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Abbreviation | CDA |
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Status | Published |
Year started | 1996 |
First published | November 2000 |
Latest version | 2.0 2005 |
Organization | Health Level Seven International |
Committee | Structured Documents Group |
Base standards |
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Related standards | |
Domain | Electronic health records |
Website | CDA® Release 2 |
The HL7 Clinical Document Architecture (CDA) is an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange. In November 2000, HL7 published Release 1.0. The organization published Release 2.0 with its "2005 Normative Edition". [1]
CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document, defined by six characteristics: [2]
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1]
An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [3]
It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.[ citation needed ]
The CDA specifies that the content of the document consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing). The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts.[ citation needed ]
In 2012, in response to conflicting CDAs in use by the healthcare industry, the Office of the National Coordinator for Health Information Technology (ONC) streamlined commonly used templates to create the Consolidated-CDA (C-CDA).
The CDA standard doesn't specify how the documents should be transported. CDA documents can be transported using HL7 version 2 messages, HL7 version 3 messages, IHE protocols such as XDS, as well as by other mechanisms including: DICOM, MIME attachments to email, http or ftp.
The standard is certified by ANSI. [1]
CDA Release 2 has been adopted as an ISO standard, ISO/HL7 27932:2009. [4]
Australia's Personally Controlled Electronic Health Record (PCEHR), known as "My Health Record", uses a specialized implementation of HL7 CDA Release 2. [5]
In the UK the Interoperability Toolkit (ITK) utilises the "CDA R2 from HL7 V3 – for CDA profiles" for the Correspondence pack. [6] [7]
In the U.S. the CDA standard is probably best known as the basis for the Continuity of Care Document (CCD) specification, based on the data model as specified by ASTM's Continuity of Care Record. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.[ citation needed ]
Health Level Seven or HL7 is a range of global standards for the transfer of clinical and administrative health data between applications. The HL7 standards focus on the application layer, which is "layer 7" in the Open Systems Interconnection model. The standards are produced by Health Level Seven International, an international standards organization, and are adopted by other standards issuing bodies such as American National Standards Institute and International Organization for Standardization. There are a range of primary standards that are commonly used across the industry, as well as secondary standards which are less frequently adopted.
openEHR is an open standard specification in health informatics that describes the management and storage, retrieval and exchange of health data in electronic health records (EHRs). In openEHR, all health data for a person is stored in a "one lifetime", vendor-independent, person-centred EHR. The openEHR specifications include an EHR Extract specification but are otherwise not primarily concerned with the exchange of data between EHR-systems as this is the focus of other standards such as EN 13606 and HL7.
Continuity of Care Record (CCR) is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors.
The Clinical Data Interchange Standards Consortium (CDISC) is a standards developing organization (SDO) dealing with medical research data linked with healthcare, to "enable information system interoperability to improve medical research and related areas of healthcare". The standards support medical research from protocol through analysis and reporting of results and have been shown to decrease resources needed by 60% overall and 70–90% in the start-up stages when they are implemented at the beginning of the research process.
The Health informatics - Electronic Health Record Communication was the European Standard for an information architecture to communicate Electronic Health Records (EHR) of a patient. The standard was later adopted as ISO 13606 and later replaced with ISO 13606-2 and recently ISO 13606-5:2010.
The ISO/TC 215 is the International Organization for Standardization's (ISO) Technical Committee (TC) on health informatics. TC 215 works on the standardization of Health Information and Communications Technology (ICT), to allow for compatibility and interoperability between independent systems.
KMEHR or Kind Messages for Electronic Healthcare Record is a Belgian medical data standard introduced in 2002, designed to enable the exchange of structured clinical information. It is funded by the Belgian federal Ministry of public health and assessed in collaboration with Belgian industry.
The Continuity of Care Document (CCD) specification is an XML-based markup standard intended to specify the encoding, structure, and semantics of a patient summary clinical document for exchange.
This article documents the effort of the Health Level Seven(HL7) community and specifically the former HL7 Architecture Board (ArB) to develop an interoperability framework that would support services, messages, and Clinical Document Architecture(CDA) ISO 10871.
The system of concepts to support continuity of care, often referred to as ContSys, is an ISO and CEN standard . Continuity of care is an organisational principle that represents an important aspect of quality and safety in health care. Semantic interoperability is a basic requirement for continuity of care. Concepts that are needed for these purposes must represent both the content and context of the health care services.
International HL7 implementations is a collection of known implementations of the HL7 Interoperability standard. These do not necessarily refer to cross-border health information systems.
The Fast Healthcare Interoperability Resources standard is a set of rules and specifications for exchanging electronic health care data. It is designed to be flexible and adaptable, so that it can be used in a wide range of settings and with different health care information systems. The goal of FHIR is to enable the seamless and secure exchange of health care information, so that patients can receive the best possible care. The standard describes data formats and elements and an application programming interface (API) for exchanging electronic health records (EHR). The standard was created by the Health Level Seven International (HL7) health-care standards organization.
Medical device connectivity is the establishment and maintenance of a connection through which data is transferred between a medical device, such as a patient monitor, and an information system. The term is used interchangeably with biomedical device connectivity or biomedical device integration. By eliminating the need for manual data entry, potential benefits include faster and more frequent data updates, diminished human error, and improved workflow efficiency.
Integrating the Healthcare Enterprise (IHE) is a non-profit organization based in the US state of Illinois. It sponsors an initiative by the healthcare industry to improve the way computer systems share information. IHE was established in 1998 by a consortium of radiologists and information technology (IT) experts.
InterSystems HealthShare is a healthcare informatics platform for hospitals, integrated delivery networks (IDNs) and regional and national health information exchanges (HIE).
Health Level Seven International (HL7) is a non-profit ANSI-accredited standards development organization that develops standards that provide for global health data interoperability.
My Health Record (MHR) is the national digital health record platform for Australia, and is managed by the Australian Digital Health Agency. It was originally established as the Personally Controlled Electronic Health Record (PCEHR), a shared electronic health summary set up by the Australian government with implementation overseen by the National Electronic Health Transition Authority (NEHTA). The purpose of the MHR is to provide a secure electronic summary of people's medical history which will eventually include information such as current medications, adverse drug reactions, allergies and immunisation history in an easily accessible format. This MHR is stored in a network of connected systems with the ability to improve the sharing of information amongst health care providers to improve patient outcomes no matter where in Australia a patient presents for treatment. PCEHR was an opt-in system with a unique individual healthcare identifier (IHI) being assigned to participants and the option of masking and limiting information available for viewing controlled by the patient or a nominated representative; MHR uses an opt-out system.
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Clinical data standards are used to store and communicate information related to healthcare so that its meaning is unambiguous. They are used in clinical practice, in activity analysis and finding, and in research and development.