HL7 Implementation Guide for CDA R2
Published August 2010
Extensive and advanced interoperability and effective information systems for patient care must consist of CDA Level 2 and Level 3 documents, yet the full understanding, use and compliance of CDA Level 2 and 3 is likely years away by all major participants, including EHR system vendors, providers, payers, carriers, etc. Much of the patient record still exists and is being captured in an unstructured format that is encapsulated within an image file or as unstructured text in an electronic file such as a WORD or PDF documents. There is a need to raise the level of interoperability for these documents to provide full access to the longitudinal patient record across a continuum of care. Until this gap is addressed, image and multi-media files will continue to be a portion of the patient record that remains difficult to access and share with all participants in a patient’s care. This project addresses this gap by providing consistent guidance on use of CDA for unstructured documents. The project will review pertinent work from IHE, most relevant is the IHE XDS-SD (Scanned Documents) which applies to plain text and PDF-A. The project will also review pertinent HITSP recommendations and will provide guidance consistent with those requirements.
Within HL7, the project is sponsored by the Structured Documents Work Group.