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Why and where CDA François Macary, Christel Daniel.

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1 Why and where CDA François Macary, Christel Daniel

2 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange and sharing. CDA is part of HL7 V3. As such, it relies on the HL7 Reference Information Model and the HL7 V3 data type. It enables to represent any static clinical content in a format, which is both human-readable and system-processable. A single xml schema validates any kind of CDA document What is CDA?

3 Messages are appropriate artifacts to support exchange of clinical information during the production of care. The output of the process of care is better captured in static documents, persistently accountable to their authors and understandable per se to care providers. The document sharing paradigm is the best fit to enable patient care coordination and care continuity among care providers and their systems, which are not coupled to one another. IHE provides a set of infrastructure profiles around XDS, to support this document sharing paradigm. The shared content is most often CDA documents. Why CDA?

4 A single xml schema CDA.xsd is used to validate any instance of CDA document. A template of a CDA document is a set of constraints applied to the general standard. It is both a specification and a schematron, which tests the conformity of document instances to that template. Validation & Conformance

5 CDA content profiles in IHE domains DomainSt.Profiles AP AP structured report (APSR): 1 generic + 20 organ specific templates Card. Cardiac Imaging Report Content (CIRC): 1 report template ITI Scanned documents (XDS-SD): 1 template with a non-structured body LAB Sharing laboratory reports (XD-LAB): 1 report template Patient Care Coordi- nation (PCC) 7: Medical Documents, Medical Summary, Referral Summary, Discharge Summary, PHR Extract, PHR Update, Emergency Department Referral, 4: Antepartum History & Physical, Antepartum Summary, Antepartum Laboratory (from XD-LAB), Education 3: Labor and Delivery History & Physical, Labor and Delivery Summary, Maternal Discharge Summary 4 in emergency department: Triage Note, Nursing Note, Composite Triage & Nursing Note, ED Physician Note Pharmacy 3 document templates

6 Testing of content profiles at Connectathons 2011 #Systems as Content Creator Actor ProfilesNorth-America 2011Europe 2011 PCC profiles282 XD-LAB53 XDS-SD132

7 A number of countries have adopted CDA R2 globally: Finland was the first broad adopter Austria: ELGA project France: CDA is mandated for patient care coordination. XD-LAB has been chosen for lab reports. APSR is required for cancer case AP reports. However, lab system vendors are not ready yet. US: in meaningful use ? In other countries, adoption is made at the regional level Italy Veneto US Regional Health Information Organizations (RHIOs), Spain Catalogna … Adoption of CDA

8 Thank You

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