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=Clinical Document Architecture (CDA)=
 
==Product Brief - Clinical Document Architecture (CDA)==
 
==Product Brief - Clinical Document Architecture (CDA)==
  
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* CDA R1: ANSI/HL7 CDA, R1-2000
 
* CDA R1: ANSI/HL7 CDA, R1-2000
 
* CDA R2: ANSI/HL7 CDA, R2-2005
 
* CDA R2: ANSI/HL7 CDA, R2-2005
 +
* ISO/HL7 27932:2008; HL7 Clinical Document Architecture, Release 2; 4/21/2005
 
* CDA R3: in-progress see Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=477 477]
 
* CDA R3: in-progress see Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=477 477]
 +
====CDA R2 [[Product_CDA_R2_IG |Implementation Guides]] and [[Product_CDA_R2_IG_CommonClinDocs|Common Clinical Document Implementation Guides]]====
 +
A growing number of implementation guides have passed the HL7 balloting process and were approved in [http://www.hl7.org/dstucomments/ Draft Standard for Trial Use (DSTU)] status. They include:
 +
*[[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_HAIRPT|Healthcare Associated Infection Reports]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending March 2010
 +
*[[Product_CDA_R2_IG_CommonClinDocs#Product_Name_-_CDA_R2_IG_Consult_Note|Consult Notes]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending August 2010
 +
*[[Product_CDA_R2_IG_CommonClinDocs#Product_Name_-_CDA_R2_IG_H.26P|History and Physical (H&P) Notes]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending August 2010
 +
*[[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_EHR_Interop_Profile|Reference Profile for EHR Interoperability]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending Sep 2010
 +
*[[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_PHM_Reports|Personal Healthcare Monitoring Report]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending Nov 2010
 +
*[[Product_CDA_R2_IG_CommonClinDocs#Product_Name_-_CDA_R2_IG_Operative_Note|Operative Notes]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending Mar 2011
 +
*[[Product_CDA_R2_IG_CommonClinDocs#Product_Name_-_CDA_R2_IG_Procedure_Note|Procedure Note]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ending July 2012
 +
*[[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_QA_.28Questionnaire_Assessments.29|CDA Framework for Questionnaire Assessments]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ends Apr 2011
 +
*[[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_QRDA|Quality Reporting Document Architecture (QRDA)]], Release 1; [http://www.hl7.org/dstucomments/ DSTU] ends Apr 2011
 +
 +
 +
Another type of HL7 balloting process was used for the Informative Document release of
 +
*HL7 Implementation Guide for CDA Release 2: [[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_DIR|Diagnostic Imaging Reports]], Release 1
 +
*HL7 Implementation Guide for CDA Release 2: [[Product_CCD|HL7/ASTM Continuity of Care Document]]
 +
*HL7 Implementation Guide for CDA Release 2: [[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_CRS|Level 1 and 2 Care Record Summary]] (US Realm)
 +
*[[Product_Claims_Attachments | Claims Attachments]]
 +
*HL7 Implementation Guide for CDA Release 2: [[Product_CDA_R2_IG#Product_Name_-_CDA_R2_IG_Public_Health_Case_Reports|Public Health Case Reports]], Release 1 (US Realm) published October 2009
  
 
===Summary===
 
===Summary===
−
The Clinical Document Architecture (CDA) is a specification for the exchange of electronic clinical documents. It can contain coded data and narrative and is compatible with the electronic health record and document management systems. CDA is at the core of virtually all standards-based exchange networks in the US and abroad and is adaptable for dictated notes and highly-structured public health and quality reporting.  
+
The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange between healthcare providers and patients.
 
===Description===
 
===Description===
−
Clinical documents are the core of a patient's lifetime health record. HL7’s CDA standard provides an exchange model for clinical documents such as discharge summaries and progress notes. A consistent approach to electronic clinical documents means that critical information contained in the documents can be used independently of the application on which it was produced. For example, CDA documents can be displayed using XML-aware Web browsers or wireless applications on mobile devices.
+
See the article at http://www.hl7.org/documentcenter/public/faq/cda.cfm.<br/>
 +
See also the [http://www.hl7.org/implement/standards/cda.cfm CDA Standard] page at the HL7.org web site.
  
