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 –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 and other multimedia content –documentation of observations and other services

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 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 –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… Header Body XML Encoding –Human readable… –…software processable –Validated by a schema Diagnostic: Asthma, history of smoking Diagnostic: Asthma, history of smoking Style sheet

CDA Release 2 (2005) HL7 v3 Standard RIM  R-MIM  HMD  Schema XML Narrative blocks  human Entries  machine A CDA R2 document consists of a mixture of « narrative blocks » and structured « entries ». Header Body text Observation Substance administration Body site Procedure Patient encounter « Organizer » Multimedia observation

CDA Information Model CDA HeaderCDA Body Ext. Ref. CDA Entries Clinical Document Participations Non-XML or Structured Body Nested Sections with Narrative Clinical Statements Custodian Record Target Encounter Related Documents Linked Artifacts Medicatio n Observatio n Procedure

Body Structure

Main Components of CDA DOCUMENTDOCUMENT SECTIONSSECTIONS BODYBODY Header ENTRIESENTRIES Narrative Block External References

Section structure Anamnese Asthma High Bloodpressure Osteoarthritis, right knee

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

Questions ?