NIST GCR 11-943 

Templated CDA: Key Concept for

Interoperability

Lantana Consulting Group 
NIST GCR 11-943

Templated CDA: Key Concept for

Interoperability

Prepared for 

 National Institute of Standards and Technology

Gaithersburg Md 20899-8202

By

Lantana Consulting Group

May 2011 

U.S. Department of Commerce 

John E. Bryson, Secretary

National Institute of Standards and Technology 

Patrick D. Gallagher, Under Secretary for Standards and Technology and Director

This publication was produced as part of contract SB1341-10-CN-0085 with the National Institute of

Standards and Technology. The contents of this publication do not necessarily reflect the views or policies

of the National Institute of Standards and Technology or the US Government.
Templated CDA:

Key Concept for Interoperability

 May 2011

Prepared by Lantana Consulting Group

for

National Institute of Standards and Technology

© 2011 Lantana Consulting Group

All rights reserved
Lantana Consulting Group

PO Box 177

East Thetford, VT 05043

www.lantanagroup.com

Bob Dolin, MD, FACP

President and Chief Medical Officer

bob.dolin@lantanagroup.com

Liora Alschuler

Chief Executive Officer

liora.alschuler@lantanagroup.com

Rick Geimer

Chief Technology Officer

rick.geimer@lantanagroup.com

Gaye Giannone Dolin, RN, MSN

Senior Nurse Informaticist

gaye.dolin@lantanagroup.com

Susan Hardy

Senior Technical Editor

susan.hardy@lantangroup.com

Jingdong Li, MD

Chief Architect

jingdong.li@lantanagroup.com

Brett Marquard

Senior Interoperability Consultant

brett.marquard@lantangroup.com

Sean McIvenna

Senior Software Architect

sean.mcilvenna@lantangroup.com

Lauren Wood, Ph.D.

Senior Project Manager

lauren.wood@lantanagroup.com

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Table of Contents

EXECUTIVE SUMMARY 5 

1 1NTRODUCTION . 6 

2 CDA TEMPLATES: MODEL-DRIVEN COMPUTABLEOBJECTS 8

3 TEMPLATED CDA FOR STANDARDS DEVELOPMENT ANDHARMONIZATION 11

4 TEMPLATED CDA FOR INFORMATION CAPTURE, REUSE, AND ANALYSIS . 13 

4.1 Information Capture and Analysis 13

4.2 Information Reuse . 13

5 A TEMPLATED CDA INTEROPERABILITY ROADMAP 15

6 CONCLUSION 18

 7 REFERENCES 19

APPENDIX A —ACRONYMS AND ABBREVIATIONS 20 

APPENDIX B —TEMPLATED CDA USECASE:NHLBI 21

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List of Figures

FIGURE 1: TEMPLATE RELATIONSHIPS AND CONSTRAINTS.............................................................9

FIGURE 2: CDA TEMPLATE LIBRARY SUPPORTING STANDARDS DEVELOPMENT AND

IMPLEMENTATION............................................................................................................................ 10

FIGURE 3: TEMPLATE PROLIFERATION IN CDA IMPLEMENTATION GUIDES..............................12

FIGURE 4: EVOLUTION TO STABLE GROWTH OF TEMPLATES....................................................... 13

FIGURE 5: EHR INTERFACE DEFINED BY THE CDA TEMPLATES IT SUPPORTS...........................15

FIGURE 6: INCREMENTAL ADOPTION OF CDA TEMPLATES............................................................ 16

FIGURE 7: TEMPLATE EXCHANGE ACROSS LIBRARIES................................................................... 17

FIGURE 8: TEMPLATE CONSTRAINTS EXPRESSED IN DATA-ENTRY FORM.................................22

FIGURE 9: GENERATION OF TEMPLATED CDA INSTANCE FROM DATA-ENTRY FORM.............23

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EXECUTIVE SUMMARY

This document supplements information about “templated CDA” in the context of the Healthcare

Information Technology (HIT) Standards Analysis Project carried out by Lantana Consulting

Group for the National Institute of Standards and Technology (NIST). 

