Clinical Document Architecture

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The Clinical Document Architecture ( CDA ) is an XML- based standard developed by HL7 for the exchange and storage of clinical content. A CDA document corresponds to a clinical document (e.g. doctor's letter, findings report). There is no combination of several documents as in a patient file.

Versions

CDA Release 1 (November 2000) and CDA Release 2 (May 2005) have been accredited by the American standardization authority ANSI / ASTM . In 2009 the Release 2.0 ISO standard ISO / HL7 27932: 2009 was published. The CDA is considered to be the first official standard in healthcare based on XML.

CDA is part of the HL7 Version 3 standard. Like other parts of the HL7 Version 3 standard, CDA was developed on the basis of the HL7 Development Framework (HDF) and is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 data types.

Properties and structure

CDA documents offer the possibility of standardized, structured transmission of medical content. CDA documents are persistent .

A CDA document is basically composed of two parts:

  • CDA header with information about the document and the documented event as well as about the patient, the healthcare professionals involved, etc.
  • CDA body with the actual clinical content such as questions, observations, diagnoses, medication, therapies, information on follow-up appointments, suggested appointments, etc. The documentation can be broken down into sections. Text formatting functions such as lists and tables are available.

The focus is always on communication between people (person-to-person interoperability), ie documentation is always in text form. In addition, the readable text can be supplemented with information blocks that can also be used by computer applications (application interoperability).

The specification distinguishes between three levels that build on one another and differ in the degree of structure of the document content:

  • CDA Level 1 : Representation of existing clinical documents in XML, focus on layout and basic formatting of free text (sections, highlighting, tables). Allows only limited interoperability, because the content is not machine-readable. This means that documents can be properly displayed by different systems , but they cannot be processed further by machine . For example, the individual laboratory values ​​contained in a CDA Level 1 document can not be automatically entered in a central laboratory value table.
  • CDA Level 2 : In addition to Level 1, value is placed on interoperability , whereby the free text content of Level 1 is retained. Level 2 adds a uniform, structured description and structure of the content (type of document, sections, subsections). The individual components are classified using standardized codes and code systems ( LOINC , SNOMED ).
  • CDA Level 3 : Machine-readable information is added so that e.g. B. transmitted laboratory values ​​can be automatically entered in the laboratory value table of the recipient. The structures used are based on the HL7-RIM, i.e. use the same data types and structures as other HL7-based communication processes, e.g. B. for the transmission of laboratory values.

For all three levels, however, the primacy of information contained as free text ( narrative block ) applies , the machine-readable data and structures only serve as a supplement and can facilitate and support the processing of the information.

literature

  • RH Dolin, L. Alschuler, C. Beebe, PV Biron, SL Boyer, D. Essin, E. Kimber, T. Lincoln, JE Mattison: The HL7 Clinical Document Architecture. In: J Am Med Inform Assoc. 8 (6), Nov-Dec 2001, pp. 552-569.
  • KU Heitmann: The Clinical Document Architecture (CDA). In: Stud Health Technol Inform. 96, 2003, pp. 279-284.
  • KU Heitmann: Standard for electronic documents in health care - the Clinical Document Architecture Release 2. In: Forum of medical documentation and medical informatics. 2, 2005, pp. 49-54.

Web links

Individual evidence

  1. ↑ ISO / HL7 27932: 2009 Data Exchange Standards - HL7 Clinical Document Architecture, Release 2 https://www.iso.org/standard/44429.html