−
====What Are Clinical Documents?====
+
===Business Case (Intended Use, Customers)===
−
Clinical documents are the core of a patient's lifetime record. A "History & Physical" or a "Discharge Summary" or an "X-ray Report" are all examples of clinical documents. Typically, they contain narrative as well as discrete data. While certain structures may apply across document types, like the common SOAP note structure, individual document types vary widely in content.
+
*Healthcare Providers,  
−
The HL7 CDA defines clinical documents as having these characteristics:
+
*Healthcare IT Vendors, 
−
*Persistence
+
*EHR Systems,
−
*Stewardship
+
*PHR Systems,
−
*Authentication
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*Departmental Systems
−
*Context
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*Dictation/transcription vendors;
−
*Wholeness
 
−
*Human readability
 
−
====Why should clinical documents be standardized?====
 
−
A consistent approach to electronic clinical documents means that the critical information contained in the documents can be used independently of the applications on which they were produced. For example, a Discharge Summary created by an electronic health record can be rendered on standard browsers and a repository of transcription documents can be indexed with the same metadata as the output of an EHR. Information created today can be migrated to future systems with little or no data conversion.
 
−
Findings encoded in clinical documents can be used for third-party decision support and mined at a later date for new applications.
 
−
====What is CDA?====
 
−
First published in 2000, The HL7 Clinical Document Architecture (CDA) is a leading standard for the exchange of healthcare information and has become a pillar of interoperability for clinical care and public health. CDA Release 2 utilizes a common syntax for all clinical documents. It preserves the integrity and structure of clinical documents. It conveys authenticated content with fidelity and supports discrete data representation that is both extractable and computable.
 
−
The CDA Release 2 provides an exchange model for clinical documents (such as discharge summaries and progress notes) - and brings the healthcare industry closer to the realization of an electronic medical record. By  leveraging the use of XML, the HL7 RIM and coded vocabularies, the CDA makes documents both machine-readable - so they are easily parsed and processed electronically, and human-readable - so they can be easily retrieved and used by the people who need them. CDA documents can be displayed using XML-aware web browsers or wireless applications
 
−
such as cell phones.
 
−
====Who is using CDA?====
 
−
There are large scale CDA implementations in North and South America, Europe and Asia Pacific. In the US, CDA is being implemented by groups such as New York Presbyterian, the Military Health System, University of Pittsburgh Medical Center, Kaiser Permanente and many others. Groups such as the Healthcare Information Technology Standards Panel (HITSP) and Integrating the Healthcare Enterprise (IHE) are also utilizing CDA in their work.
 
  
−
===Business Case (Intended Use, Customers)===
 
−
*
 
−
*
 
 
===Benefits===
 
===Benefits===
−
*
+
*CDA supports the exchange of clinical documents between those involved in the care of a patient.  In addition CDA support the re-use of clinical data for public health reporting, quality monitoring, patient safety and clinical trials. 
−
*
+
*Stewardship, 
 +
*Potential for authentication, 
 +
*Context
 +
*and Wholeness
 +
 
 
===Implementations/ Case Studies (Actual Users)===
 
===Implementations/ Case Studies (Actual Users)===
−
====CDA Implementation Guides====
+
*see http://www.showmeyourcda.net
−
Several implementation guides passed the HL7 balloting process and were approved in 2008 in the Draft Standard for Trial Use (DSTU) status. They are as follows:
+
*see [http://productsandservices.hl7.org/Home.aspx HL7 CDA Products and Services Guide]
−
=====CDA IG for Reference Profile for EHR Interoperability, Release 1=====
 
−
This guide describes characteristics of interoperable EHR Records. An EHR Record is a persistent artifact which may be independent of the EHR or other System from which it originated.
 
−
This profile shows how HL7's CDA, Release 2 fulfills requirements of the Common EHR Record Unit, as specified in the HL7 EHR Interoperability Model DSTU. It is the result of an ongoing collaboration between the HL7 EHR, Structured Documents, and Security Work Groups.
 
−
=====CDA IG for Healthcare Associated Infection (HAI) Reports, Release 1=====
 
−
This implementation guide was developed in conjunction with the Structured Documents Work Group and the Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases (NCPDCID), Centers for Disease Control and Prevention (CDC). The purpose of this Implementation Guide is to specify a standard for electronic submission of Healthcare Associated Infection (HAI ) reports to the National Healthcare Safety Network (NHSN) of the CDC. It defines the overall approach and method of electronic submission and develops a set of appendices defining specific HAI report types. As reports are modified and new report types are defined, additional appendices will be developed and published by CDC and HL7.
 
