Transcript CDA Clinical Document Architecture

CDA
Clinical Document Architecture
Charlie Bishop
http://www.hl7.org.uk
Agenda
• What is CDA ?
• CDA overview
• Technical insight
• CDA and the MiM
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
Characteristics
• A Clinical Document has the following characteristics:
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Persistence
Stewardship
Authentication
Context
Wholeness
Human Readability
• Conformance with these characteristics is an integral
part of the standard
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
Structure and representation
• Structure
– A header which provides contextual data:
Header
• Facilitates the exchange and interpretation of
the document and its storage in an EHR.
Body
– A body:
• Clinical information, structured in the form of
sections, paragraphs, lists, tables…
• XML Encoding
– Human readable…
Diagnostic:
Asthma, history of smoking
Style sheet
– …software processable
– Validated by a schema
<section>
<caption>Diagnostic:</caption>
<content>Asthma, history of smoking </content>
</section>
CDA Release 2 (2005)
RIM v3
R-MIM
 HMD  Schema XML
• HL7
Standard
Header
Body
Narrative blocks
A CDA R2 document
consists of a mixture of
« narrative blocks » and
structured « entries ».
 human
text
Observation
Substance administration
Body site
Entries
Procedure
 machine
Patient encounter
« Organizer »
Multimedia observation
CDA Information Model
Participations
Clinical
Document
Related
Documents
Clinical Statements
Non-XML
or
Structured
Body
Linked
Artifacts
Observatio
n
Procedure
Medicatio
n
Record
Target
Custodian
CDA Header
Encounter
Nested Sections
with Narrative
CDA Body
CDA Entries
Ext.
Ref.
Body Structure
Main Components of CDA
<ClinicalDocument>
...
<StructuredBody>
<Section>
<text>...</text>
<Observation>
...
</Observation>
<Observation>
<reference>
<ExternalObservation>
...
</ExternalObservation>
</reference>
</Observation>
</Section>
<Section>
<Section>...</Section>
</Section>
</StructuredBody>
</ClinicalDocument>
Header
Narrative Block
External
References
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B
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D
Y
D
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M
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N
T
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>
Clinical Statement
• HL7 v3 model for structured
clinical information
• Allows consistent representation
across domains
• Used by CDA
Questions