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Compare electronic Mac EMR Software to find the best fit for your practice. Get free demos, price quotes and reviews of leading Mac systems. We also speak with more and more doctors who want to run medical billing software or electronic medical records (EMRs)—also often called electronic health records (EHRs)—on Macs. A Mac-native. C-CDA documents “require” a limited number of sections EHR vendors frequently support inclusion of only required sections even if information exists in the medical record for “optional” sections. The major care providers and hospitals generally use Electronic Health Record (EHR) or Electronic Medical Record (EMR) systems by a company called Epic, although there are plenty of companies that do substantially the same thing: Practice Fusion, Allscripts, athenahealth, eClinicalWorks, drchrono, and countless others.J Am Med Inform Assoc. 2001 Nov-Dec; 8(6): 552–569. This article has been corrected. See J Am Med Inform Assoc. 2002; 9(3): 307.
Mac EMR software is electronic medical records software built specifically to run on the Mac operating system (OS). This OS is designed specifically for the Apple hardware it runs on, which supports easy integration between different types of Apple products. Find and compare top Medical Transcription software on Capterra, with our free and interactive tool. Quickly browse through hundreds of Medical Transcription tools and systems and narrow down your top choices. Filter by popular features, pricing options, number of users, and read reviews from real users and find a tool that fits your needs.This article has been cited by other articles in PMC.Abstract
Many people know of Health Level 7 (HL7) as an organization that creates health care messaging standards. Health Level 7 is also developing standards for the representation of clinical documents (such as discharge summaries and progress notes). These document standards make up the HL7 Clinical Document Architecture (CDA). The HL7 CDA Framework, release 1.0, became an ANSI-approved HL7 standard in November 2000. This article presents the approach and objectives of the CDA, along with a technical overview of the standard.
The CDA is a document markup standard that specifies the structure and semantics of clinical documents. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. The document can be sent inside an HL7 message and can exist independently, outside a transferring message. The first release of the standard has attempted to fill an important gap by addressing common and largely narrative clinical notes. It deliberately leaves out certain advanced and complex semantics, both to foster broad implementation and to give time for these complex semantics to be fleshed out within HL7.E-reader For Mac
Being a part of the emerging HL7 version 3 family of standards, the CDA derives its semantic content from the shared HL7 Reference Information Model and is implemented in Extensible Markup Language. The HL7 mission is to develop standards that enable semantic interoperability across all platforms. The HL7 version 3 family of standards, including the CDA, are moving us closer to the realization of this vision.
Health Level 7 (HL7)1 is a standards-setting organization accredited by the American National Standards Institute (ANSI). They have developed communication protocols widely used in the United States, with growing international recognition and implementations. A vendor- and provider-supported organization, its mission is to provide standards for the exchange, management, and integration of data that support clinical patient care and the management, delivery, and evaluation of health care services. This encompasses the complete life cycle of a standards specification—development, adoption, market recognition, utilization, and adherence. The HL7 specifications are unified by shared reference models of the health care and technical domains. The HL7 version 2.4 messaging standard is currently in use, and version 3, which represents several fundamental changes to the HL7 messaging approach, is in an advanced stage of development.
Many people know of HL7 as an organization that creates health care messaging standards. Health Level 7 is also developing standards for the representation of clinical documents (such as discharge summaries and progress notes). These document standards make up the HL7 Clinical Document Architecture (CDA). The HL7 Clinical Document Architecture, release 1.0, became an ANSI-approved HL7 Standard in November 2000.4
This article is intended to serve as an introduction to the CDA standard. It is geared toward medical informaticians who do not have significant familiarity with HL7 version 3, and it is intended to introduce the approach and objectives used in the creation of the standard and present an overview of the standard—not sufficient for implementation but sufficiently detailed to enable the reader to understand the scope and contents of the standard. Interested readers looking for detailed descriptions are encouraged to contact HL7 (www.hl7.org) for a copy of the normative specification.Overview of the CDA
The need for a clinical document standard stems from the desire to unlock the considerable clinical content currently stored in free-text clinical notes and to enable comparison of content from documents created on information systems of widely varying characteristics. Given the variability in clinical notes, including structure, underlying information models, degree of semantic encoding, use of standard healthcare terminologies, and platform- and vendor-specific features, it is currently difficult to store and exchange documents with retention of standardized semantics over both time and distance. And while the current CDA standard does not fully enable these main driving objectives, it takes us a step closer.
The CDA is a document markup standard that specifies the structure and semantics of “clinical documents.” A clinical document is a documentation of observations and services and has the following defining characteristics:
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Persistence. A clinical document continues to exist in an unaltered state, for a time period defined by local and regulatory requirements.