As part of our HIT Standards Analysis and our goal to move towards more testable

interoperability standards, we frequently assert in the various reports prepared under this contract

that an architecture based on model-driven standards (i.e., standards derived from formal

and computable models) enable far more robust testing strategies than we have in use

today. The key model-driven technology is one underlying the Continuity of Care Document

(CCD) and other Health Level Seven (HL7) Clinical Document Architecture (CDA)

implementation guides known as “templated CDA”. This document lays out the key concepts of

templated CDA to help the reader weigh the assertions and recommendations we have made

throughout our reports. Templated CDA touches all aspects of interoperability. From the

perspective of test and validation, this is critical as it provides an organic, single, and structured

source for the deployment of structured information exchange. 

Such a comprehensive approach is critical for large scale, rapid adoption because a modest initial

investment leverages the templated approach to achieve large-scale, cost-effective extensibility. It

gives implementers a roadmap for test validation so that they can interpret narrowly targeted

interoperability goals within a wider context and using a consistent tool set. 

This document’s Introduction begins by laying out the business case for CDA and for templated

CDA. The next section on CDA Templates: Model-driven Computable Objects presents a high-level

technical overview and discusses how CDA templates streamline both standards development and

standards implementation. Templated CDA for Standards Development and Harmonization provides

data on the growing use of CDA templates, and the growing reuse across CDA implementation

guides. Templated CDA for Information Capture, Reuse, and Analysis describes how CDA templates

drive greater consistency in data capture and data representation, leading to greater capabilities

for comparative effectiveness and retrospective analyses. A Templated CDA Interoperability

Roadmap lays out a concrete set of steps that support an incremental path to semantic

interoperability based on CDA and templated CDA. The appendix on Templated CDA Use Case:

NHLB presents a more detailed scenario, illustrating how CDA templates might be used in

practice to achieve our ultimate objective of improving patient care.

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INTRODUCTION

Clinicians all over the country capture patient data through their method of choice—a voice

interface, keyboard, or menu-driven interface. The user interface is customized to their

preferences for sequence and naming conventions and includes prompts or fields for all the

customary elements. What if the prompts ensured that the same basic information was captured

via all modalities in all venues and that, once captured, could be shared with clinicians across the

country? And what if the underlying encoding was transparent to all EHRs and supported clinical

trials, comparative effectiveness and all manner of secondary use? 

What if the interface also prompted clinicians for missing data required to complete a quality

measure or public health report? 

If we could do this with minimal disruption to current clinical workflow while maximizing test

and validation, the country would be well launched on an incremental path to semantic

interoperability—the path to Meaningful Use. In this paper, we describe how a library of CDA

templates can meet many of the evolving interoperability and testing requirements in the United

States. 

Health Level 7 (HL7) Clinical Document Architecture, Release 2 (CDA) is an American National

Standards Institute (ANSI) accredited standard specification for the representation of clinical

documents (such as Discharge Summary, Diagnostic Imaging Report, Operative Report, and

Progress Note). Based on Extensible Markup Language (XML), CDA is a document markup

standard that specifies the structure and semantics of clinical documents for the purpose of

information exchange. A CDA document is a defined and complete information object that can

exist outside of a message and can include text, images, sounds, and other multimedia content1.

Any tool that works with clinical information—an electronic medical record (EMR), clinical

information system, or transcription system—can produce CDA; in fact, you can create a CDA

with a word processor or XML editor. 

CDA’s features: 

Consistency. There is a single specification (and single XML schema) for all CDA

documents.

Stability. CDA has been a normative ANSI standard since 2000. Release 2 has been

integrated into production applications since its release in 2005. 

Consensus driven. CDA was developed by volunteers and balloted through HL7's

consensus process, drawing input from hundreds of organizations, large and small, from

over a dozen countries. 

Extensibility. CDA templates allow incremental expansion to meet new use cases while

avoiding proliferation of incompatible extensions. 

Broad implementation experience. CDA is widely implemented across the globe2.

