A clinical document is maintained by a person or organization entrusted with its care. A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements. The CDA is a document markup standard that specifies the structure and semantics of “clinical documents.” A clinical document is a documentation of observations and services and has the following defining characteristics: And while the current CDA standard does not fully enable these main driving objectives, it takes us a step closer. Given the variability in clinical notes, including structure, underlying information models, degree of semantic encoding, use of standard healthcare terminologies, and platform- and vendor-specific features, it is currently difficult to store and exchange documents with retention of standardized semantics over both time and distance. The need for a clinical document standard stems from the desire to unlock the considerable clinical content currently stored in free-text clinical notes and to enable comparison of content from documents created on information systems of widely varying characteristics. Interested readers looking for detailed descriptions are encouraged to contact HL7 ( for a copy of the normative specification. It is geared toward medical informaticians who do not have significant familiarity with HL7 version 3, and it is intended to introduce the approach and objectives used in the creation of the standard and present an overview of the standard-not sufficient for implementation but sufficiently detailed to enable the reader to understand the scope and contents of the standard. This article is intended to serve as an introduction to the CDA standard.
The HL7 Clinical Document Architecture, release 1.0, became an ANSI-approved HL7 Standard in November 2000. These document standards make up the HL7 Clinical Document Architecture (CDA). Health Level 7 is also developing standards for the representation of clinical documents (such as discharge summaries and progress notes).
Many people know of HL7 as an organization that creates health care messaging standards. The HL7 version 2.4 messaging standard is currently in use, and version 3, which represents several fundamental changes to the HL7 messaging approach, is in an advanced stage of development. The HL7 specifications are unified by shared reference models of the health care and technical domains. This encompasses the complete life cycle of a standards specification-development, adoption, market recognition, utilization, and adherence. A vendor- and provider-supported organization, its mission is to provide standards for the exchange, management, and integration of data that support clinical patient care and the management, delivery, and evaluation of health care services. They have developed communication protocols widely used in the United States, with growing international recognition and implementations. Health Level 7 (HL7) 1 is a standards-setting organization accredited by the American National Standards Institute (ANSI). The HL7 version 3 family of standards, including the CDA, are moving us closer to the realization of this vision. The HL7 mission is to develop standards that enable semantic interoperability across all platforms. It deliberately leaves out certain advanced and complex semantics, both to foster broad implementation and to give time for these complex semantics to be fleshed out within HL7.īeing a part of the emerging HL7 version 3 family of standards, the CDA derives its semantic content from the shared HL7 Reference Information Model and is implemented in Extensible Markup Language. The first release of the standard has attempted to fill an important gap by addressing common and largely narrative clinical notes. The document can be sent inside an HL7 message and can exist independently, outside a transferring message. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. The CDA is a document markup standard that specifies the structure and semantics of clinical documents. This article presents the approach and objectives of the CDA, along with a technical overview of the standard. The HL7 CDA Framework, release 1.0, became an ANSI-approved HL7 standard in November 2000. Many people know of Health Level 7 (HL7) as an organization that creates health care messaging standards.
0 kommentar(er)
