Clinical Document Architecture

Clinical Document Architecture (CDA) is a popular, flexible markup standard developed by HL7 International to structure clinical documents. This standard is part of the HL7 health informatics suite of standards, which aim to improve the interoperability of health information technology (HIT) systems.

Overview

The CDA standard is designed to allow clinicians to share clinical documents, such as discharge summaries, medical histories, and progress notes, among different healthcare providers and systems. It uses XML for encoding the documents and ensures that the structure and semantics of the clinical content are preserved and unambiguous.

Structure

A CDA document is composed of a header and a body. The header contains information about the patient, the author of the document, and the document type. The body contains the clinical content of the document. It can be either a structured body, where the content is divided into sections, or a narrative body, where the content is a single block of text.

Levels

There are three levels of CDA documents, each with increasing degrees of structure and standardization:

• Level 1: This level includes the most basic information, such as patient demographics and document type. The body of the document is a block of unstructured text.
• Level 2: This level adds more structure to the document body by dividing it into sections. Each section can still contain unstructured text.
• Level 3: This level is fully structured and standardized. Each section in the document body contains entries, which are discrete pieces of clinical data.

Benefits

The use of CDA has several benefits, including:

• Interoperability: CDA documents can be shared and understood by different HIT systems.
• Flexibility: The three levels of CDA allow for varying degrees of structure and standardization, depending on the needs of the users.
• Clinical relevance: CDA preserves the clinical context of the document content, making it more meaningful and useful for clinicians.

See also

• Health Level Seven International
• Health informatics
• Electronic health record
• Interoperability

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