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Continuity of Care Record (CCR) in Germany? PROREC activities on the way to EHR interoperability


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Herzlich Willkommen!

EHTEL Telemed eHealth IOP Satellite – Heidelberg, 12 June 2008

Continuity of Care Record (CCR) in Germany ? –

PROREC activities on the way to EHR interoperability

Sebastian Claudius Semler

- Vice Chair PROREC-DE –



ªfounded in Dec. 2002

ªGerman association (e.V.)

ªprivate and institutional memberships

ªnational EUROREC centre (member of EUROREC) ªPROREC intentions:

ªfoster implementation and pervasiveness of EHR / EPR ªcontribute to standardisation of EHR / EPR

ªdissemination of EHR / EPR benefits ªChairmen PROREC-DE:

ªHorst Strüter (2002-2005) ªBernd Blobel (2005-2007) ªRolf Engelbrecht (2007- ) ªParticipant in EU project QREC

ª2002 association with VHitG; 2006 first new industrial members ªworkshop acitivites; 2007/08: CCR workshops







EuroRec - Institute

«European Institute for Health Records»

ª non-profit organisation ª established 16 April 2003

ª goal: promotion of applications and systems based on

Electronic Health Record systems (EHRs) in Europe

ª Support of national ProRec centres in Europe ª EUROREC repository & tools

EU Funding periods

ª PROREC (1996-99) – WIDENET (2001-03) – Q-REC (2006-08)

Participation in EU projects


Zentren Belgium Bulgaria Danmark Germany France Ireland Italy Rumania Serbia Slovakia Slovenia Spain Antragsteller Greece Great-Britain Netherlands Norway Poland Portugal Sweden Turkey Hungaria Cyprus

“ Differences in Language, Culture und Health Care System ”



European Quality Labelling and Certification of Electronic Health Record systems (EHRs)

Duration: 2006 - 2008

Contract No: IST-27370-SSA

Coordinator: Prof. Georges De Moor http://www.eurorec.org/


National policies for EHR implementation in the European area: social and organizational issues

Duration: 2007 - 2010

Contract No: IST-27370-SSA Coordinator: Dr. Laurence Esterle



A Roadmap for Interoperability of eHealth Systems in Support of COM 356 with Special Emphasis on Semantic Interoperability

Duration: 2006 - 2007 Contract No: IST-027065

Coordinator: Prof. Asuman Dogac




Project Goals:

ªMethods and Processes for “Quality labelling and

Certification” of EHR systems in Europe

ªEstablishing of a central EUROREC repository for quality

and certification criteria, suitable for testing, benchmarking etc.

ªHarmonisation via national PROREC centres

ª12 Partner and 2 “subcontractors”

ªEuroRec Institute = coordinating partner ª30 months (01-01-2006 – 30-06-2008)


Repository Workflow


Continuity of Care Record (CCR)

ªdeveloped 2003 – 2006 by ASTM

(American Society for Testing and Material)

ªASTM E 2369-05

Standard Specification for the Continuity of Care Record (CCR)

ªASTM Committee E31 on Healthcare Informatics –

SUBCOMMITTEE E31.28 on ELECTRONIC HEALTH RECORDS / CCR Initiative (c/o Claudia Tessier)

ªsupported by > 12 clinical associations and institutions (US),

representing 500.000 MDs – e.g. American Academy of Family Physicians (AAFP), American Academy of Pediatrics

ªbasic idea:

ªCCR = core data set as (patient) summary

of all the key current and historical data

that defines that patient’s current clinical status


Technical Design of the CCR

(Source: ASTM – CCR)

Comprehensive Security, Confidentiality, and Privacy

ª Support for compete dis-identification of data from patient and provider(s).

ª Support for static encryption and encryption in transport (IETF/W3C Compliant). ª Support for blinded patient, provider, and data identifiers.


ª IETF/W3C Compliant - all content tagged, all formatting supported through

external .xslt(s).

ª Maximized for parsing efficiency and system scalability.

ª Language (tag and content) independence. ª Human readability.

ª Ease of implementation. Data Model

ª XML-based object-relational data model.

ª De-normalized for processing (processor) efficiency. ª UML object data model representation.

Implementation Support

ª Designed to map seamlessly with PHR and EHR architectures. ª Support for 100% open-source implementation if desired.

ª Implemented using widely supported machine-readable (XML) and display/print output (PDF/H) formats.


Continuity of Care Record (CCR) Structure

XML-based, flexible data representation, scalable

ªCCR Header ªCCR Identification ªPatient Identification ªCCR Body ªPayers ªAdvance Directives

ªFunctional Status, Problems (incl. Diagnoses) ªFamily & Social History, Alerts


ªVital Signs, Results (incl. Lab)

ªProcedures, Plan of Care, Addresses ª…

ªCCR Footer


Continuity of Care Record (CCR) Problems


ªto identify & extract the key clinical data needed

from the patient and the medical record to make clinical decisions

ªneed to have interoperable data models

ªneed to have data access (export & import) to EHR systems ªcomplementary to HL7 CDA

ªexchange of “data sets” vs. “electronic documents” ª“de-normalized” vs. “redundant”

ª“flexible” vs. “not binding / not mandatory” ªno (obligate) controlled terminology

ªexisting model convenient to US MDs, not fully compatible


Continuity of Care Record (CCR) in Germany ?

ªEHR situation in Germany:

ªno central mission and national institution

to push nation-wide EHRs (no “masterplan”) ªGematik ?

ªwill § 291a EPR ever come ?

ªsecondary use scenarios restricted by law

ªTechnical, organizational and financial resources are bound

to implementation project of the health card and the gematik telematics infrastructure.

ªlocal and regional approaches and projects

ªwith different business models ªwith different standards

ªfrustration and declination of IT / EPR projects by the


Continuity of Care Record (CCR) in Germany ?


ª3rd Workshop: “CCR-DE – a medical data set

supporting continuity of care”

ªMunich, 27 – 29 April 2008 Topics: ªBasis ªExperiences from CCR-implementations in US (ASTM CCR) ªEHR-COM international standard (EN 13606) ªGoals

ªDevelopment of a concept for CCR-DE ªImplementation considerations


Continuity of Care Record (CCR) in Germany ? PROREC Project Idea

Project Idea:

ªEvaluation of CCR data set with German MDs

(is CCR suitable for the German routine ?)

ªEvaluation of CCR data sets concerning usability for clinical /

epidemiological research, public health

ªGerman translation of CCR specification and field definitions ªconceptual integration of archetypes (EN 13606 – openEHR) ªconceptual integration of well-defined nomenclature

elements (controlled terminology)

ªconceptual integration of gematik security architecture ªpilot implementation with German practitioners – using

medication export data sets for gematik ePrescription

ªShowcase: … bringing back benefits of structured data

exchange to the German MDs ! (no CCR vs. CDA project!) Support: Bavaria Min. Health, Baymatik / Go-In (eGK-Testregion),


Thank you for your attention !

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