The Consolidated CDA Document (CCDA) is an XML document that is specified in HITECH act "Meaningful Use"(MU) as a document to be used in exchange of patient records. Every MU certified EHR can create, send, receive and ingest CCDA documents. This makes it an extremely powerful standard for exchanging both episodic and longitudinal care records. Unlike other documents like PDFs or faxes, the XML data is easy to use in computing, with specified fields, and codes.
The combination of using Direct messaging, with CCDA payload allows providers to send or receive records with virtually every EHR in the US!
Here's some reference information on CCDAs.
1) Example CCDA: NIST Example of Ambulatory CCDA (attached)
2) Overview of the C-CDA, background and good high level diagram:
3) HL7 C-CDA Product Brief:
- The brief of the document from the standards body itself. Note: you have to register at HL7, but no payment is required to download the brief
4) Companion Guide to C-CDA:
- ONC's Companion Guide to Consolidated CDA for Meaningful Use Stage 2 makes for a long read (95 pages) but actually does a fair job of giving information in a usable form.
A Table showing minimum set of data elements for each Summary Type of doc:
As you can see, the big elements people are looking for (Medications, labs and procedures) are included in all of the summary type.
Table 3: MU2 Data Requirements
ToC Designated Category | MU2 Data Elements | Transition of Care/Referral Summary | Export Summary | Ambulatory or Inpatient Summary | Clinical Summary (Ambulatory) |
| Care Team Members | X | X | X | X | |
| Date of Birth | X | X | X | X |
| Ethnicity | X | X | X | X | |
| Patient Name | X | X | X | X | |
| Preferred Language | X | X | X | X | |
| Race | X | X | X | X | |
| Sex | X | X | X | X | |
| Care plan field(s), including goals and instructions | X | X | X | X | |
| Problems | X | X | X | X | |
| Medication Allergies | X | X | X | X | |
| Medications | X | X | X | X | |
| Laboratory Test(s) | X | X | X | X | |
| Laboratory Value(s)/Result(s) | X | X | X | X | |
| Smoking Status | X | X | X | X | |
| Vital signs (height, weight, BP, BMI) | X | X | X | X | |
| Procedures | X | X | X | X | |
| Admission and Discharge Dates |
|
| X |
| |
| Admission and Discharge Location |
|
| X |
| |
| Date of Visit |
|
|
| X | |
Provider Name and Office Contact Information | X | X | X | X | |
| Visit Location |
|
|
| X | |
| Clinical Instructions |
|
|
| X | |
| Diagnostic Test(s) Pending |
|
|
| X | |
| Discharge Instructions | X | X | X |
| |
| Future Scheduled Appointments |
|
|
| X | |
| Future Scheduled Test(s) |
|
|
| X | |
| Recommended Patient Decision Aids |
|
|
| X | |
| Referrals to Other Providers |
|
|
| X | |
| Encounter Diagnoses | X | X |
|
| |
| Reason for Hospitalization |
|
| X |
| |
| Reason for Referral | X | X |
|
| |
| Reason for Visit |
|
|
| X | |
| Immunizations | X | X |
| X | |
| Medications Administered during the Visit |
|
|
| X | |
| Cognitive Status | X | X |
|
| |
| Functional Status | X | X |
|
|