CDA Overview HL7 CDA IHE Meeting, February 5, 2002 Slides from Liora Alschuler, alschuler.spinosa Co-chair HL7 Structured Documents TC Updates by C; Parisot

The HL7 Clinical Document Architecture A document markup specification HL7 clinical documents: –persistence –stewardship –potential for authentication –wholeness –human readable

The HL7 Clinical Document Architecture priority is patient care, other applications facilitated minimize technical barriers to implementation promote longevity of clinical records scoped by exchange, independent of transfer or storage enable policy-makers to control information requirements

CDA Structure Overview CDA Body (Level1): Sections (coded) Paragraph Lists Tables Content is text, links, multimedia CDA Document Document Body Class/Identifier Patient Encounter Provider CDA Header: identifiers/class of document, authentication info Encounter Patient Provider

The HL7 Clinical Document Architecture CDA header –rigorously defined, RIM-derived, based on 10+ years Medical Records management –ground up compatibility with DICOM SR CDA Level One body –loose XML, fits any report type –has image link, coded vocabulary CDA Release 2 in development –specific to document type, coded entries –permit rigorous specification at arbitrary levels of granularity

A Sample CDA Document

Summary of CDA Use Cases standardized metadata document persistence document independent of transport supported by heterogeneous tool set, users retain choice of tools integrates diverse, distributed applications integrate XML and non-XML sources with common metadata mixing of data and narrative (choice of usage)

access across distributed systems low point of entry, ability to scale up supports shared care knowledge integration: links to other documents outcomes research claims attachments: retains full document context continuity with paper world flexibility of XML Summary of CDA Use Cases

CDA and the document-centric EHR The CDA Header: “The purpose of the CDA Header is to enable clinical document exchange across and within institutions; facilitate clinical document management; and facilitate compilation of an individual patient's clinical documents into a lifetime electronic patient record.” CDA, 3.2.1

The Document-centric EHR Documenting patient care Shared care Clinical trials Public health Orders Quality improvement Reimbursement Diagnostic imagingPathway, guidelines Decision support Relationships: Equal Derive Incorporate Link Transform

The Next Gen CDA Release 2 –alignment with current RIM, V3 methodology –minor enhancements to CDA Header –added functionality for CDA Body reference coordinates “Link CDA” (strong link for inclusion) –templates layered on basic XML spec Level Two: templates for headings Level Three: templates for contents –enables detailed clinical encoding

A Sample Next Gen CDA Document

HL7 Templates Joint project of Templates SIG, Structured Documents TC, Conformance SIG –“A template is a structured collection of data, aggregated for some purpose, of interest to one or more healthcare stakeholders. An HL7 V3 Template specifically is a constraint against a normative HL7 V3 (message or document) specification.”(draft language, Bob Dolin principal author)

HL7 Templates template expression format will be normative; individual templates may be balloted open template registry/repository –can register templates created by other standards orgs, professional societies, providers, vendors –will contain normative and non-normative templates tools for generating and validating templates will be developed