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. 2001 Nov-Dec;8(6):552-69.
doi: 10.1136/jamia.2001.0080552.

The HL7 Clinical Document Architecture

R H Dolin  1 , L Alschuler, C Beebe, P V Biron, S L Boyer, D Essin, E Kimber, T Lincoln, J E Mattison
Affiliations

The HL7 Clinical Document Architecture

R H Dolin et al. J Am Med Inform Assoc. 2001 Nov-Dec.

Abstract

Many people know of Health Level 7 (HL7) as an organization that creates health care messaging standards. Health Level 7 is also developing standards for the representation of clinical documents (such as discharge summaries and progress notes). These document standards make up the HL7 Clinical Document Architecture (CDA). The HL7 CDA Framework, release 1.0, became an ANSI-approved HL7 standard in November 2000. This article presents the approach and objectives of the CDA, along with a technical overview of the standard. The CDA is a document markup standard that specifies the structure and semantics of clinical documents. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. The document can be sent inside an HL7 message and can exist independently, outside a transferring message. The first release of the standard has attempted to fill an important gap by addressing common and largely narrative clinical notes. 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. Being 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 HL7 mission is to develop standards that enable semantic interoperability across all platforms. The HL7 version 3 family of standards, including the CDA, are moving us closer to the realization of this vision.

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Figures

Figure 1
Figure 1
Subset of RIM version 0.98. A small subset of the HL7 Referenced Information Model, Version 0.98, used in the derivation of the CDA.
Figure 2
Figure 2
Structure “context” in CDA body. Attribution ascribed to structural components in the CDA Body (sections, paragraphs, lists, tables) define the structure's “context”. These attributes are applicable to the contents of the structure, and are inherited by nested structures, unless overridden.
Figure 3
Figure 3
Referencing original text with . In the first case, is used to simply insert a code into a CDA document, without referencing the original text. In the second case, explicitly references the original text that supports the assigned code.
See this image and copyright information in PMC

References

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    1. Dolin RH, Alschuler L, Boyer S, Beebe C. An update on HL7's XML-based document representation standards. Proc AMIA Annu Symp. 2000:190–4. - PMC - PubMed

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