About Clinical Document Architecture
Clinical Document Architecture (CDA) is an HL7v3, XML-based standard that provides a structure for encoding, formatting, and exchanging electronic clinical documents, such as patient and discharge summaries, progress notes, imaging and lab reports, and other medical reports. CDA enables interoperability between different healthcare IT systems.
CDA consists of the following core elements:
- The method for transporting documents is not specified.
- Documents have a consistent structure with required and optional sections (for example, patient demographics, observations, and medications).
- Codes from standard vocabularies are implemented, supporting interoperability and data exchange.
- Long-term storage of documents as part of a patient's medical record is supported.
- Accommodations of new requirements across different clinical environments are supported.
Common CDA use cases include the following:
- A continuity of care document (CCD) is exchanged between providers through a health information exchange (HIE) or direct secure exchange such as REST. An HIE enables health care providers to securely access and share a patient's medical information electronically across different healthcare organizations, such as hospitals, clinics, and labs.
- A patient receives their discharge summary from a patient portal.
- A primary care provider (PCP) refers a patient to a specialist such as a physician from oncology, podiatry, cardiology, immunology, or another department.