−
=====CDA IG for History & Physical Notes, Release 1=====
 
−
The implementation guide for this HL7 Draft Standard for Trial Use (DSTU) was developed in conjunction with the CDA for Common Document Types (CDA4CDT) project, which has an Associate Charter Agreement with HL7. The guide describes constraints on the CDA Header and Body for History & Physical Notes, which are two-part medical reports that document the current and past conditions of the patients.
 
−
=====CDA IG for Consultation Notes, Release 1=====
 
−
The implementation guide for this HL7 Draft Standard for Trial Use (DSTU) was developed
 
−
in conjunction with the CDA for Common Document Types (CDA4CDT) project, which has an Associate Charter Agreement with HL7. The guide reuses templates developed for the HL7 Continuity of Care Document (CCD) and for the History and Physical DSTU and is suitable for consultation notes.
 
−
=====CDA IG for Operative Notes, Release 1=====
 
−
The implementation guide for this HL7 Draft Standard for Trial Use (DSTU) was developed
 
−
in conjunction with the CDA for Common Document Types (CDA4CDT) project, which has an Associate Charter Agreement with HL7. The guide reuses templates developed for the HL7 Continuity of Care Document (CCD) and is suitable
 
−
for any type of operative report.
 
−
=====CDA IG for Quality Reporting Document Architecture (QRDA), Release 1=====
 
−
This HL7 DSTU was supported by the Child Health Corporation of America (CHCA) with participation from the American College of Physicians, American Health Information Management Association (AHIMA), Alliance for Pediatric Quality, Iowa Foundation for Medical Care, The Collaboration of Performance Measure Integration with EHR Systems (“The Collaborative”), HITSP, Integrating the Healthcare Enterprise (IHE) and others. The guide covers patient-centric quality data reporting and lays out a framework for aggregate, population-based quality reports.
 
−
=====CDA IG for Personal Healthcare Monitoring Reports, Release 1=====
 
−
The implementation guide for this HL7 DSTU was co-developed by Continua Health Alliance, which has a Liaison Agreement with HL7. The guide conforms with the HL7 CCD and describes how to use CCD templates for communicating home health data to an electronic health record.
 
−
=====CDA IG for Diagnostic Imaging Reports, Release 1=====
 
−
The implementation guide for this informative document was developed by DICOM, with support from the HL7 Imaging Integration Work Group and CDA4CDT. It is consistent with a companion guide for transforming
 
−
DICOM Structured Reports to CDA Release 2 and is suitable for use with both structured and narrative data capture.
 
−
=====More=====
 
−
There are three more CDA, Release 2 Implementation Guides are currently in the
 
−
balloting process. They include the second release of the Healthcare Associated Infection Reports (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=319 319]) as well as Patient Assessments, Release 1 (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=381 381]) and Plan-to-plan Personal Health Record (PHR) Data Transfer, Release 1 (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=208 208]).
 
−
 
 
  
 
===Resources===
 
===Resources===
−
 
+
*Link to [http://www.hl7.org/documentcenter/public/faq/cda.cfm FAQ]
 +
* members-only database for entering and tracking suggestions and corrections to the CDA standard [http://www.hl7.org/memonly/cdasub.cfm here]
 
====Work Groups====
 
====Work Groups====
−
* [http://wiki.hl7.org/index.php?title=Structured_Documents Structured Documents]
+
*[http://www.hl7.org/Special/committees/structure/index.cfm Structured Documents] WG - HL7.org Web page
 +
*[http://wiki.hl7.org/index.php?title=Structured_Documents Structured Documents] WG - Wiki page
  
 
====Education====
 
====Education====
−
* See more at http://hl7new.amg-hq.net/implement/training.cfm
+
* See more at http://www.hl7.org/implement/training.cfm
 
* Clinical Document Architecture (CDA) Introductory Tutorial
 
* Clinical Document Architecture (CDA) Introductory Tutorial
 
* Clinical Document Architecture (CDA) Advanced Tutorial  
 
* Clinical Document Architecture (CDA) Advanced Tutorial  
 +
*Continuity of Care Document (CCD) Tutorial
 
*CDA Certification Test Preparation  
 
*CDA Certification Test Preparation  
 
=====Certification Available=====
 
=====Certification Available=====
 
*CDA Certified Specialist
 
*CDA Certified Specialist
 +
 
====Presentations====
 
====Presentations====
 +
[http://www.hl7.org/Library/Committees/structure/CDAQuickStart_v1.1.zip Quick Start Guide]
 +
 
