Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. Clinical Document Architecture Standard

The developing versions of the Clinical Document Architecture (CDA) standard highlight the need for coordinated approaches that will enable the electronic exchange of clinical documents (e.g., progress notes, histories). Also developed by HL7, the CDA standard is heavily dependent on, or leverages, the HL7 message formats mentioned above.

Essentially, a CDA standard is necessary to enable the algorithmic location of pertinent information within current documents, to logically organize documents in document management systems, to categorize information within the document according to a defined structure, and to display documents in electronic systems (including web-based and wireless systems). There is no uniform document structure for paper-based records in long-term care facilities. The lack of a uniform record structure presents significant constraints in deriving data from an electronic record to support reporting requirements such as the MDS.

Three releases of the CDA standard are planned and described by HL7. It is in the HL7 version 3 CDA standard that the format of the electronic medical record and clinical content of electronic documents will be formally specified and modeled using appropriately structured terminology coding systems (www.hl7.org).

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