Consolidated Health Informatics Initiative
Final Recommendation Information Sheet[1]

Domain Title and Team Leads:

Text-Based Reports:  VA Co-Leads: Linda Nugent and Dr.Viet Nguyen (VA)

Scope:

Identify standards and terminologies used to define the messaging architecture and syntax of clinical text documents.  Initially, all clinical documents types were considered as possible sub-domains. Additional sub-domains were further delineated from initial analysis of content of clinical document types, including section headings and data-types.  The group reached consensus that inclusion of these sub-domains would result in scope that was much too broad to be completed in the short time frame and resources allocated.  Document components and data domains contained in text-documents overlap broadly with areas already covered by other CHI groups.

Domain/Sub-domain In-Scope (Y/N)
Text-Document structure and syntax Y

Electronic Signature

 Y

Document Section Headings

 Y

Clinical Document Types/Titles

 Y

Document Components and Data Domains

N

Clinical Signs and Symptoms

 N

Vital Signs

 N

Physical Exam Observations and Findings

 N

Laboratory Findings

 N

Diagnoses and Problems

 N

Orders

 N

Alternatives Identified 

  1. SNOMED CT
  2. HL 7CDA (Clinical Document Architecture)
  3. Continuity of Care Record
  4. ASN.1 (Abstract Syntax Notation One)
  5. HTML
  6. XML
  7. Rich Text Format
  8. PDA (Portable Document Architecture)
  9. Clinical LOINC (Logical Observation Identifiers Names & Codes)
  10. CEN (European Committee for Standardization)
  11. ASTM E1384-02 Guide for Content and Structure of the Electronic Health Record

Final Recommendation:

HL7 Clinical Document Architecture (CDA), current (1.0-2000) and subsequent releases. (HL7 released the ballot for CDA Release 2.0 on December 8th, 2003. It is anticipated that this new release will be ANSI-certified before the end of 2004.)

The workgroup considers the GSA/OMB E-Authentication Policy and the NIST FIPS Pub 199 as the defining documents for authentication control.  Upon the release of the final E-Authentication Policy and the companion NIST technical guidance, the workgroup recommends that CHI reconvene a workgroup to review the guidelines and recommend adherence to risk assessment evaluation and application of appropriate security technology.

Content Coverage:

The HL7 CDA draws its vocabulary from the HL7 Reference Information Model (RIM). The RIM has internal HL7 vocabulary tables but to the greatest extent possible relies on externally maintained standard vocabularies, such as LOINC, ICD, SNOMED, etc.

Acquisition:

Standards are available from HL7.  HL7 asserts and retains copyright in all works contributed by members and non-members relating to all versions of the Health Level Seven standards and related materials, unless other arrangements are specifically agreed upon in writing. No use restrictions are applied.

However some of the externally maintained standard vocabularies contained in the HL7 RIM, such as LOINC, ICD, SNOMED CT, etc. require licensing fees. Of note, on July 1, 2003, Secretary Thompson announced that the Department of Health and Human Services (DHHS) entered into a licensing agreement to make a clinical terminology database, SNOMED CT, available without charge to the U.S. health care industry.

Conditions:

No conditions.

[1] Information Sheet designed specifically to facilitate communication between CHI and NCVHS Subcommittee on Standards and Security resulting from May 20, 2003 testimony.  CHI may seek assistance to help further define scope, alternatives to be considered and/or issues to be included in evaluation process.