Document Detail

HL7 Clinical Document Architecture, Release 2.
MedLine Citation:
PMID:  16221939     Owner:  NLM     Status:  MEDLINE    
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.
Robert H Dolin; Liora Alschuler; Sandy Boyer; Calvin Beebe; Fred M Behlen; Paul V Biron; Amnon Shabo Shvo
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Publication Detail:
Type:  Journal Article     Date:  2005-10-12
Journal Detail:
Title:  Journal of the American Medical Informatics Association : JAMIA     Volume:  13     ISSN:  1067-5027     ISO Abbreviation:  J Am Med Inform Assoc     Publication Date:    2006 Jan-Feb
Date Detail:
Created Date:  2006-01-02     Completed Date:  2006-02-16     Revised Date:  2013-06-07    
Medline Journal Info:
Nlm Unique ID:  9430800     Medline TA:  J Am Med Inform Assoc     Country:  United States    
Other Details:
Languages:  eng     Pagination:  30-9     Citation Subset:  IM    
Kaiser Permanente, Pasadena, CA, USA.
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MeSH Terms
Computer Communication Networks / standards
Forms and Records Control / standards
Medical Record Linkage
Medical Records Systems, Computerized / standards*
Programming Languages*
Terminology as Topic

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