Gentle on-ramp to information exchange. CDA is straightforward to implement. It

provides a mechanism for “incremental semantic interoperability” beginning with a

1 HL7 Standard: Clinical Document Architecture, Release 2 (CDA). ANSI-approved HL7 Standard; May 2005. 

2

 See these web sites, which reference a sampling of CDA implementations: http://tinyurl.com/cda-around-theworld, http://www.showmeyourcda.net/

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simple, universally accessible and readable narrative and adding interoperable coded data

over time based on local and national priorities.

Why are templates needed to achieve consistent capture and validation? Imagine wanting to

communicate information about diabetes. Not only is there a wide range of representations (e.g.,

different codes, different interoperability profiles), there is a wide range of ways to describe

exactly which representation to use in a given scenario. Organizations create local

implementation guides as paper documents, as various types of electronic profiles, et cetera. The

variability in the ways in which constraints or profiles are asserted, coupled with the wide range

of representations, makes it almost impossible to determine what the alternatives are when

wanting to communicate information about diabetes. CDA templates, in contrast, are structured,

patterned representations, in a common formalism. 

The templates are modular, reusable building blocks, layered on top of the base CDA standard.

The templates enable the semantic representation of a wide variety of data elements, under a wide

variety of scenarios. As model-driven computable objects, they can be manipulated via a wide

variety of automated processes. For example, standards developers can search a library of CDA

templates to support template reuse, harmonization, and test.

The audience for templated CDA can be divided roughly into standards developers (includes

profilers, regulators, et cetera) and implementers. The rationale and business case for the use of

templates differs by audience, addressing the needs of both, as follows:

Streamlined standards development. A building-block approach that reuses templates,

where new standards only have to create additional needed templates, supports more

rapid, robust, and cost-effective standards development. 

Streamlined standards implementation. A building-block approach that reuses

templates across a variety of CDA implementation guides leads to a more rapid and less

expensive test and deployment.

Reuse. CDA templates (for example blood pressure, discharge diagnosis, and active

problems) can be thought of as atomic clinical statements, built for reuse. They can be

repackaged with other templates in any number of CDA implementation guides.

CDA’s “incremental interoperability” strategy. As noted above, a minimally

conformant CDA document is easy to construct. Building on the minimum, Stage 1

Meaningful Use requires adoption of a limited number of CDA templates to construct a

valid Health Information Technology Standards Panel, HITSP/C32 instance. Stages 2 and

3 of Meaningful Use will likely recommend adoption of additional templates. 

Built on open standards. CDA templates are application independent and do not require

a novel or proprietary syntax. 

Built on experience with data element repositories. Data element repositories such as

the Agency for Healthcare Research and Quality’s (AHRQ) United States Health

Information Knowledgebase (USHIK)3 and the National Cancer Institute’s (NCI) Cancer

Data Standards Registry and Repository (caDSR)4 are based on the International

Organization for Standardization (ISO) 11179 data element model. Advances in semantic

interoperability in such areas as vocabulary binding and safe context, have led to the

enhancements embodied in the underlying formal representation of CDA templates.

3 http://ushik.ahrq.gov/

4 https://cabig.nci.nih.gov/concepts/caDSR/

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CDA TEMPLATES: MOD EL-DRIVEN COM PU TABLE

OBJECTS

A template, here, is a named set of formal, computable constraints on the base CDA standard.

CDA document types can be constrained through the application of one or more templates to

meet a need for a particular type of clinical document.

Templates, drawn from a library of reusable templates, can be assembled into various kinds of

implementation guides according to use case. A set of templates collected in a CDA

implementation guide details the machine processable representation of the underlying business

requirements. Professional society recommendations, national clinical practice guidelines, and

standardized data sets can be expressed as CDA templates.

Many kinds of templates can be created. The most relevant are: (1) those that represent individual

data elements (CDA entry-level templates); (2) those that represent document sections (CDA

section-level templates); (3) those that represent documents (CDA document-level templates);

and (4) those that constrain the document-level metadata in the CDA header (CDA header

templates).

As noted above, a template is a named set of constraints on the base CDA standard (see the figure

Template relationships and constraints). Templates can relate to other templates through containment

or specialization relationships. The constraints typically restrict the cardinality of a CDA field or

restrict the allowable values within a CDA field. In many cases, a constraint may bind the CDA

field to a value set (a list of allowed codes).

