http:// cda clinical document architecture charlie bishop
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http://www.hl7.org.uk
CDAClinical Document Architecture
Charlie Bishop
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Agenda
• What is CDA ?
• CDA overview
• Technical insight
• CDA and the MiM
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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
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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
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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
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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…
HeaderHeader
BodyBody
• XML Encoding– Human readable…
– …software processable– Validated by a schema
Diagnostic:
Asthma, history of smoking
<section>
<caption>Diagnostic:</caption>
<content>Asthma, history of smoking </content>
</section>
<section>
<caption>Diagnostic:</caption>
<content>Asthma, history of smoking </content>
</section>
Style sheet
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CDA Release 2 (2005)
• HL7 v3 StandardRIM R-MIM HMD Schema XML
Narrative blocks
human
Entries
machine
A CDA R2 document consists of a mixture of « narrative blocks » and structured « entries ».
HeaderHeader
BodyBody
text
Observation
Substance administration
Body site
Procedure
Patient encounter
« Organizer »
Multimedia observation
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CDA Information Model
CDA Header CDA BodyExt. Ref.CDA Entries
Clinical Document
Participations
Non-XMLor
StructuredBody
Nested Sectionswith Narrative
Clinical Statements
Custodian
RecordTarget Encounter
RelatedDocuments
LinkedArtifacts
Medication
Observation
Procedure
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Body Structure
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Main Components of CDA
<ClinicalDocument> ... <StructuredBody> <Section> <text>...</text> <Observation> ... </Observation> <Observation> <reference> <ExternalObservation> ... </ExternalObservation> </reference> </Observation> </Section> <Section> <Section>...</Section> </Section> </StructuredBody></ClinicalDocument>
DOCUMENT
SECTIONS
BODY
Header
ENTRIES
Narrative Block
ExternalReferences
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Section structure
<Section> <code code="10153-2" codeSystem="LOINC">Anamnese</code> <text> <list> <item><content>Asthma</content></item> <item><content>High Bloodpressure</content></item> <item><content ID="a3">Osteoarthritis, right knee</content></item> </list> </text> <entry> <contextConductionInd value="TRUE"/> <Observation classCode="COND"> <code code="G-1001" codeSystem="SNOMED" displayName="prior diagnosis"/> <value code="D1-201A8" codeSystem="SNOMED" displayName="Osteoarthritis"> <originalText><reference value="#a3"/></originalText> </value> <targetSiteCode code="T-15720" codeSystem="SNOMED" displayName="Knee"> <qualifier> <name code="G-C220" codeSystem="SNOMED" displayName="Laterality"/> <value code="G-A100" codeSystem="SNOMED" displayName="right"/> </qualifier> </targetSiteCode> </Observation> </entry></Section>
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Clinical Statement
• HL7 v3 model for structured clinical information
• Allows consistent representation across domains
• Used by CDA
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Questions
?