HL7-CDA-R2
HL7 CDA R2 clinical document architecture XML structured 2005.
Définition
HL7 CDA R2 architecture : (1) ClinicalDocument root XML element : document type (templateId), document identifier (id), document creation timestamp (effectiveTime), confidentiality code, document languages, etc. (2) Document header : recordTarget (patient), author (clinician + organization), custodian (organization holding document), legalAuthenticator (signature), informant, participant. (3) Document body : structured body (sections + entries) OR nonXMLBody (PDF, RTF, etc. embedded). Structured body recommended. (4) Sections : standard sections (allergies, medications, problems, procedures, diagnoses, lab results, vital signs, etc.), each with text narrative + entries (coded clinical statements). (5) Entries : Acts (Act, Observation, Substance Administration, Procedure, etc.) coded SNOMED CT + LOINC + RxNorm + ICD-10 + etc. (6) Templates : reusable constraints on CDA (CCD, Consultation Note, Discharge Summary, Operative Note, Progress Note, Procedure Note, Referral Note, etc.). (7) Consolidated CDA (CCDA) : ONC C-CDA published 2012 (CCDA R1.1 + R2.0 + R2.1), consolidated US-Realm Templates used for Meaningful Use + ONC Certification + Promoting Interoperability + CMS Patient Access. (8) International deployments : CDA R2 used in France (Phast), Italy (FSE), Germany (eFA), Switzerland (eHealth Suisse), Austria (ELGA), multiple LATAM countries. CDA R2 vs FHIR : CDA document-centric (document is unit of exchange), FHIR resource-centric (granular API). Both coexist 2024, FHIR adoption accelerating.
Origine
HL7 CDA R1 published 2000 ; HL7 CDA R2 published 2005 ANSI/HL7 standard ; CCDA R1.1 published 2012 ONC ; CCDA R2.1 published 2014 ; widely deployed 2024.
Exemple en contexte
Hospital discharge summary uses CDA R2 CCDA Discharge Summary template : ClinicalDocument with templateId CCDA Discharge Summary R2.1, header (patient + author physician + custodian hospital), body with sections (Hospital Course narrative + Discharge Diagnosis with ICD-10 coded entries + Discharge Medications with RxNorm coded entries + Hospital Discharge Instructions narrative + Reason for Visit + Functional Status etc.), signed XAdES-X-L Long Term, submitted to HIE via IHE XDS.
Termes liés
- IHE XDS — transport for CDA documents.