Figure 1: Template relationships and constraints

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CDA templates are model-driven computable objects that can be stored in a database that

functions as a CDA template library. Such template libraries support both standards development

and implementation. 

Figure 2: CDA template library supporting standards development and implementation

Template library functions: 

Quality assurance. CDA templates can be tested to ensure that they are built correctly.

Discoverability. CDA templates allow searches via template metadata, template

structure, and semantics, including value sets. 

Vocabulary binding. CDA templates adhere to the latest HL7 recommendations for

vocabulary binding.

Management. CDA templates have formal relationships to one another (e.g.,

containment and specialization relationships) supporting template management. 

Consistency. CDA templates can be tested for consistency with corresponding HL7

Version 3 domain models.

Template library outputs:

CDA implementation guides. Libraries export templates that are aggregated into CDA

implementation guides. 

CDA instance validation. Model-driven libraries generate CDA instance validation rules

(e.g., Schematron or other modalities).

Runtime application programming interface. CDA templates can be transformed into

source code (e.g., JAVA, .NET) to support the programmatic creation and/or parsing

and/or validation of CDA document instances.

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greenCDA XML. CDA templates can generate small, implementation-specific XML

schemas, following the principals described in HL7 Implementation Guide for CDA

Release 2: greenCDA, Release 1. The greenCDA philosophy is to collapse everything

for a particular use case into a simple XML schema to streamline instance creation,

parsing, and validation. The simplified XML has clinically meaningful element and

attribute names, is 100% transformable into canonical CDA, and hides certain CDA

complexities (such as fixed attributes). As such, it is easy to implement and can be

automatically transformed into canonical CDA to meet robust processing requirements.

Data entry form. CDA templates can drive data entry. (For an example, see the appendix

Templated CDA Use Case: NHLBI).

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TEMPLATED CDA FO R STANDARDS DEVELO PM ENT

AND HARMONIZATION

Templates reduce the level of effort in developing a standard by providing ready-made and

consistent patterns on which to build. In some cases, standards developers may satisfy a use case

requirement through minor changes to existing templates or, better yet, by recombining existing

templates into new packages that address the requirement without additional modeling. 

In the US, this process is already well established. The first set of formal templates for CDA was

developed for CCD in 20075. Since then, the syntax and formalism for templates has evolved in

minor ways, and the original CCD templates have been reused by Integrating the Healthcare

Enterprise (IHE), the Health Story Project, and HITSP, and within virtually all subsequent HL7

implementation guides. 

The next figure illustrates the growth and reuse of CDA templates across standards via a sampling

of CDA implementation guides balloted through HL7 over the past few years. 

Figure 3: Template proliferation in CDA implementation guides

In this figure, the horizontal axis is roughly chronologic and shows that, as new guides are

developed, a significant number of templates are reused from existing guides. The first guide,

5 CCD: Continuity of Care Document (CCD) ASTM/HL7.

http://www.hl7.org/documentcenter/ballots/2007JAN/downloads/CDAR2_IMPL_CCD_I2_2007JAN.zip

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Care Record Summary (CRS), contains no formal templates; CCD contains fewer than 100

templates. The balloted HL7 guides tallied here have 623 unique templates or, on average, 42

templates per guide, 24 new, and 18 reused.

Over time, we anticipate that the number of CDA templates will continue to grow—a thousand

flowers will bloom as more organizations create and adapt templates to their own requirements.

During the past four years, IHE and HITSP have contributed significantly to the available pool.

With freely flowering template proliferation, inevitably some duplication and incongruities will

occur. We expect the number of templates to expand rapidly and then decrease through

harmonization and consolidation of requirements. The next figure illustrates a potential evolution

to stable template growth and adoption. 

Figure 4: Evolution to stable growth of templates

Harmonization without a common basis and formal representation could easily become an

intractable problem, particularly where requirements cover a range of stakeholders, in various

formats, in different repositories, in different organizations, et cetera. With all players on board

for templated CDA, harmonization is already underway via projects such as the HL7/IHE Health

Story Consolidation Project6 under the auspices of the Office of National Coordinator (ONC)

Standards and Interoperability (S&I) Framework.

