Findings from the SMART C-CDA Collaborative

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Upgrades to electronic health records (EHRs) were scheduled to be introduced in the US in 2014 and had the aim of advancing the interoperability of documents amongst clinicians. Meaningful use the second stage of the EHR adoption program, requires the use of the Consolidated Clinical Document Architecture (C-CDA) [1] for the exchange of documents. A group of EHR vendors were brought together in order to examine and improve the C-CDA based exchange. [2]


Emails were sent out to various organizations listed on the Certified Health IT Product List inviting them to participate in the study ( In order to participate the vendor organizations were required to submit a C-CDA document that showed the exportation of a fake patient’s health record form their software program. C-CDA documents from vendors as well as non-vendors were collected and compared or samples.


Only 44 organizations out of the 107 invited responded to the emailed invitations. Fourteen of those organizations submitted at least one C-CDA sample from their application. 91 C-CDA documents were collected in total. Samples were then put in categories based on whether or not the vendor application was MU2 (Meaningful use stage 2) certified.

Barriers to semantic interoperability

  • Present in automated detection
  • Potential for automated detection
  • Issues difficult to detect automatically

Improving C-CDA document quality

The following are recommendation to improve quality:

  • Provide richer samples in publically accessible format
  • Validate codes
  • Reduce data optionality
  • Monitor and track real-world document quality


Based on the errors observed in the C-CDA documents produced it is concluded that technologies in stage 2 will most likely omit important clinical information and often require the use of manual data reconciliation during exchange. This study demonstrated the powerful effect a group collaborative can have on identifying challenges to interoperability. More research is needed to determine if C-CDA documents will be able to be progress to strong pillars of interoperability.


The ability to effectively communicate patient information in a timely manner is critical for continuity of care. Patients can be better treated if their records are at the point of care to ensure that appropriate decisions are made.


  1. Implementing Consolidated-Clinical Document Architecture (C-CDA) for Meaningful Use Stage 2
  2. Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative John D D'Amore, Joshua C Mandel, David A Kreda, Ashley Swain, George AKoromia, Sumesh Sundareswaran, Liora Alschuler, Robert H Dolin, Kenneth DMandl, Isaac S Kohane, Rachel B Ramoni Journal of the American Medical Informatics Association Nov 2014, 21 (6) 1060-1068, retrieved September 30, 2015, from DOI: 10.1136/amiajnl-2014-002883