From HIMSS 2009 <br/>
 
From HIMSS 2009 <br/>
 
* [http://www.hl7.org/documentcenter/public/calendarofevents/himss/2009/presentations/HIMSS2009_Bob_CDA_Sunday.pdf CDA presentation]  
 
* [http://www.hl7.org/documentcenter/public/calendarofevents/himss/2009/presentations/HIMSS2009_Bob_CDA_Sunday.pdf CDA presentation]  
 
* [http://www.hl7.org/documentcenter/public/calendarofevents/himss/2009/presentations/HIMSS2009_Bob_What's%20New%20with%20CDA_Tue.pdf What's new with CDA?]
 
* [http://www.hl7.org/documentcenter/public/calendarofevents/himss/2009/presentations/HIMSS2009_Bob_What's%20New%20with%20CDA_Tue.pdf What's new with CDA?]
−
<br/> Contacts: Liora Alschuler, Calvin Beebe, Keith Boone, Bob Dolin
 
  
 
====Relationship to/ Dependencies on, other standards====
 
====Relationship to/ Dependencies on, other standards====
−
*
+
*RIM,
 +
*Vocabulary,
 +
*Datatypes,
 +
*XML ITS
 
====Links to current projects in development====
 
====Links to current projects in development====
 
* CDA R3: in-progress see Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=477 477]
 
* CDA R3: in-progress see Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=477 477]
−
*
+
*There are more CDA, Release 2 Implementation Guides are currently in the
 +
balloting process. They include the Plan-to-plan Personal Health Record (PHR) Data Transfer, Release 1 (Project # [http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?action=edit&ProjectNumber=208 208]).
 +
 
 +
 
 +
[[CATEgory:Products]]

Latest revision as of 21:29, 12 October 2010

Clinical Document Architecture (CDA)

Product Brief - Clinical Document Architecture (CDA)

back to Main_Page

Product Name

Clinical Document Architecture (CDA)

Topics

Standard Category

Health Information Exchange Standards

Integration Paradigm

Documents

Type

Normative, ANSI Standard

Releases

  • CDA R1: ANSI/HL7 CDA, R1-2000
  • CDA R2: ANSI/HL7 CDA, R2-2005
  • ISO/HL7 27932:2008; HL7 Clinical Document Architecture, Release 2; 4/21/2005
  • CDA R3: in-progress see Project # 477

CDA R2 Implementation Guides and Common Clinical Document Implementation Guides

A growing number of implementation guides have passed the HL7 balloting process and were approved in Draft Standard for Trial Use (DSTU) status. They include:


Another type of HL7 balloting process was used for the Informative Document release of

Summary

The HL7 Clinical Document Architecture (CDA) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange between healthcare providers and patients.

Description

See the article at http://www.hl7.org/documentcenter/public/faq/cda.cfm.
See also the CDA Standard page at the HL7.org web site.

Business Case (Intended Use, Customers)

  • Healthcare Providers,
  • Healthcare IT Vendors,
  • EHR Systems,
  • PHR Systems,
  • Departmental Systems
  • Dictation/transcription vendors;

Benefits

  • CDA supports the exchange of clinical documents between those involved in the care of a patient. In addition CDA support the re-use of clinical data for public health reporting, quality monitoring, patient safety and clinical trials.
  • Stewardship,
  • Potential for authentication,
  • Context
  • and Wholeness

Implementations/ Case Studies (Actual Users)

Resources

  • Link to FAQ
  • members-only database for entering and tracking suggestions and corrections to the CDA standard here

Work Groups

Education

  • See more at http://www.hl7.org/implement/training.cfm
  • Clinical Document Architecture (CDA) Introductory Tutorial
  • Clinical Document Architecture (CDA) Advanced Tutorial
  • Continuity of Care Document (CCD) Tutorial
  • CDA Certification Test Preparation
Certification Available
  • CDA Certified Specialist

Presentations

Quick Start Guide

From HIMSS 2009

Relationship to/ Dependencies on, other standards

  • RIM,
  • Vocabulary,
  • Datatypes,
  • XML ITS

Links to current projects in development

  • CDA R3: in-progress see Project # 477
  • There are more CDA, Release 2 Implementation Guides are currently in the

balloting process. They include the Plan-to-plan Personal Health Record (PHR) Data Transfer, Release 1 (Project # 208).

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