HL7 adds four guides to clinical documentation standards

Health Level Seven (HL7), a developer of healthcare standards, has approved four new implementation guides for its Clinical Document Architecture (CDA). The guides address documentation requirements for diagnostic imaging, consultations, quality reporting and home health monitoring.

“Getting healthcare standards to market quickly has been a longstanding issue, while the
sheer propagation of standards and the resulting lack of interoperability is a growing
concern,” said Bob Dolin, MD, chair-elect for HL7 and co-chair of the HL7 Structured
Documents Work Group (SDWG). “We have found, however, that CDA can be quickly and easily tailored for a broad number of use cases.”

First published in 2000, CDA is a standard for the exchange of healthcare information and interoperability for clinical care and public health.

The implementation guides are:

• CDA IG for Operative Notes – The implementation guide for this HL7 Draft Standard for Trial Use (DSTU) reuses templates developed for the HL7 Continuity of Care Document (CCD) and is suitable for any type of operative report;
  
• CDA IG for Quality Reporting Document Architecture – This HL7 DSTU covers patient-centric quality data reporting and lays out a framework for aggregate, population-based quality reports;
  
• CDA IG for Personal Healthcare Monitoring Reports – The implementation guide for this HL7 DSTU is conformant with the HL7 CCD and describes how to use CCD templates for communicating home health data to an EHR; and
  
• CDA IG for Diagnostic Imaging Reports – The implementation guide for this document is consistent with a companion guide for transforming DICOM Structured Reports to CDA Release 2 and is suitable for use with both structured and narrative data capture.