CDAQuickStart.docx

CDAQuickStart.docx

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CDAQuickStart

QuickStartGuide

HL7ImplementationGuide:

ForSimpleCDARelease 2Documents

Version1.5November15,2007

Acknowledgments

ThisguidewasoriginallywrittenbyBobYenchaandLioraAlschuler,AlschulerAssociates,LLC,undersponsorshipofCol.DavidWilliams,AN,DeputyDirector,IM,Tricare,MilitaryHealthSystem.ItwillbeexpandedandspecializedforusewithinTricareandisofferedhereforgeneralusewithintheCDAimplementorcommunity.Comments,questions,correctionsandsuggestionsshouldbedirectedtocdaqsg@.

Thisguidewaswrittenanddevelopedby:

TableofContents

RevisionHistory4

WhoShouldReadThisQuickStartGuide5

Introduction5

AboutThisQuickStartGuide7

DocumentNotationalConventions7

AuthoritativeSources7

Assumptions8

ReferenceInformation8

BeforeYouBegin–UseofIDsandCodes9

DocumentDesign11

CDAMinimumRequiredElements12

ClinicalDocument12

typeID12

id12

code13

effectiveTime13

confidentialityCode14

recordTarget14

author15

custodian15

CDAOptionalHeaderElements17

relatedDocument17

setId:

:

versionNumber17

componentOf:

:

encompassingEncounter17

legalAuthenticator17

templateId17

documentationOf:

:

serviceEvent18

CDABodyandNarrativeBlock19

CDAEntriesandClinicalStatements21

AppendixA–SampleCDAInstance–structuredBody23

AppendixB–AdditionalInformationonISO8601–TimeandDateStamps26

RevisionHistory

Date

Version

Comments

October17,2005

1.0

Initialrelease

November1,2005

1.1

Clarifiedtimeinformation

fixedstylesheetreferenceinexamplesandrelatedinfoCreatedbrowserversionofdocandreadme.txtforinclusionduetobuginWordthatpreventslinksfromworkingcorrectly.

Addednewsupportemailaddress.

September2,2006

1.2

Minorupdatesandcorrections

August31,2007

1.3

Minorupdatesandcorrections（typo’s,links）

October9-21,2007

1.4

Editsperthemeetingnotesof10/9/2007–BobYencha

November15,2007

1.5

AcceptedBobYencha’schanges

Added“WhoShouldReadThisDoc”

Introrewritten

AddeddefforcomponentOf/encompassingEncounter

WhoShouldReadThisQuickStartGuide

Thisdocumentisintendedforapplicationdesigners,developers,andimplementersofstandards-based,interoperablehealthcareinformationsystems.ReadersmusthaveaccesstothespecificationsreferencedinthisQuickStartGuide（QSG）.（SeeReferenceInformationforfullinformationonhowtoaccessHL7specifications.）

CDAutilizesExtensibleMarkupLanguage（XML）.ReadersandimplementersmustbeversedinXMLandshouldreadXPathsyntaxaswell.Whilenotrequired,manyapplicationsuseXSLTtodisplayCCDandasampleXSLTstylesheetisavailablewiththespecification.FormoreinformationontheserecommendationsfromtheWorldWideWebConsortium,seewww.W3.org.

CDAisderivedfromtheHL7ReferenceInformationModel（RIM）anduser-controlledterminologysuchasSNOMEDCT,LOINC,CPT,ICD,andRxNorm.KnowledgeoftheRIMisnotnecessaryforCDAimplementers.Somefamiliaritywithterminologysystemsisrequired.

ThisQSGpresupposesnoconsensusoncontentorcodingbeyondtheCDAspecificationitself.ItismerelyaninformativeaidtoimplementersandappliestoallimplementationsofCDA,althoughoptionalaspectsofCDAmayberequiredthroughlocal,regional,ornationalguidelinesandagreements.

IfthroughanerrorthisQSGdeviatesinanywayfromtheCDARelease2.0specification,thespecificationshouldbefollowed.

Introduction

TheHL7CDAisadocumentmarkupstandardthatspecifiesthestructureandsemanticsofclinicaldocumentsforthepurposeofexchange.

ThegoalsofCDAare:

∙Giveprioritytodeliveryofpatientcare.

∙Allowcosteffectiveimplementationacrossaswideaspectrumofsystemsaspossible.

∙Supportexchangeofhuman-readabledocumentsbetweenusers,includingthosewithdifferentlevelsoftechnicalsophistication.

∙Promotelongevityofallinformationencodedaccordingtothisarchitecture.

∙Enableawiderangeofpost-exchangeprocessingapplications.

∙Becompatiblewithawiderangeofdocumentcreationapplications.

∙Promoteexchangethatisindependentoftheunderlyingtransferorstoragemechanism.

∙Preparethedesignreasonablyquickly.

∙Enablepolicy-makerstocontroltheirowninformationrequirementswithoutextensiontothisspecification.

Akeytothisacceptanceisthe“A”forarchitectureinCDA,whichpromotesreusabilityacrossasufficientlywiderangeofdocumentstocoverclinicalinformationsharing,publichealth,qualityreporting,andclinicaltrials.

