

In fact, she adds, behavioral health providers need to know the patient’s conditions, what the diagnoses are, what medications the patient is taking, and any medication allergies.

“They need to know about clinical lab test results, especially around primary healthcare indicators like tests for blood pressure and blood glucose levels,” she says. “So it is really about changing the perspective that the behavioral providers have about their role in the system and also about changing the perspective of the primary and specialty care system.”

Reason to upgrade

Clearly the challenges are more than attitudinal, and so far, success stories of behavioral and other providers regularly exchanging CCDs are few and far between. In 2013, the Commonwealth of Pennsylvania launched a pilot project designed to use CCDs to exchange data between behavioral providers and primary care settings.

Matt McGeorge is a senior consultant with Health Management Associates in Harrisburg, Pa., and served as the health information technology coordinator for the Pennsylvania Medical Assistance Program during the pilot. He says that because behavioral health providers were not eligible for the federal EHR incentive program, many of their EHRs were older and insufficiently prepared to produce and exchange a CCD, which is addressed under the incentive program’s certification requirements.

Even with certified EHRs, some providers found their systems created CCDs in an unusable format, he says. For example, several systems created CCDs that were difficult to read because they were prepared in a certain type of electronic language format. As part of the 2013 pilot, providers worked with consultants and EHR vendors to identify and attach an appropriate style sheet to translate CCDs into something readable at the receiving end.

Furthermore, many providers found they were not able to integrate the incoming CCDs directly into their EHRs. Instead, they created workarounds, such as sending the CCD as a PDF and then manually uploading or attaching the PDF to the record, so that providers were able to access patient information. Those providers needed to modify workflow processes to accommodate the lack of automatic consumption of the CCD.

“We knew there were going to be challenges, but we didn’t think it would be as much of an issue around the ability to get things integrated from one setting to the other and make the workflows less clunky,” McGeorge says. “In hindsight, we realized that just because you have certified products on both ends doesn’t mean they are going to be able to make use of the data from one setting to the other.”

Many providers in the Pennsylvania pilot told the Commonwealth that if they had not been approached with offers of technical assistance and training, they would not have considered exchanging CCDs a top organizational priority.

Serving up data

Data exchange is becoming a success story in some regional health communities. The EHR system at Providence Center, a community mental health center based in Providence, R.I., is set up to automatically create a CCD and send it via a Direct message to CurrentCare, which is the state’s hub for health information exchange. With nearly half of the state’s patient population opting in to allow such coordinated data swapping among providers, CurrentCare has been serving up behavioral health data since 2013.

To get the information to flow, the Providence Center EHR vendor had to make a change so that at the end of a patient encounter, the system would automatically generate a CCD, attach it to a Direct message, and send it off. The clinical data is then attached to the patient’s CurrentCare account, making that data available to all members of the patient’s care team.

“What we send is demographics, allergies, problems and diagnoses, including substance use diagnoses, medications and lab results,” says Bill Cadieux, chief information officer for Providence Center. “If one of our clients is enrolled in CurrentCare, we get a Direct message if they are hospitalized or seen in an emergency room or discharged. That is a call to action to us.”

He says clinicians can leverage the information to see medication reconciliation on admissions and discharges. For substance use disorder information, the client must give separate consent to release data from CurrentCare, in compliance with privacy laws.

In another example, Western Colorado’s Quality Health Network is working to integrate behavioral health data into its data exchange hub. Mind Springs Health validates and secures the patient consent to share reports with referring providers, then sends a CCD via Direct to the hub. The report is then “pushed” to the referring provider with the patient consent attached.

The National Council’s O'Donnell says it is important to remember that the CCD is not just a data set. It is a tool that providers can use to exchange patient information to improve the quality of care and to improve effectiveness and efficiency on both sides.

She provides a hypothetical example of working with a patient who is angry and agitated: “In the treatment plan I am working on, I am treating him for anger management. It turns out he has a diagnosis of diabetes, and I didn’t know that because I don’t have clinical lab test results or the problem list,” she says. “I don’t have his medication list, so I don’t know if he is taking any medications for diabetes. There is no question that exchanging this information makes an enormous difference in the quality of care and effectiveness of care.”

David Raths is a freelance writer based in Pennsylvania.