ASTM E2369-12

1.1.1 The CCR data set includes a summary of the patient’s health status (for example, problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and the patient’s care plan. It also includes identifying information and the purpose of the CCR. (See 1.1.2 The CCR may be prepared, displayed, and transmitted on paper or electronically, provided the information required by this specification is included. When prepared in a structured electronic format, strict adherence to an XML schema and an accompanying implementation guide is required to support standards-compliant interoperability. The Adjunct1.2 The primary use case for the CCR is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.

1.4 Security—The data contained within the CCR are patient data and, if those data are identifiable, then end-to-end CCR document integrity and confidentiality must be provided while conforming to regulations or other security, confidentiality, or privacy protections as applicable within the scope of this specification.

1.5 The CCR is an outgrowth of the Patient Care Referral Form (PCRF) designed and mandated by the Massachusetts Department of Public Health for use primarily in inpatient settings.

1.6 It is assumed that information contained in a CCR will be confirmed as appropriate in clinical practice. For example, the CCR insurance fields should not be construed to address all reimbursement, authorization, or eligibility issues, and current medications and other critical data should be validated.

1.7 Committee E31 gratefully acknowledges the Massachusetts Medical Society, HIMSS (Health Information Management and Systems Society), the American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Association, the Patient Safety Institute, the American Health Care Association, the National Association for the Support of Long Term Care, the Mobile Healthcare Alliance (MoHCA), the Medical Group Management Association (MGMA) and the American College of Osteopathic Family Physicians (ACOFP) as co-leaders with ASTM in the standard’s development and adoption, and joins them in inviting the collaboration of all stakeholders, including other clinical specialty societies, other professional organizations, insurers, vendors, other healthcare institutions, departments of public health, and other government agencies.

1.8 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory limitations prior to use.