Sinceitsissuancein2005,severalimplementationguidesdescribingspecifictypesofCDAdocumentshavebeendeveloped,ballotedandpublished.TheContinuityofCareDocument（CCD）isajointprojectbyHL7andASTMInternationalthatimplementstheclinicalrequirementsspecifiedintheContinuityofCareRecord（CCR）usingtheCDAarchitecture.CCDwasballotedbyHL7in2006andpublishedinApril2007.

Startingin2007,theCDAforCommonDocumentTypes（CDA4CDT）projectdevelopedandballotedimplementationguidesfortheHistory&PhysicalandConsultNotethatreusetemplatesdefinedinCCD,ensuringconsistencyacrossthesedocumenttypes.CDA4CDTwasinitiatedbytheprimaryplayersinthedictation/transcriptionindustrytorapidlyincreasetheavailabilityofCDAdocumentsforimportationintoelectronichealthrecordsandutilizationintheemerginghealthinformationexchanges.

Alsoin2007,theHL7AttachmentsSpecialInterestGroup（ASIG）reviseditsimplementationguidesforHIPAAclaimsattachmentstoconformtoRelease2,andIntegratingtheHealthcareEnterprise（IHE）expandeditsguidanceonCDAthroughaseriesofpatientcareprofiles.ProjectsareunderwaytodevelopguidanceontheuseofCDAforpublichealthandqualityreportingandtomeetthespecializedrequirementsoflong-termcare.InformationonhowtoobtaineachoftheseguidesisincludedintheReferenceInformationsection.

ThisQuickStartGuidewillhelpimplementerscreateasimpleCDAdocumentandthenastheyincreasetheirknowledgeofCDA,goontocreatemorecomplexversionsusingtheresourcescitedinthisQSGandtheirownexperience.

AboutThisQuickStartGuide

DocumentNotationalConventions

NarrativetextwillappearinTimesNewRomanfont,plainface.

elementwhenanXMLelementisdiscussedinnarrativetext

attributewhenanXMLattributeisdiscussedinnarrativetext

CodingexampleswillappearasCourierfontwithcolorforclaritywhereapplicable.

ReferencesaremadethroughoutthisdocumenttothenormativeHL7ClinicalDocumentArchitecture（CDA）,Release2.0.Toimprovereadability,allreferencestothisdocumentwillappearattheendofeachtopicas

[CDARelease2.0,SectionX.x.x.x–SectionTitle]

Additionalreferencestootherpartsofthespecificationwillincludethetitleofthedocumentinaddtiontothesectionnumberandtitle,i.e.:

[HL7ReferenceInformationModel,Section3.4.1.3–InfrastructureRoot.typeId]

NOTE:

Referencestolocationsontheinternetareactivelinks.

ThereaderofthisdocumentshouldhaveacopyoftheHL7ClinicalDocumentArchitecture（CDA）,Release2.0specification.,availablefromHL7atwww.hl7.org/memonly/downloads.PleasenotethatyoumustbeanHL7membertoaccessanddownloadthespecification.

AuthoritativeSources

NOTE:

PortionsofthisdocumentareabstractedfromthenormativeeditionoftheHL7ClinicalDocumentArchitecture（CDA）,Release2.0specification.ThisQSGisnotacompletereferencetotheCDAschemasandshouldbeusedinconjunctionwiththefullnormativespecificationforimplementationanddevelopment.PleaserefertothenormativeeditionforacompletedescriptionoftheCDAanditsusage.Anydeviationfromthespecificationisanerrorandthespecificationshouldbefollowedinallcases.

ThisQSGisbasedontheHL7ClinicalDocumentArchitecture2.0,May2005.ItdescribeshowtoimplementabasicCDAthatwillfacilitatethecollectionofpatientinformationasaseriesofCDAdocumentsorinamixedarchivewithothertypesofstandards-basedpersistentobjects.TheresultingCDAinstancewillbecomprisedofanXML-encodedheaderandabodywhichiseithernon-XMLorthesimpleXMLoftheCDAnarrativeblock.

TheQSGcoversallrequiredelementsoftheCDAHeaderandgivesguidanceonsomeoptionalelements,suchasthosethatidentifyrelatedordersandprocedures.

[CDARelease2.0,Section1.2.2-The"A"in"CDA"]

[CDARelease2.0,Section4.3.5-SectionNarrativeBlock]

Assumptions

ThisdocumentassumesthatthereaderhasathoroughunderstandingofXMLandtheW3CRecommendation.AsanXMLapplicationsdeveloper,thereadershouldbefamiliarwithW3Cschemas,XMLvalidation（parsing）,andmethodsofconstructinganddeconstructingXMLfiles.

KnowledgeoftherelevantHL7standardsandapproachesarehelpful.Additionalinformationtofurtherthereader’sunderstandingcanbefoundinthefollowingsection.

ReferenceInformation

HL7ClinicalDocumentArchitecture（CDA）,Release2.0–TheCDASpecificationisavailablefromhl7.org.

TheHL7StructuredDocumentsTechnicalCommitteemaintainsalistservthathostsongoingdiscussionsontheimplementationofCDAandrelatedspecifications.Implementersshouldsubscribetothelistwheretheycanpostimplementationquestionsandstaycurrentwithissuesraisedbyothers.

ASIG

HAI

QRDA

CDA4CDT

BeforeYouBegin–UseofIDsandCodes

TheCDAallowsmorethanonetypeof