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Submitted on June 12, 2005
Accepted on September 20, 2005
Affiliation of the authors: 1 Kaiser Permanente, Pasadena, CA; 2 Alschuler Associates, LLC, East Thetford, VT; 3 Consultant, Laguna Beach, CA; 4 Mayo Clinic, Rochester, MN; 5 LAI Technology, Homewood, IL; 6 IBM Haifa Research Lab, Haifa, Isreal
* To whom correspondence should be addressed.
CDA, Release One (CDA R1) became an American National Standards Institute (ANSI)-approved HL7 Standard in November, 2000, representing the first specification derived from the 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 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 wide-spread adoption, while providing a mechanism for incremental semantic interoperability.
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