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E-Patient Update: Apple Offers iPhone EMR Access

Posted on June 22, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 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. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Over the last few years, Apple has steadily beefed up the health data access provided by its iPhone operating system, in ways that have made some sense. But depending on how consumers react, its latest effort may have the biggest impact of all of its data sharing efforts to date.

In its latest mobile operating system, Apple is allowing users to store their EMR data directly in its Health app, using the HL7 CCD standard. And while this isn’t a huge step forward for interoperability, it does give e-patients like me a greater sense of control, which is definitely a good thing.

In recent years, Apple has made increasingly sophisticated efforts to unify healthcare data. Perhaps the highest profile effort is the summer 2014 launch of HealthKit, a healthcare data integration platform whose features include connecting consumer-generated data with traditional clinical sources such as the Epic EMR.

Meanwhile, it has steadily added capabilities to the Health app, which launched with iOS 8. Since then, it has been encouraging consumers to manage health data on their phone using HealthKit-enabled apps like the Epic MyChart patient portal app. The new EMR data retrieval function is available in the iOS 10 version of Health.

According to Apple blog 9to5Mac, consumers can import the CCD data from Mail, Safari and other applications as well as into Health. When consumers add the CCD file to Health, the app opens and providers a quick preview of the document’s data, including the healthcare provider’s name, patient’s name and document owner’s name. It also identifies the document’s custodian. Once downloaded, the device stores the document in encrypted form, indefinitely.

Also, when a user confirms that they want to save the record to the Health app, the CCD info is added to a list of all of the health record documents stored in the app, making it easier to identify the entire scope of what a user has stored.

Looked at one way, the addition of medical record storage capabilities to the latest iOS release may not seem like a big deal. After all, I’ve been downloading broad swaths of my healthcare data from the Epic MyChart app for a couple of years now, and it hasn’t rocked my world. The document MyChart produces can be useful, but it’s not easily shareable. How will it change patients’  lives to store multiple records on their cell phone, their tablet or heaven help us, their Apple Watch?

On the surface, the answer is almost certainly “not much,” but I think there’s more to this than meets the eye. Yes, this solution doesn’t sound particularly elegant, nor especially useful for patients who want to share data with clinicians. My guess is that at first, most consumers will download a few records and forget that they’re available.

However, Apple brings something unique to the table. It has what may be the best-integrated consumer technology base on the planet, and can still claim a large, fanatical following for its products. If it trains up its user base to demand EMR data, they might trigger a cultural shift in what data patients expect to have available. And that could prove to be a powerful force for change.

Direct Messaging: The Logistics of Exchange

Posted on June 12, 2014 I Written By

Julie Maas is Founder and CEO of EMR Direct, a HISP (Health Information Service Provider) whose mission is to simplify interoperability in healthcare through the use of Direct messaging EHR integration and other applications. EMR Direct works with a large developer community to enable Direct for MU2 and other workflows using a custom, rapid-integration API that's part of the phiMail Direct Messaging platform. Julie is passionate about improving quality of care and software user experience, and manages ongoing interoperability testing within DirectTrust. Find Julie on Twitter @JulieWMaas.

Once you enable digital health data exchange via Direct instead of by fax, you’ll want to share your address with other providers, so you no longer have to deal with all those pesky scanned attachments, subtly linked to electronic patient records.

Direct directories are enabling address lookup to meet this need, and you can also let your most common business partners know your address by including it on document templates you already exchange today, so they can begin to exchange with you via Direct when they’re ready.  You can also contact your referring docs using another method you trust (such as the fax where you usually send them medical records, or their business phone number) to ask for their Direct address.

It’s wise to confirm expectations with exchange partners about the use cases/data payloads for which you intend to exchange via Direct, as Direct isn’t used just like email by everyone.  Some will use Direct solely for Transitions of Care and patient Transmit, others may use it for Secure Messaging with patients, and still other providers will be happy to conduct general professional correspondence with patients and other providers over Direct.  This service information may or may not be reflected in the first provider directories.  And even within the Transitions of Care use case, if standards aren’t implemented for optimal receiving, a sending system may generate a CCDA (Continuity of Care Document) with a subtly different structure than a receiving system is able to completely digest.  So, just a heads up as you receive your first message or two from a system with whom you haven’t exchanged before: you’ll want to carefully monitor what data is incorporated by the receiving system and what is not, and you may need to iterate slightly between sender and receiver to get the data consumption right.  You’ll still be miles ahead of the custom interfaces model.

All in all, Direct is easy to use and is working much better than the naysayers would have you believe.  Direct software follows the specification outlined in the document lovingly known in the industry as the “Applicability Statement”, crafted by consensus through a public/private collaborative effort known as the “Direct Project” and led by the Office of the National Coordinator of Health Information Technology (ONC).   Direct Project volunteers have also written reference implementations following this specification which have been used by many HISPs and EHRs as the basis for their own Direct offerings.  Other private entities have developed their own APIs and implementations of the protocol from scratch.  These different systems and varying configurations regularly test and collaborate with each other, to make Direct work as seamlessly as possible for the end users.  Because the whole system only works as well as our joint efforts, HISPs (Health Information Service Providers who provide Direct services) within the DirectTrust Network take interoperability seriously and work together to iron out any kinks.

A tremendous amount of collaboration is taking place to bring interoperability to fruition for Direct’s well-established standards and policies, and this work is producing a larger and more robust network each day.

Are EMRs And Paper Records Incompatible?

Posted on July 15, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

I just caught a blog post by the indefatigable Fred Trotter (a high-profile Open Source guy focused on HIT) which raised an important issue.  In his article, Trotter argues credibly that once a healthcare organization implements an EMR, its records are more or less incompatible with standard paper records.

Trotter cites the troubling case of two primary care groups which, despite the using same major EMR system, can only share data by printing out massive paper transcripts of a patient’s electronic record.

Apparently, each have a custom version of the system in place, which means that the two groups couldn’t share data directly. So when a patient from Practice A moves to Practice B, Practice A’s only option is to generate what — from a photo included in the article  — looks like thousands of pages of data.

Not only are such paper printouts awkward to store and manage, they’re painfully difficult to use. While traditional handwritten records provide a familiar, and relatively concise, source of medical data, this blizzard of paper could actually bury critical information.

After all, while the data might make sense when access via the EMR’s digital templates, doctors may not know where to find what they’re looking for when confronted with the print equivalent of a massive Excel spreadsheet.

Not only that, when Practice B scans this paper monster into its system, the problem just gets worse. When caring for the patient, B’s doctors will doubtless begin entering data into their own EMR system, piling structured data on top of incompatible scanned data. How clinicians will figure out what’s up with the patient is a mystery to me.

As commentors to Trotter’s item noted, the two practices could probably have shared a summary in Continuity of Care Document format. However, unless practices are willing to make do with a summary over the long term, they’re likely to confront paper printouts for quite some time.  Not a pretty picture, is it?

Information on CCR, CCD and EMR

Posted on November 4, 2009 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.

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