6 http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

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TEMPLATED CDA FO R INFORMATION CAPTU RE,

REUSE, AND ANALYSIS

This section illustrates several advantages templated CDA provides in various stages of the

information lifecycle. 

1.1 Information Capture and Analysis

We started this paper asking you to imagine that providers across the country captured data in a

consistent manner. Such a picture would represent major progress compared with the status quo,

where providers may not capture the same information and, when they do, may make the same

assessment yet capture the data in myriad forms. For example, one provider captures “drinks per

day” whereas another provider captures “ounces of wine, beer, or hard liquor per week”.

Similarly, providers capture data elements with different timestamps (e.g., “recently”, “in the past

month”, “since January”, and so on), and providers are given different selection lists to capture

clinical data (e.g., one provider can select “disorder of bilirubin metabolism” whereas another

provider can select the more specific “Gilbert's syndrome” or “Crigler-Najjar syndrome”).

Much of this variability can be addressed as template compliance is pushed up the information

“food chain” to influence data capture. The templates themselves provide the means to do so. Any

data capture tool can be constrained by the requirements of a template. Some applications go

further, instantiating a direct relationship between template and data entry form. NCI is

developing a system to drive data capture for clinical trials from a library of CDA templates; IBM

demonstrated the same basic functionality for public health at Healthcare Information and

Management Systems Society (HIMSS) 20107. 

At minimum, template specifications clearly delineate data capture requirements and provide the

means to validate compliance through automated processes. Various validation methods are

feasible8, ranging from XML schema language to compiled XML Path Language (XPath)

statements (Schematron) to programming languages such as Java or .NET.

While the gold standard for data analysis is data captured under a strict collection protocol, where

patients have been randomly assigned to different treatments, data captured in accordance with

CDA templates are more consistent, leading to greater capabilities for comparative

effectiveness and retrospective analyses. 

1.2 Information Reuse

Stage 1 Meaningful Use criteria require generation of a HITSP/C32 instance containing

standardized problems, medications, lab results, et cetera. Certified electronic health records

(EHRs) can create and convey instance data in this standardized way. It follows that EHRs can

then respond to quality measure criteria and decision support rules expressed in a similarly

standardized manner. To the extent that an EHR can instantiate a CDA template, that EHR

can process a corresponding quality measure criterion and decision support rule.

7

 Renly, S., Demonstration of XForms and IHE RFD for Public Health Case Report (PHCR) Influenza, HIMSS

Interoperability Showcase, March 2010.

8

 The advantages and limitations of various approaches is the subject of a companion paper on CCD definition:

“Continuity of Care Document (CCD) Coverage Report”, May 2011.

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This vision of coupling quality reporting and shareable decision support to an EHR interface

defined by CDA templates is far from theoretical. It is the basis for the eMeasure development

work done by HITSP and by the National Quality Forum (NQF). That project aligns NQF’s

Health Information Technology Expert Panel (HITEP) Quality Data Elements (QDE) with CDA

templates, reusing them as eMeasure building blocks.

The majority of implementations prefer to use existing, localized schemas rather than rip-andreplace to achieve standards compliance. The templated CDA vision for an interoperability

infrastructure has a CDA template library at its foundation that provides a virtual interface

between the external, standards-based exchanges, and the localized data store. Templates in

the library define a standard interface. Via this interface, the EHR can (1) generate many types of

CDA documents, (2) interpret quality measure criteria, and (3) interpret decision support rules.

Simply stated, and illustrated in the next figure, an EHR’s standard interface approximates those

CDA templates that the EHR can instantiate.

Figure 5: EHR interface defined by the CDA templates it supports

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A TEMPLATED CDA INTEROPERABILITY ROADMAP

Templated CDA creates minimal disruption to current clinical workflow while putting you

on an incremental path to semantic interoperability—a path that leads to Meaningful Use. 

