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[1] [2] [3] All certified Electronic health records in the United States are required to export medical data using the C-CDA standard. [4] While the standard was developed primarily for the United States as the C-CDA incorporates references to terminologies and value set required by US regulation, it has also been used internationally.
It is designed to be flexible and adaptable, so that it can be used in a wide range of settings and with different health care information systems. The standard describes data formats and elements (known as "resources") and an application programming interface (API) for exchanging electronic health records (EHR).
The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [7] [8]
An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [ 3 ] It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.
HL7 v2.x has allowed for the interoperability between the plethora of digital health systems, from Patient Administration Systems, to Electronic Health Records, and specialised Laboratory and Radiology Information Systems. Currently, the HL7 v2.x messaging standard is supported by every major health informatics vendor in the United States. [7]
A central part of the openEHR specifications is the set of information models, known in openEHR as 'reference models'. [6] The models constitute the base information models for openEHR systems, and define the invariant semantics of the Electronic Health Record (EHR), EHR Extract, and Demographics model, as well as supporting data types, data structures, identifiers and useful design patterns.