Understanding the Acronym Puzzle: What Health Professionals Need to Know About C-CDAs, CDAs, and CCDs

For more than a decade, healthcare institutions have been using electronic health records (EHRs), as well as standardized templates for files containing medical information, in order to share data electronically.  By 2011, the number of physicians using EHR systems had grown to 57% – and since then, with the introduction of the federal government’s EHR Incentive Program, electronic data exchange has become nearly ubiquitous, with most providers providing a CCDA patient portal.  

Despite their common use, many healthcare professionals remain perplexed about the templates that are used to create patient medical data files.  This confusion is likely a result of:

  • Multiple organizations having designed templates containing similar information, including:
    1. HL7 (Health Level 7)
    2. ASTM (American Society of Testing Materials)
    3. IHE (Integrating the Healthcare Enterprise)
    4. HITSP (Health Information Technology Standards Panel)
  • Many of the templates having similar-sounding names.

Electronic Data Transfer: Understanding the Past

When the CCD (Continuity of Care Document) was first released in 2007, it was trumpeted as the progressive electronic data transfer template for healthcare IT: it contained all pertinent information for a transfer of care, and was housed within a library of HL7 templates that could be applied to a variety of scenarios.  This library of HL7 templates was collectively known as “clinical document architecture” (or “CDA”) files.

The primary advantage of CDA files is that they use a “bucket” of reusable templates as building blocks for multiple file types, which makes it easier to develop applications that can support those file types.  

This “bucket” of available templates for CDA files includes:

Advanced Directives
Chief Complaint
Family History
Functional Status
Medical Equipment
Plan of Care
Problems List
Review of Systems
Social History
Vital Signs








The table below gives visual explanation of how multiple section templates are used to build CDA files. The section templates in green are used in both the CCD and H&P files.

Table source: “Implementing C-CDA for Meaningful Use Stage 2” from the office for the National Coordinator for Health Information Technology.   

The family of CDA files currently includes:

  1. Care Plan – including Home Health Plan of Care (HHPoC)
  2. Consultation Note
  3. Continuity of Care Document (CCD)
  4. Diagnostic Imaging Report
  5. Discharge Summary
  6. History and Physical (H&P)
  7. Operative Note
  8. Progress Note
  9. Procedure Note
  10. Referral Note
  11. Transfer Summary
  12. Miscellaneous or Unstructured Document

To learn more, see the HL7 CDA R2 Implementation guide.

Lessons Learned from Stage 1 MU

Despite the declaration that electronic data templates like the CCD would streamline patient care among disparate healthcare providers, widespread use of the templates during Meaningful Use stage 1 brought several issues to light.

The problems can be divided into two main categories:

  1. There were multiple data formats.  At the same time that the HL7 was producing CDA templates in XML format, other standardization organizations were producing different templates using different coding formats.  ASTM produced the CCR (Continuity of Care Record), and IHE produced the PCC (Patient Care Coordination) file.
  2. The referencing standards were complicated.  For example, the accepted CCD in stage 1 MU was the C32. Though the C32 was produced by HITSP, the file format was developed by HL7. So to understand how to implement the C32, users needed to dig through documentation from both HL7 and HITSP.

Standardized Templates in 2017 and Beyond: Why C-CDA Was Created

To address the issues identified in stage 1 of MU, HL7 – in collaboration with other standardization organizations – released the consolidated CDA (or “C-CDA”) implementation guide.  The primary objective of the C-CDA was to improve interoperability by:

  1. Simplifying the referencing standards.
  2. Improving the framework of CDA files.
  3. Establishing a library of all CDA templates.
  4. Providing guidance on implementing the CCD (the most common CDA file).

Click here for HL7’s guide to C-CDA implementation.

C-CDA files are the document standard for stage 2 of Meaningful Use, and over 90% of major US hospitals are using HL7 templates.  But in spite of this, widespread interoperability problems continue to exist. These issues are primarily related to ambiguity in data format requirements.  HL7 recognizes that interoperability is hindering advancements in data sharing, and has launched the “Partners in Interoperability” program to address the problem.

Where are CCDA patient portals Heading?

Since the first implementations of EHR systems began more than a decade ago, the seamless exchange of healthcare data has moved from an unattainable ideal to a necessity of healthcare.  It’s becoming a requirement for all types of healthcare software systems, including patient portals, to be able to read and accommodate multiple file types.  Bridge Patient Portal’s interface expertise and proprietary C-CDA parser offer a data sharing platform suitable for large practices, health systems, and hospitals. Call us at 866-838-9455 to learn more or view a demo demonstrating patient access to C-CDAs in our patient portal.

Blake Rodocker
Blake Rodocker

Blake joined Bridge Patient Portal in 2016 after transferring from our parent company Medical Web Experts. Since then, he’s acted as Bridge’s Business Development Manager. Blake is passionate about driving collaboration with clients, partners, and internal teams to achieve performance goals and successful relationships.