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CDA Clinical Document Architecture. Charlie Bishop. Agenda. What is CDA ? CDA overview Technical insight CDA and the MiM. Overview. Clinical Document Architecture (CDA) CDA = International Standard a development of the HL7 standards developing organization CDA is

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Presentation Transcript
agenda
Agenda
  • What is CDA ?
  • CDA overview
  • Technical insight
  • CDA and the MiM
overview
Overview
  • Clinical Document Architecture (CDA)
  • CDA = International Standard
    • a development of the HL7standards developing organization
  • CDA is
    • a document markup standard for the structure and semantics of exchanged "clinical documents"
    • a defined and complete information object
      • for storage and exchange
      • can include text, images, sounds andother multimedia content
    • documentation of observations and other services
characteristics
Characteristics
  • A Clinical Document has the following characteristics:
    • Persistence
    • Stewardship
    • Authentication
    • Context
    • Wholeness
    • Human Readability
  • Conformance with these characteristics is an integral part of the standard
brief history
Brief History
  • Level 1
    • Generic document structure (section, paragraphs, list, tables…)
  • Level 2
    • domain-specific document types
    • document ontology
    • constrainable for (domain-) compliant content
  • Level 3
    • fine-grained definitions / markup as defined in the RIM
structure and representation
Structure and representation

Header

Body

Diagnostic:

Asthma, history of smoking

Style sheet

  • Structure
    • A header which provides contextual data:
      • Facilitates the exchange and interpretation of the document and its storage in an EHR.
    • A body:
      • Clinical information, structured in the form of sections, paragraphs, lists, tables…
  • XML Encoding
    • Human readable…
    • …software processable
    • Validated by a schema

<section>

<caption>Diagnostic:</caption>

<content>Asthma, history of smoking </content>

</section>

cda release 2 2005
CDA Release 2 (2005)

HL7 v3 Standard

Header

Body

text

A CDA R2 document consists of a mixture of « narrative blocks » and structured « entries ».

Observation

Substance administration

Body site

Procedure

Patient encounter

« Organizer »

Multimedia observation

RIM  R-MIM  HMD  Schema XML

Narrative blocks

 human

Entries

 machine

cda information model
CDA Information Model

Ext. Ref.

CDA Header

CDA Body

CDA Entries

Clinical Document

Participations

Related

Documents

Clinical Statements

Non-XML

or

Structured

Body

Linked

Artifacts

Observation

Procedure

Medication

Record

Target

Encounter

Custodian

Nested Sections

with Narrative

main components of cda
Main Components of CDA

Header

Narrative Block

DOCUMENT

SECTIONS

ENTRIES

BODY

External

References

<ClinicalDocument>

...

<StructuredBody>

<Section>

<text>...</text>

<Observation>

...

</Observation>

<Observation>

<reference>

<ExternalObservation>

...

</ExternalObservation>

</reference>

</Observation>

</Section>

<Section>

<Section>...</Section>

</Section>

</StructuredBody>

</ClinicalDocument>

section structure
Section structure

<Section>

<code code="10153-2" codeSystem="LOINC">Anamnese</code>

<text>

<list>

<item><content>Asthma</content></item>

<item><content>High Bloodpressure</content></item>

<item><content ID="a3">Osteoarthritis, right knee</content></item>

</list>

</text>

<entry>

<contextConductionInd value="TRUE"/>

<Observation classCode="COND">

<code code="G-1001" codeSystem="SNOMED" displayName="prior diagnosis"/>

<value code="D1-201A8" codeSystem="SNOMED" displayName="Osteoarthritis">

<originalText><reference value="#a3"/></originalText>

</value>

<targetSiteCode code="T-15720" codeSystem="SNOMED" displayName="Knee">

<qualifier>

<name code="G-C220" codeSystem="SNOMED" displayName="Laterality"/>

<value code="G-A100" codeSystem="SNOMED" displayName="right"/>

</qualifier>

</targetSiteCode>

</Observation>

</entry>

</Section>

clinical statement
Clinical Statement

HL7 v3 model for structured clinical information

Allows consistent representation across domains

Used by CDA