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CDA Clinical Document Architecture

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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CDA Clinical Document Architecture

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  1. CDAClinical Document Architecture Charlie Bishop

  2. Agenda • What is CDA ? • CDA overview • Technical insight • CDA and the MiM

  3. 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

  4. 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

  5. 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

  6. 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>

  7. 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

  8. 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

  9. Body Structure

  10. 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>

  11. 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>

  12. Clinical Statement HL7 v3 model for structured clinical information Allows consistent representation across domains Used by CDA

  13. Questions ?

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