HL7 Clinical Document Architecture (CDA®) R2.0 Specification Online Navigation, Edition 2024

DESCRIPTION

The HL7 Clinical Document Architecture (CDA®) is a primary standard of Health Level Seven (HL7) and used millions of times each day for the exchange of patient summaries and other medical documents.

The HL7 Version 3 Clinical Document Architecture (CDA®) is a document markup standard that specifies the structure and semantics of clinical documents for the purpose of exchange between patients, healthcare providers and other stakeholders. It defines a clinical document as having the following six characteristics:

1. Persistence,
2. Stewardship,
3. Potential for authentication,
4. Context,
5. Wholeness
6. Human readability.

 

ALTERNATIVE NAMES

HL7 Clinical Document Architecture (CDA®) R2.0 Specification Online Navigation, Edition 2024 may also go by the following names or acronyms:

TARGETS

• Healthcare Providers
• Healthcare IT Vendors
• EHR and PHR Systems
• Departmental Systems
• Dictation/Transcription Vendors

BENEFITS

• Supports the exchange of clinical documents between those involved in the care of a patient
• Supports the re-use of clinical data for public health reporting, quality monitoring, patient safety and clinical trials
• Can be reused in multiple applications

IMPLEMENTATIONS/CASE STUDIES

• In the United States, Sequoia/eHealthExchange support exchange of billions of CDA documents annually
• Health information exchange (HIE) is well established in the European Union through eHealthNetwork/myhealth@eu
• Australia and New Zealand (in addition to other nations) support widespread use and multiple document types
• Multiple Implementation Guides using CDA R2.0 are cited in national regulations among multiple countries
• Dozens of academic studies have examined the use of CDA documents

DEVELOPMENT BACKGROUND

CDA® grew out of work that originated outside of HL7 in early 1996 when a group of physicians including Tom Lincoln, John Spinosa, Dan Essin, John Mattison and Bob Dolin began to meet to discuss the potential for structured markup in clinical documents. The earliest draft was called the Kona Architecture and was developed in 1997 after the group had joined HL7. Since that time, many people have worked on it and the basic ideas have been refined and developed along with the HL7 Version 3 framework and the Reference Information Model (RIM). The original group morphed into the HL7 Structured Documents Work Group which is responsible for CDA and other HL7 document types.

CDA introduces the concept of incremental semantic interoperability. What this means is that there is a range of complexity allowed within the specification and users must set their own level of compliance. The minimal CDA is a small number of XML-encoded metadata fields (such as provider name, document type, document identifier, and so on) and a body which can be any commonly-used MIME type such as pdf or .doc (Microsoft Word) or even a scanned image file.Extensive structured information may also be relayed in CDA documents, which are widely cited in interoperability regulations worldwide.

CDA also supports the exchange of a rich set of structured data elements encompassed within an organization of standardized sections comprised by the document. The body of the document presents the information it contains in a human readable format. It also carries the information in data structures that are machine processable. The discrete data is interpretable for applications like decision support and quality measurement and can be used to improve efficiency and effectiveness of many clinical and administrative processes within healthcare.

The current normative version of CDA is Release 2.0. Previous efforts to advance the standard, such as 2.1, did not achieve industry adoption and future work on structured clinical documents are expected to primarily focus on Fast Healthcare Interoperability Resources for the future.

RELATED DOCUMENTS

HL7 Clinical Document Architecture (CDA®) R2.0 Specification Online Navigation, Edition 2024

ADDITIONAL DETAILS

For quick answers to the most frequently asked questions about the Clinical Document Architecture (CDA) standard, see the CDA® Frequently Asked Questions page at http://www.hl7.org/about/FAQs/index.cfm.

TOPICS

• Attachments
• Clinical Quality
• Patient Care
• Patient Referral
• Public Health

BALLOT TYPES

• Normative

STATUS DATE

2024-08-20

RESPONSIBLE WORK GROUPS

PRODUCT TYPES

• Document
• Standard Reference Materials

STAKEHOLDERS

• Clinical and Public Health Laboratories
• EHR, PHR Vendors
• Emergency Services Providers
• Health Care IT Vendors
• Healthcare Institutions
• HIS Vendors
• Local and State Departments of Health
• Payors
• Quality Reporting Agencies
• Regulatory Agency
• Standards Development Organizations (SDOs)

FAMILY

• CDA

CURRENT STATE

• Active

REALM

• Universal