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Stewardship. A clinical document is maintained by a person or organization entrusted with its care.
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Potential for authentication. A clinical document is an assemblage of information that is intended to be legally authenticated.
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Wholeness. Authentication of a clinical document applies to the whole and does not apply to portions of the document without the full context of the document.
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Human readability. A clinical document is human readable.
Many draft and existing standards have helped inform the development of the CDA,14 and several guiding principles have driven the design:
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Give priority to documents generated by clinicians involved in direct patient care. There are many requirements and uses for clinical information, such as direct patient care, outcome research, and public health reporting. The CDA will give priority to defining documents that are created by clinicians involved in direct patient care, assuming the other uses will be derivable. The CDA will define documents produced by providers seeing patients and will not define views or downstream uses of those documents.
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Minimize the technical barriers needed to implement the Standard. There are estimated to be hundreds of thousands of nonstandardized clinical documents in existence. The CDA will facilitate standardization of these documents by allowing cost effective implementation across as wide a spectrum of systems as possible; by supporting exchange of human-readable documents between users, including those with different levels of technical sophistication; by enabling a wide range of post-exchange processing applications; by providing compatibility with a wide range of document creation applications; and by using non-health-care–specific standards where possible.
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Promote longevity of all information encoded according to this architecture. The CDA documents will be application- and platform-independent and can be viewed and edited by a number of tools, both now and in the future.
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Promote exchange that is independent of the underlying transfer or storage mechanism. The ability to exchange or store CDA documents will be application- and platform-independent. These documents can be exchanged in HL7 messages, via e-mail, on a floppy disc, etc. A CDA document can be stored as an independent file, within a document management system, within a database, etc.
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Enable policy makers to control their own information requirements without extension to this specification. The CDA will define an extensibility mechanism that allows local implementations to represent information that is not formally represented in the standard.
The CDA is part of the HL7 version 3 family of standards. This family, which includes both CDA and the evolving version 3 message standards, all derive their semantic content from the shared HL7 Reference Information Model (RIM)15 and are implemented in Extensible Markup Language (XML).16 The process for generating an XML-based implementation from the RIM is part of the version 3 development methodology. The exact style of HL7’s XML representation was a carefully considered balance of technical, practical, and functional considerations.18–
At the heart of the HL7 version 3 family of standards lies a shared information model, the HL7 RIM.14 An object-oriented model created as part of the version 3 methodology, the RIM is a large pictorial representation of clinical data and identifies the life cycles of events that messages and documents convey. All version 3 products derive their semantic content from the RIM. The various committees in HL7 engage in an iterative consensus process to continually refine the RIM to meet identified use cases. Figure 1▶ is a small subset of RIM version 0.98 that was used in the derivation of the CDA.
Subset of RIM version 0.98. A small subset of the HL7 Referenced Information Model, Version 0.98, used in the derivation of the CDA.
The RIM includes a new set of data types developed for use in the HL7 version 3 family of standards. These data types include some of the familiar ones used in HL7 v2.x messaging, such as STRING (ST), INTEGER (INT), and TIME STAMP (TS), as well as new data types such as ENCODED DATA (ED), which supports multimedia; INTERVAL of TIME (IVL<TS>), which allows for the expression of a time range; and CONCEPT DESCRIPTOR (CD), which supports the post-coordination of codes (or, stated in another way, the combining of codes from a terminology to create a new concept).
A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. The document can be sent inside an HL7 message and can exist independently outside a transferring message. There is a critical interdependence between clinical documents and document management systems. If CDA documents are viewed outside the context of a document management system, it cannot be known with certainty whether or not the viewed document is current. Clinical documents can be revised, and they can be appended to existing documents. In practice, it is impossible to guarantee an explicit forward pointer from an outdated version to the newer version. Document management systems and HL7 messages that carry CDA documents convey critical contextual information that minimizes the risk of viewing superseded information.The “A” in “CDA”
The complete CDA will include a hierarchic set of document specifications. This hierarchy is referred to as an “architecture” (the “A” in “CDA”). This architecture, which can be thought of as a set of hierarchically related XML Document Type Definitions (DTD) or schemas,24,25 is envisioned for future releases of the CDA standard. The current CDA standard has defined only the top node of the hierarchy, known as “CDA Level One.”
Level One is sufficiently detailed to represent largely narrative clinical notes. The specification defines the document header in detail, while the document body is largely structural. Level One is intended to minimize the technical barriers to adoption of the standard while providing a gentle introduction to the RIM. It intentionally lacks some of the complex semantics that will be used in HL7 version 3 messaging (such as the ability to fully encode orders and observations). It is hoped that the provision of deeper levels of the architecture will provide a migration pathway for implementers to iteratively add greater markup to clinical documents.
