As the healthcare industry continues to wrestle with interoperability challenges, two standards are poised to play a central role in facilitating the electronic exchange of health information—one is a blunt tool for data sharing, while the other is a surgical instrument.

First adopted in 2012 as part of the Office of National Coordinator for Health IT’s 2014 Edition final rule, the Consolidated Clinical Document Architecture (C-CDA) version 1.1—developed through the joint efforts of ONC and Health Level Seven (HL7) International—is now widely used among healthcare providers. However, as HL7’s emerging Fast Health Interoperability Resources (FHIR) standard matures, stakeholders are taking stock of their respective strengths and weaknesses.

“C-CDA is a document standard for pushing complete medical record or encounter data from one organization to another,” says John Halamka, MD, chief information officer at Boston’s Beth Israel Deaconess Medical Center. “FHIR is a query/response transaction for pulling specific data types on demand, such as problems, medications, and allergies.”

As a result, Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, sees C-CDA and FHIR complement each other.

“C-CDAs are unwieldy because they contain a lot of data and XML ‘overhead,’ while FHIR is very clean by comparison because it focuses at the data level,” observes Tripathi, who is also project manager of the Argonaut Project, an industry-wide effort to accelerate the development and adoption of FHIR.

“On the other hand, patient context is very important in clinical care, so there are very many use cases where a provider wants to know the ‘story’ and not just an isolated data point—a C-CDA can provide that type of context,” he adds. “One of the common criticisms of FHIR by providers is that it doesn’t contain enough of the textual story of the patient.”

Nonetheless, Tripathi points out that the Argonaut Implementation Guides—designed to simplify and standardize the exchange of basic clinical data—support both data-level and document-level query, including C-CDA.

“Moving to FHIR APIs thus doesn’t eclipse the use of C-CDAs, it supplements them by giving a richer array of choices to the provider,” he notes. “That’s why it’s important to have both—the ability to retrieve an entire document, or the ability to get specific data elements. FHIR APIs are flexible for both.”

Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.
Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative.

Also See: FHIR expected to supplement, not replace, other standards

National Coordinator for Health IT Donald Rucker, MD, believes C-CDA, “like many standards, has room to evolve,” he said during a recent briefing. “Everybody who looks at that standard says ‘yeah, there are some good things there, but there are still things that could be fixed,’ ” Rucker proclaimed.

According to Steve Posnack, director of ONC’s Office of Standards and Technology, the agency established a cooperative agreement with HL7 to improve the C-CDA’s implementation consistency, enhance its computability and usability, as well as provide more transparency and feedback to the industry about the quality of C-CDAs generated in production.

This three-part strategy on the part of ONC is an attempt to address the “warts” associated with C-CDA implementations, says Posnack.

In particular, he points to two 2015 Edition certification criteria which are aimed specifically at addressing the C-CDA’s implementation consistency and usability. Posnack also references HL7’s multiple C-CDA Implementation-a-Thons at which health IT developers are given the opportunity to exchange documents in real time, collaboratively work out bugs and document implementation improvements, and come up with potential best practices.

Under the contract with ONC, HL7 has held a series of Implementation-a-Thons to “reduce the variability of C-CDA, to reduce the optionality, and to improve conformance testing,” says HL7’s CEO Chuck Jaffe, MD. “Those efforts have resulted in a significantly improved product as well as some testing tools.”

On that front, ONC has released two such tools: the C-CDA Scorecard and the One Click Scorecard.

The C-CDA Scorecard provides scores for C-CDAs submitted by developers and providers to help determine whether a document meets the requirements of the 2015 Edition Health IT Certification for Transitions of Care (pass/fail), and gives a grade based on a set of enhanced interoperability rules developed by HL7. For its part, the One Click Scorecard is a benchmarking tool for providers that evaluate the quality of clinical summary documents received or created by their respective systems.

A common complaint from providers is that C-CDAs are too long and include too many pages. “Allowing clinicians to find data elements when they request them, rather than pages of a C-CDA, is a work in progress,” acknowledges Jaffe. “There’s a lot of room for improving it.”

At the same time, Posnack describes FHIR as “more implementer-friendly,” compared with C-CDA, which he says requires a steeper learning curve to implement.

“We do see, at least for the foreseeable future, both FHIR and C-CDA coexisting,” comments Posnack. “That’s because they’re at different stages of maturity, but also because they’re being used for different purposes.”

Likewise, Tripathi says that “C-CDAs will be with us for a long time.”

“Because C-CDA is in regulation, and hundreds of millions of dollars have been spent on solutions which are C-CDA-based, it’s not going away for quite some time,” concludes Jaffe.

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