Add Level 4 to CDA R3

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Submitted by: Rene Spronk (Rene spronk) Revision date: 20091014
Submitted date: 20091014 Change request ID: <<Change Request ID>>


  • CDA uses Levels to indicate the level of detail (software processability, granularity thereof) of data in entry data. This proposal seeks to add the notion of "Level 4" to CDA R3, to identify entries that are linked (by means of content ID, see section of CDA R2) to the section text. A level 4 document is a level 3 document *with content links*.


  • Add a description of Level 4 (next to the current Levels 1,2,3) to CDA vR3.
  • The description of level 4 should be as follows: The CDA specification with the entry-level requirement that the entry is linked to the semantically equivalent part of the human readable text in a section.


The mechanism of associating pieces of the section text with an entry is part of the current CDA R2 standard, see section of CDA R2. Establishing the link, and its rendering, are already covered by CDA R2. I'm not suggesting to change the current wording. The proposal only seeks to label the use of such links as "level 4".

The linking of entries and text is optional (in future: level 4), just as the use of entries is optional (level 3). If we regard content links as a desirable feature (the ultimate end goal in structuring the data in a CDA section), it is worth the effort to label it as such. Therefore, mainly for conformance and marketing reasons (desirability of content links) the notion of "level 4" should be added to CDA R3.


Feb 9, 2010 SDWG teleconference: Unclear on the value of calling out Level 4. Will invite Rene to discuss.

  • Rene: (additional clarification) To me the feature of 'content links' is one that we should promote.
    1. Given that most parts of the narrative will be generated from structured content this is a relatively simple issue for CDA implementers
    2. What are the benefits? Two that I can think of right now
      1. it allows the human reader (when reading a CDA doc) to inspect the corresponding coded element and e.g. see the ICD-10 code. Some humans know these codes by heart..
      2. it alows for "native CDA text editors" (and we've only seen some beta of these) to copy a textual element to a new CDA document, and automatically copy the corresponding entries as well. If a section has multiple entries the only way to know what entries should be copied is to have content links.
  • To summarize: if the WG thinks that in general it is desirable to have content links, i.e. especially in DRIV entries one SHOULD use content links, then having a 'level 4', as a publication/marketing instrument for this level of refinement would be useful. Calling it 'level 4' stresses the importance/desirability of this level of refinement, whilst still retaining it as an optional level of refinement.

Recommended Action Items

  • Implement the recommendation as documented in this proposal.


Sept 9, 2010: While the idea is intriguing, no one understood the need for this. Opposed (to closing): 0; Abstain: 0; in favor: 14.