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. 2006 Jan-Feb;13(1):30-9.
doi: 10.1197/jamia.M1888. Epub 2005 Oct 12.

HL7 Clinical Document Architecture, Release 2

Robert H Dolin  1 , Liora Alschuler, Sandy Boyer, Calvin Beebe, Fred M Behlen, Paul V Biron, Amnon Shabo Shvo
Affiliations

HL7 Clinical Document Architecture, Release 2

Robert H Dolin et al. J Am Med Inform Assoc. 2006 Jan-Feb.

Abstract

Clinical Document Architecture, Release One (CDA R1), became an American National Standards Institute (ANSI)-approved HL7 Standard in November 2000, representing the first specification derived from the Health Level 7 (HL7) Reference Information Model (RIM). CDA, Release Two (CDA R2), became an ANSI-approved HL7 Standard in May 2005 and is the subject of this article, where the focus is primarily on how the standard has evolved since CDA R1, particularly in the area of semantic representation of clinical events. CDA is a document markup standard that specifies the structure and semantics of a clinical document (such as a discharge summary or progress note) for the purpose of exchange. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. It can be transferred within a message and can exist independently, outside the transferring message. CDA documents are encoded in Extensible Markup Language (XML), and they derive their machine processable meaning from the RIM, coupled with terminology. The CDA R2 model is richly expressive, enabling the formal representation of clinical statements (such as observations, medication administrations, and adverse events) such that they can be interpreted and acted upon by a computer. On the other hand, CDA R2 offers a low bar for adoption, providing a mechanism for simply wrapping a non-XML document with the CDA header or for creating a document with a structured header and sections containing only narrative content. The intent is to facilitate widespread adoption, while providing a mechanism for incremental semantic interoperability.

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Figures

Figure 1.
Figure 1.
Major components of a Clinical Document Architecture (CDA) document.
Figure 2.
Figure 2.
Clinical Document Architecture (CDA) Release 2 object model showing a portion of the header and its connection to the document body.
Figure 3.
Figure 3.
Clinical Document Architecture (CDA) Release 2 object model showing the connection from a document section to a portion of the CDA clinical statement model.
Figure 4.
Figure 4.
An example of a simple observation.
Figure 5.
Figure 5.
An example of a more complex observation.
Figure 6.
Figure 6.
An example of family history observations.
Figure 7.
Figure 7.
An example of allergies and adverse reactions.
Figure 8.
Figure 8.
An example of a substance administration.
See this image and copyright information in PMC

References

    1. Dolin RH, Alschuler L, Beebe C, Biron PV, Boyer SL, Essin D, Kimber E, et al. The HL7 Clinical Document Architecture. J Am Med Inform Assoc. 2001;8:552–69. - PMC - PubMed
    1. Alschuler L, Dolin RH, Boyer S, Beebe C, editors. HL7 Clinical Document Architecture Framework, Release 1.0. ANSI-approved HL7 Standard, Nov 2000. Ann Arbor, MI: Health Level Seven, Inc., 2000.
    1. Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo A, editors. HL7 Clinical Document Architecture, Release 2.0. ANSI-approved HL7 Standard, May 2005. Ann Arbor, MI: Health Level Seven, Inc., 2005.
    1. 2nd International Conference on the Clinical Document Architecture. Oct 2004, Acapulco, Mexico. Available from: http://www.hl7.de/iamcda2004/cdainfo.html/. Accessed 2005 Jun 11.
    1. Poulymenopoulou M, Vassilacopoulos G. An electronic patient record implementation using clinical document architecture. Stud Health Technol Inform. 2004;103:50–7. - PubMed

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