Consolidated Clinical Document Architecture is a core part of health IT infrastructure in the United States, and in 2022, was the most common standard for health information exchange across care settings. Established in 2012, this format improves on the efforts of the Clinical Document Architecture (CDA) to promote the Meaningful Use of health data.
The C-CDA determines the framework for structuring healthcare data so it is easily captured, stored, accessed, and exchanged electronically within Electronic Health Records (EHRs). This architecture permits structured and unstructured information that make up clinical documents like pathology and imaging reports.
We’ll cover how the C-CDA operates as a library of CDA elements to simplify data access and retrieval, making information easier to analyze and implement. To understand the practical impact of this standard on information exchange, we’ll identify the fields provided under this framework, and the impact of this standard on simplifying data transfer.
The C-CDA is a standard for organizing and sharing health information electronically. This format is the joint effort of Health Level 7, Integrating the Healthcare Enterprise (IHE), and the Health Information Technology Standards Panel (HITSP), and became necessary to manage the broad use cases supported by the CDA.
The goal of the CDA is to support the Meaningful Use of patient data, helping healthcare organizations exchange patient information freely. The architecture required implementation guides detailing clinical document creation, structure, and formats. But as a highly customizable standard, healthcare organizations could personalize everything from a discharge summary, progress note, or consultation report to include relevant sections, or other elements for care delivery.
Likewise, health facilities were free to create CDA templates that accommodated the structure and content of documents to best suit their needs. For example, a hospital could customize a CDA template for a discharge summary to include patient instructions for post-discharge care and follow-up appointments.
This lack of standardization created hiccups for efficient data exchange between organizations. Identifying this challenge, the relevant stakeholders developed the C-CDA to streamline the CDA standard, gathering the most common CDA document types into one implementation guide. These include the Continuity of Care Document (CCD), consultation note, diagnostic imaging report, discharge summary, history and physical, operative note, procedure note, progress note, and unstructured data. Under the updated C-CDA R2.0, these documents also include the care plan, referral note, and transfer summary.
To promote the CDA’s contributions towards interoperability, stakeholders recognized fewer customizations and more uniform structures could make a difference. The C-CDA established stricter rules for representing the structure of CDA clinical documents.
This standard shifted document structures from having separate and personalized implementation guides, instead providing a central database for providers, EHR vendors, Health Information Exchanges, and other stakeholders to have a standardized reference when building CDA documents.
After the requirements of Meaningful Use 2 were introduced in 2014, the C-CDA became the default standard for exporting health information. As a library of CDA templates, this standard defines the structure of each document, with elements arranged in three levels, namely the document, section, and entry.
The document level templates detail the type of CDA document which can be a discharge summary, CCD, etc. At the level of the sections, the format avoids the CDA shortcoming of ‘recreating the wheel’, where providers duplicated data across different sections. For example, a medications section can be included in both the Medication List and Discharge Summary document, and so both sections would use the same template.
Lastly, the entry-level templates define clinical statements, specifying the structure of data elements like a specific medication or procedure. Entries are specific templates to document an event or observation. Like the CDA, C-CDA is represented in XML, a widely supported and platform-independent language format.
The C-CDA is a leading effort to support consistency and interoperability in health data exchange. To achieve this, this data architecture adopts placeholders, or fields where relevant patient data is organized and stored to fit into standardized requirements.
Like the CCD, whose field requirements are specified under Meaningful Use standards, the following are common fields of the C-CDA:
This field contains introductory information about the patient. Here, the structure to hold the name, date or birth, gender, plus added information such as the medical record number are provided.
Here’s a snippet of C-CDA code on patient demographics:
This field documents information on the test carried out, observed results, plus other comments necessary to continue care for the patient.
Here's an example:
The medication a patient has previously been prescribed and is currently administering can have a significant impact on wellbeing. The C-CDA contains fields to detail this information such as the drug name, dosage, start and end dates, etc.
This would be represented in the following code:
The C-CDA provides a standardized format to communicate procedures and surgeries carried out on a patient. This field will include fillers for the procedure name, date it was performed, plus other related information.
A procedure code snippet would look like this:
This format also accommodates fields to note a patient’s allergies and reactions.
The allergy format in CDA will appear in this structure:
The C-CDA standard also captures details on previous vaccines received by a patient, date received, plus other relevant records.
Immunization activity is represented in CDA in this format:
Fields promote accurate data capture, and a core feature for supporting seamless data exchange. These sections may change depending on the content or purpose of the document.
On one end, the C-CDA is an available format that edged data exchange closer to interoperability and standardization, while advancing care coordination across health structures.
This architecture is not without challenges. As a record of every patient encounter, C-CDA documents could be voluminous, with records running into hundreds of pages. Sifting records was difficult. A query on prescribed medications could require sifting through patient records to discover the information.
These shortcomings made the standard unpopular, and paved the way for the next generation of data exchange formats — HL7 FHIR.
Metriport’s FHIR API closes the information gap between healthcare organizations. Our service enables the easy access and retrieval of patient information to promote collaboration in care.
While the C-CDA is being gradually phased out to accommodate newer developments, the legacy of this data standard showed healthcare’s potential for achieving true interconnectedness in care delivery.