The HL7 Clinical Document Architecture (CDA) is an

XML Extensible Markup Language (XML) is a markup language and file format for storing, transmitting, and reconstructing data. It defines a set of rules for encoding electronic document, documents in a format that is both human-readable and Machine-r ...

-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".

Content

CDA specifies the syntax and supplies a framework for specifying the full semantics of a clinical document, defined by six characteristics: # Persistence # Stewardship # Potential for authentication # Context # Wholeness # Human readability CDA can hold any kind of clinical information that would be included in a patient's

medical record The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and health care, care across time within one particular health care provide ...

; examples include: * Discharge summary (following

inpatient care Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremel ...

) *

History History is the systematic study of the past, focusing primarily on the Human history, human past. As an academic discipline, it analyses and interprets evidence to construct narratives about what happened and explain why it happened. Some t ...

& physical * Specialist reports, such as those for

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...

pathology Pathology is the study of disease. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatme ...

An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in

pdf Portable document format (PDF), standardized as ISO 32000, is a file format developed by Adobe Inc., Adobe in 1992 to present documents, including text formatting and images, in a manner independent of application software, computer hardware, ...

docx Office Open XML (also informally known as OOXML) is a zipped, XML-based file format developed by Microsoft for representing spreadsheets, charts, presentations and word processing documents. Ecma International standardized the initial version ...

, or rtf, as well as image formats like

jpg JPEG ( , short for Joint Photographic Experts Group and sometimes retroactively referred to as JPEG 1) is a commonly used method of lossy compression for digital images, particularly for those images produced by digital photography. The degr ...

and png. 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. 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 The Systematized Nomenclature of Medicine (SNOMED) is a systematic, computer-processable collection of medical terms, in human and veterinary medicine, to provide codes, terms, synonyms and definitions which cover anatomy, diseases, findings, pr ...

and

LOINC Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit m ...

) to represent concepts.

Consolidated Clinical Document Architecture

In 2012, in response to conflicting CDAs in use by the

healthcare industry The healthcare industry (also called the medical industry or health economy) is an aggregation and integration of sectors within the economic system that provides goods and services to treat patients with curative, preventive, rehabilitative, ...

, the Office of the National Coordinator for Health Information Technology (ONC) streamlined commonly used templates to create the Consolidated-CDA (C-CDA).

Transport

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 Digital Imaging and Communications in Medicine (DICOM) is a technical standard for the digital storage and Medical image sharing, transmission of medical images and related information. It includes a file format definition, which specifies the str ...

MIME A mime artist, or simply mime (from Greek language, Greek , , "imitator, actor"), is a person who uses ''mime'' (also called ''pantomime'' outside of Britain), the acting out of a story through body motions without the use of speech, as a the ...

attachments to

email Electronic mail (usually shortened to email; alternatively hyphenated e-mail) is a method of transmitting and receiving Digital media, digital messages using electronics, electronic devices over a computer network. It was conceived in the ...

http HTTP (Hypertext Transfer Protocol) is an application layer protocol in the Internet protocol suite model for distributed, collaborative, hypermedia information systems. HTTP is the foundation of data communication for the World Wide Web, wher ...

ftp The File Transfer Protocol (FTP) is a standard communication protocol used for the transfer of computer files from a server to a client on a computer network. FTP is built on a client–server model architecture using separate control and dat ...

Standard certification and adoption

The standard is certified by

ANSI The American National Standards Institute (ANSI ) is a private nonprofit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States. The organiz ...

. CDA Release 2 has been adopted as an

ISO The International Organization for Standardization (ISO ; ; ) is an independent, non-governmental, international standard development organization composed of representatives from the national standards organizations of member countries. Me ...

standard,

/ HL7 27932:2009.

Country-specific implementations

Australia

Australia's Personally Controlled Electronic Health Record (PCEHR), known as "My Health Record", uses a specialized implementation of HL7 CDA Release 2.

United Kingdom

In the UK the Interoperability Toolkit (ITK) utilises the "CDA R2 from HL7 V3 – for CDA profiles" for the Correspondence pack. See 'What standards does ITK utilise?'

United States

In the U.S. the CDA standard is probably best known as the basis for the

Continuity of Care Document 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. Structure The CCD specification is a constraint o ...

(CCD) specification, based on the data model as specified by

ASTM ASTM International, formerly known as American Society for Testing and Materials, is a standards organization that develops and publishes voluntary consensus technical international standards for a wide range of materials, products, systems and s ...

Continuity of Care Record Continuity or continuous may refer to: Mathematics * Continuity (mathematics), the opposing concept to discreteness; common examples include ** Continuous probability distribution or random variable in probability and statistics ** Continuous g ...

. The U.S. Healthcare Information Technology Standards Panel has selected the CCD as one of its standards.

References

External links

* * * * {{cite web , title=C-CDA to SQL app and API , website=cda2sql.com , url=https://www.cda2sql.com/ Standards for electronic health records Computer file formats Industry-specific XML-based standards