Tuesday, June 29, 2010


Can you name the six key features of the Clinical Document Architecture?
  • Context
  • Human Readability
  • Persistence
  • Potential for Legal Authentication
  • Stewardship
  • Wholeness
Of these six features, Human Readablility is the most important, and Stewardship is perhaps the next most important.  I can derive almost all of the other features from these two, and most from Stewardship.  In being a steward of a document, it is incumbent on an organization to ensure that:
  1. It is stored and related to other records with respect to context.  You can think of most context information as "search keys" into a repository of clinical documents.  It is the context of the CDA document that drove the development of the XDS Metadata.
  2. The document is accessible (accessible implies: readable by humans) over long periods of time, which implies persistence.
  3. It is authoritative in its content, which implies a need for verification and authentication of its contents.
  4. The entire content is available.
In September of last year, the US National Committee on Vital and Health Statistics put together a primer on this topic titled: Health Data Stewardship: What, Why, Who, How.  This document what it is, why it is necessary, who is responsible for it, and how to find out more about it.  It includes an appendix describing some key resources on Health Data Stewardship published over the last decade.  It's a useful read for people who are just being introduced to the topic of stewardship.


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