Level Two is envisioned as a set of templates or constraints that can be layered on top of the CDA Level One specification. A template may, for instance, specify that a document of type “history-and-physical” will contain a mandatory “subjective” section; a mandatory “physical-examination” section containing a mandatory “vital-signs” section and an optional “cardiovascular-examination” section; and a mandatory “assessment” section followed by a “plan” section. This type of template development will require considerable domain knowledge and participation from professional societies so that created templates are widely embraced and supported. Health Level 7 is now in the process of establishing necessary liaison relationships with professional societies.
Level Three of the CDA will add additional RIM-derived markup to the CDA Level One specification, enabling clinical content to be formally expressed to the extent that is it modeled in the RIM or to the extent that it can be expressed in an HL7 version 3 message. This could, for instance, allow an order message to be extracted from a clinical document, allow for a detailed representation of symptoms and findings, and allow for billing codes to be automatically extracted.
The clinical content of CDA documents will remain invariable across all levels of the architecture. Each level both enables and enhances the standardized expression of richer shared semantics. Thus, a single report can be marked up as a Level One, Level Two, or Level Three document, and its clinical content will not vary. What will vary between the levels are the degree to which clinical content can be machine processible in an exchange context and the degree to which clinical document specifications can impose constraints on content.Clinical Document Architecture Technical Overview
A CDA document has a header and a body. The header conveys the context in which the document was created, and the body contains the informational (factual) statements that make up the actual content of the document. The purpose of the header is to make clinical document exchange possible across and within institutions; facilitate clinical document management; and facilitate compilation of an individual patient’s clinical documents into a lifetime electronic health record.
The header has four logical components:
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Document information identifies the document, defines confidentiality status, and describes relationships to other documents and orders.
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Encounter data describes the setting in which a documented encounter occurred
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Service actors include those who authenticate the document, those intended to receive a copy of the document, document originators and transcriptionists, and health care providers who participated in the service(s) being documented
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Service targets include the patient and other significant participants (such as family members).
The CDA body comprises sections, paragraphs, lists, and tables. These structural components have captions, can nest (so that, for instance, a section can contain a section), and can contain character data, multi-media, and codes drawn from standard terminologies.
Appendix 1 shows a sample clinical document, and Appendix 2 shows a CDA-encoding of that sample document. The sample CDA document includes many optional components (including some that are not explicitly shown in Appendix 1) to better illustrate more features. Line numbers in Appendix 2 are be referenced throughout this technical overview to help illustrate the described concepts.CDA Header (Appendix 2, Lines 4–120)
Document Information (Appendix 2, Lines 5–25)
A CDA document can be an original document, an addendum to an existing document, or a revision of an existing document. An original document is the first version of a document. An addendum is an appendage to an existing report that contains supplemental information. The parent report being appended remains in place and its content and status are unaltered. A replacement report is a revision that replaces an existing report. The replacement report gets a new globally unique <id>* value but uses the same value for <set_id> as the parent report being replaced, and increments the value of <version_nbr> by 1 (Appendix 2, lines 5–7). The parent report is considered superseded but is still retained in the system for historical reference. Addendum and replacement documents reference the parent report via a <document_relationship> (Appendix 2, lines 13–20).Pdf Reader For Mac
Documents can also be related to one or more orders. The <fulfills_order> component relates the current document to the unique identifier(s) of the orders that have been fulfilled (Appendix 2, lines 21–25) by this document.
Every document has a required document type code, <document_type_cd> (Appendix 2, lines 8–9), which classifies the document. Abbyy business card reader for mac. The externally defined vocabulary domain for <document_type_cd> is drawn from LOINC (Logical Observation Identifiers, Names and Codes).26, The creation of an ontology of clinical document names and codes in LOINC was accelerated by the contributions of the Document Ontology Task Force, a consortium of standards and vocabulary organizations sponsored by HL7 with support from the Veterans Health Administration, charged with this task. On the basis of the analysis of more than 2,000 clinical document names, the task force formulated a terminology model that was given to LOINC to guide the creation of fully specified document names.28,29
Many temporal events come into play in the creation and validation of a CDA document. Some of the relevant times are part of the document information (e.g., <origination_dttm>, which represents the time a document is initiated), while other times relate to the encounter (e.g., <encounter_tmr>), and the time during which various service actors and targets played a role (e.g., <participation_tmr>). Some temporal events can be represented as a specific point in time (indicated by an XML element name ending in “_dttm” and using the H

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