Our roadmap begins with minimally conformant CDA documents. Such documents are easy for

clinical document applications to produce, deliver immediate value to point-of-care clinicians,

and lay out a high-level structure for common clinical documents such as Discharge Summary,

Diagnostic Imaging Report, Operative Report, and Progress Note. From there, we envision

adoption of templates in a staged and incremental fashion, largely directed by Meaningful Use

stages, as illustrated in the next figure.

Figure 6: Incremental adoption of CDA templates

Building upon this incremental strategy, our roadmap describes key activities needed to drive

towards a more testable semantic interoperability infrastructure over the next two to three years.

2011 activities:

Template tooling. The capabilities described above (see CDA Templates: Model-driven

Computable Objects) are real; however, we expect the tooling, including a variety of

automated and semi-automated processes, to be greatly improved in the near future.

CDA “simplification”. greenCDA technology will streamline instance creation, parsing,

and validation while maintaining the common basis required for semantic

interoperability.

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Template harmonization. Template harmonization activities have begun, such as those

through the ONC-sponsored HL7/IHE/Health Story CDA Implementation Guide

Consolidation Project9. Harmonization begins to encompass claim attachments for

adjudicating reimbursement claims. 

Template exchange. A template exchange formalism that allows sharing CDA templates

across tools and across libraries will be developed.

Templates expand for reuse. The current National Healthcare Safety Network (NHSN)

Healthcare Associated Infection (HAI) reporting, a national, templated-CDA initiative is

instantiated as a model for reporting public health, quality, and research data. 

Figure 7: Template exchange across libraries

2012 activities:

Template tooling. We expect further enhancement of the template tooling, making

development and implementation of templates much easier compared to current

capabilities and further uptake by a variety of vendors and open source projects.

Template harmonization. We expect HL7, IHE, and/or ONC to work on new template

harmonization projects. The template library supports rulemaking on claims attachments.

Template prioritization. Templates developed under the ONC-sponsored

HL7/IHE/Health Story CDA Implementation Guide Consolidation Project are likely

candidates for Stage 2 Meaningful Use, and, if so adopted, will establish a bedrock of

EHR capabilities for the exchange of common clinical documents (e.g., Discharge

Summary, Diagnostic Imaging Report, Operative Report, and Progress Note).

CDA Release 3. With growing adoption of CDA, we anticipate an increased number of

requirements that push the envelope of CDA Release 2. CDA Release 3 will have a richer

underlying data model, which will support the development of a larger set of templates.

Cohesion across domain model formalisms. Growing interest in technologies similar to

templated CDA and a growing interest in international harmonization will lead to a

9 http://wiki.siframework.org/CDA+Harmonization+WG

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comparison of templates, “archetypes”10, “detailed clinical models”11, “domain analysis

models”12, and “clinical element models”13, along with a process for mapping subjectmatter expertise captured via many of these formalisms into CDA templates.

2013 and ongoing activities:

Template tooling. Ongoing enhancement of template tooling.

Template harmonization. New template harmonization projects.

Template prioritization. Ongoing prioritization.

Template migration. Some templates written for CDA Release 2 will be revised to better

use the richer semantics in CDA Release 3.

10 http://www.openehr.org/116-OE.html; http://esearch.cen.eu/Details.aspx?id=3704020

11 http://wiki.hl7.org/index.php?title=Detailed_Clinical_Models

12 http://wiki.hl7.org/index.php?title=Domain_Analysis_Model

13 http://intermountainhealthcare.org/cem/

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CONCLUSION

In this document, we have provided supplemental background information and details on

templated CDA. 

A templated-CDA strategy streamlines standards development, standards implementation, and

standards-based test and validation. As a result, we are seeing growing adoption of this approach

across both standards development and standards recognizing bodies.

Templated CDA is a key technology underlying CCD and other HL7 CDA implementation

guides. As formal computable objects, CDA templates enable far more and more robust HIT

interoperability standards testing strategies than we have in use today.

This model-based architecture provides the critical context, on-ramp, and roadmap so that

Meaningful Use can target specific objectives without compromise to the broad goals of

interoperability. 

