HL7 Implementation Guide for CDA®, Release 2: Unstructured Documents

DESCRIPTION

This Implementation Guide provides consistent guidance for sending/receiving unstructured clinical documents including images, scanned documents, faxed and word processor output. This Implementation Guide describes constraints on use of the Clinical Document Architecture (CDA) header and body elements for an Unstructured Document. 

In many environments much of the patient record is still captured in an unstructured format that is encapsulated within an image file, or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents. 

ALTERNATIVE NAMES

HL7 Implementation Guide for CDA®, Release 2: Unstructured Documents may also go by the following names or acronyms:

TARGETS

• Providers and Clinicians
• Health Care IT Vendors, Healthcare Institutions (hospitals, long term care, home care, mental health)
• EHR Vendors
• PHR Vendors
• Dictation/Transcription Systems Vendors
• Health Information Exchange networks

BENEFITS

• Allows capture of patient record in an unstructured format that is encapsulated within an image file or as unstructured text in an electronic file such as a word processing or Portable Document Format (PDF) documents
• Enables higher level of interoperability for these documents to provide full access to the longitudinal patient record across a continuum of care

IMPLEMENTATIONS/CASE STUDIES

• In development

DEVELOPMENT BACKGROUND

CDA Consolidation Guide contains Unstructured Documents (Release 1.1), which supersede existing release 1 publications.

 

This implementation guide is a conformance profile, as described in the Refinement and Localization section of the HL7 Version 3 standards.  The base standard for this implementation guide is the HL7 Clinical Document Architecture, Release 2.0.  As defined in that document, this implementation guide is both an annotation profile and a localization profile.  CDA R2 is not fully described in this guide, so implementers must be familiar with the requirements of the base specification. This guide addresses only Level 1 constraints because of the nature and purpose of this guide: additional levels of coding are not applicable since they require the use of a structuredBody, which this implementation guide prohibits.

The approach taken in the development of this specification was to review existing draft and final specifications or implementation guides for similar artifacts in the U.S.:
• Clinical LOINC® document and section codes
• Health Information Technology Standards Panel (HITSP) Constructs, including the Encounter Document Using IHE Medical Summary (XDS-MS) Component (C48)
• HL7 Clinical Document Architecture, Release 2 Normative Web Edition, 2005
• Integrating the Healthcare Enterprise (IHE) Profiles, including the content profiles within Patient Care Coordination (PCC) and specifically the IHE IT Infrastructure Technical Framework Volume 3 (ITI TF-3) Cross-Transaction Specifications and Content Specifications Revision 6.0. (See  Relationship to IHE's XDS-SD on the relationship of this guide to XDS-SD.)
• Non-CDA sample documents supplied by participating providers and vendors

This guide is not intended to be a replacement for IHE’s XDS-SD (Cross-Transaction Specifications and Content Specifications, Scanned Documents Module) profile. Rather, it serves a more generic use case. XDS-SD is specifically for scanned documents, and limits content to PDF-A or text. This Unstructured Documents implementation guide is applicable not only for scanned documents in non-PDF formats, but also for clinical documents produced through word processing applications, etc.

RELATED DOCUMENTS

HL7 Implementation Guide for CDA®, Release 2: Unstructured Documents

ADDITIONAL DETAILS

This Draft Standard for Trial Use (DSTU) was produced and developed through the Health Story Project. The project was initiated by the Association for Healthcare Documentation Integrity (AHDI), Medical Transcription Industry Association (MTIA), American Health Information Management Association (AHIMA), and M*Modal and is being managed by Alschuler Associates, LLC and Optimal Accords, LLC.

TOPIC

• Patient Care

BALLOT TYPE

• DSTU

STATUS DATE

2012-10-22

RESPONSIBLE WORK GROUP

STAKEHOLDERS

• Health Care IT Vendors
• Healthcare Institutions

FAMILY

• CDA

CURRENT STATE

• Retired

REALM

• US Realm