Clinical Document Architecture with Australian Schema

Clinical Document Architecture with Australian Schema, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/cda-au-schema/ and changes regularly. See the Directory of published versions

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Introduction

This Australian Digital Health Agency FHIR Implementation Guide is a representation of the Clinical Document Architecture (CDA) R2.0 specification using HL7^® FHIR^®© Logical Models expressed as HL7^® FHIR^®© StructureDefinition instances.

It is an adaptation of the HL7 International CDA Logical Model Specification with specific modifications and inclusions to represent the CDA schema including Australian CDA extensions using the FHIR StructureDefinition framework.

Document purpose and scope

The primary aim of this implementation guide is to support implementers who are contemplating a transition from CDA to FHIR. It contains CDA extensions in Australian context and the HL7 CDA classes using the Australian extensions.

This implementation guide does not describe presentation of the information, user experience, or expected behaviour of producing and receiving systems.

Wherever possible, material in this specification is based on existing standards. All efforts have been made to minimise divergence from the HL7 international CDA classes to provide for system interoperability and compatibility with other classes. Issues of an editorial nature in the source material (such as spelling or punctuation errors) are intentionally reproduced.

Context and use

This CDA extensions logical model FHIR implementation guide should be read in conjunction with the remaining documentation available from HL7 International CDA Logical Model Specification.

The guide includes:

• CDA extensions used in Australian context
• CDA classes in the form of structure definitions
• Vocabularies for the content exchange

Intended audience

This implementation guide is aimed at software development teams, architects, and designers of CDA implementation in Australia.

This implementation guide and related artefacts are technical in nature and the audience is expected to be familiar with the language of health data specifications and to have some familiarity with health information standards and specifications, such as CDA.

Document information

Intellectual property considerations

This implementation guide and the underlying FHIR specification are licensed as public domain under the FHIR license.

This publication includes IP covered under the following statements.

• ISO Maintains the copyright on the country codes, and controls it's use carefully. For futher details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
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  • ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code: AD, ClinicalDocumentArchitectureAuSchema... Show 98 more, Container, EntryRelationship, Specimen, SpecimenRole, TEL, administrativeGenderCode, admissionReferralSourceCode, asEmployment, asEntityIdentifier, asIngredient, asPersonalRelationship, asQualifications, asQualifiedEntity, asSpecimenInContainer, assigningGeographicArea, au-Act, au-AssignedAuthor, au-AssignedCustodian, au-AssignedEntity, au-AssociatedEntity, au-Author, au-AuthoringDevice, au-ClinicalDocument, au-Component, au-ComponentOf, au-Custodian, au-CustodianOrganization, au-Device, au-EncompassingEncounter, au-Encounter, au-EncounterParticipant, au-Entity, au-EntityName, au-Entry, au-ExternalAct, au-ExternalDocument, au-HealthCareFacility, au-InFulfillmentOf, au-Informant, au-InformationRecipient, au-IntendedRecipient, au-LegalAuthenticator, au-ManufacturedProduct, au-Material, au-Observation, au-ObservationMedia, au-ObservationRange, au-Order, au-Organization, au-OrganizationName, au-OrganizationPartOf, au-Organizer, au-ParentDocument, au-Participant1, au-Participant2, au-ParticipantRole, au-Patient, au-PatientRole, au-Performer2, au-Person, au-PersonName, au-Place, au-PlayingEntity, au-Precondition, au-Procedure, au-RecordTarget, au-Reference, au-RegionOfInterest, au-RelatedDocument, au-Section, au-StructuredBody, au-SubstanceAdministration, au-Supply, au-languageCommunication, code, completionCode, controlAct, coverage, coverage2, deceasedInd, deceasedTime, desc, employerOrganization, entitlement, expirationTime, formCode, id, ingredientManufacturedMaterial, methodCode, multipleBirthInd, multipleBirthOrderNumber, name, participant, personalRelationship, subjectOf1, subjectOf2, substitutionPermission and telecom
• This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
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  • LOINC: ClinicalDocument, ExternalDocument, ParentDocument, au-ExternalDocument and au-ParentDocument
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
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  • ActCode: Act, CDAActCode... Show 27 more, CDAActSubstanceAdministrationCode, Consent, Criterion, EncompassingEncounter, Encounter, ExternalAct, ExternalObservation, ExternalProcedure, Observation, ObservationRange, Order, Organizer, RegionOfInterest, SubstanceAdministration, Supply, au-Act, au-EncompassingEncounter, au-Encounter, au-ExternalAct, au-Observation, au-ObservationRange, au-Order, au-Organizer, au-RegionOfInterest, au-SubstanceAdministration, au-Supply and controlAct

Relationships with other work

This implementation guide builds on other specifications, helping ensure a consistent approach to data sharing that should ease adoption. The specific guides used, and the portions relevant from each of them are as follows:

IG	Package	FHIR	Comment
Clinical Document Architecture with Australian Schema	au.digitalhealth.cda.schema#1.0.1	R5
FHIR Extensions Pack	hl7.fhir.uv.extensions.r5#5.3.0	R5	Automatically added as a dependency - all IGs depend on the HL7 Extension Pack
HL7 Terminology (THO)	hl7.terminology.r5#5.2.0	R5
FHIR Tooling Extensions IG	hl7.fhir.uv.tools.r5#1.1.2	R5	for example references

Global profiles

There are no Global profiles defined

Known issues

This table lists known issues with this specification at the time of publishing. We are working on solutions to these issues and encourage comments to help us develop these solutions.