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REF ERENCES

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Release 2, May 2005. http://www.hl7.org/v3ballot/html/infrastructure/cda/cda.htm 

CDA Harmonization Workgroup, http://wiki.siframework.org/CDA+Harmonization+WG

CCD: Continuity of Care Document (CCD) ASTM/HL7.

http://www.hl7.org/documentcenter/ballots/2007JAN/downloads/CDAR2_IMPL_CCD_I2_2007J

AN.zip

“Continuity of Care Document (CCD) Coverage Report”, May 2011

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HL7/IHE Health Story Consolidation Project,

http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

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HL7 Standard: Clinical Document Architecture, Release 2. ANSI-approved HL7

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HL7 Wiki, 

Detailed Clinical Models: http://wiki.hl7.org/index.php?title=Detailed_Clinical_Models

Domain Analysis Model: http://wiki.hl7.org/index.php?title=Domain_Analysis_Model

Intermountain Healthcare, Clinical Element Model,

http://intermountainhealthcare.org/cem/Pages/LicenseAgreement.aspx

Lantana Consulting Group. Continuity of Care (CCD) Coverage Report, May 2011.

Related document prepared for NIST.

National Cancer Institute’s (NCI) Cancer Data Standards Registry and Repository

(caDSR), https://cabig.nci.nih.gov/concepts/caDSR/

ONC-sponsored HL7/IHE/Health Story CDA Implementation Guide Consolidation

Project. http://jira.siframework.org/wiki/display/SIF/CDA+Consolidation+Project

OpenEHR, http://www.openehr.org/116-OE.html

Renly, S., Demonstration of XForms and IHE RFD for Public Health Case Report

(PHCR) Influenza, HIMSS Interoperability Showcase, March 2010.

“Show Me Your CDA” Interoperability Forum. http://www.showmeyourcda.net/

United States Health Information Knowledgebase (USHIK) http://ushik.ahrq.gov/

“Where in the World is XDS and CDA” Google Map. http://tinyurl.com/cda-around-theworld

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APPENDIX A — ACRONYM S AND ABBREVIATIONS

AHRQ Agency for Healthcare Research and Quality

ANSI American National Standards Institute

caDSR Cancer Data Standards Registry and Repository

CCD Continuity of Care Document

CDA Clinical Document Architecture

CRS Care Record Summary 

EHR electronic health record

EMR electronic medical record

HIMSS Healthcare Information and Management Systems Society

HIT Health information technology

HITEP Health Information Technology Expert Panel 

HITSP Health Information Technology Standards Panel 

HL7 Health Level Seven

IHE Integrating the Healthcare Enterprise 

ISO International Organization for Standardization

NCI National Cancer Institute

NIST National Institute of Standards and Technology

NHLBI National Heart, Lung, and Blood Institute's

NQF National Quality Forum

ONC Office of National Coordinator 

QDE Quality Data Elements

S&I Standards and Interoperability

USHIK United States Health Information Knowledgebase

XML Extensible Markup Language

XPath XML Path Language

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APPENDIX B — TEMPLATED CDA USE CASE: NHLBI

The following scenario, based on the National Heart, Lung, and Blood Institute's (NHLBI)

Guidelines for the Diagnosis and Management of Asthma, illustrates templated CDA. In this

scenario, the objective is to integrate the NHLBI guidelines directly into the process of care via

the construction of a corresponding data entry form, thereby making it easier to provide optimal

patient care.

Domain experts review the NHLBI guideline and construct a number of CDA templates. CDA

entry-level templates include “frequency of wheezing observation”, “wheezing episodes per week

observation”, “peak flow measurement observation”, “pneumococcal vaccine recommendation”,

“asthma severity assessment”, et cetera. CDA section-level templates include “history section”,

“lab section”, “assessment section”, and “plan section”. Together, they create a single documentlevel “NHLBI Asthma Management Progress Note” template.

The templates, which are formal and testable constraints on the base CDA specification, are

transformable into a data-entry form, as shown in the next figure.

Figure 8: Template constraints expressed in data-entry form

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The next figure shows that, upon completion of data-form entry, a corresponding CDA instance is

generated. This instance validates against the base CDA standard and against asserted templates.

Figure 9: Generation of templated CDA instance from data-entry form

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