Clinical Document Architecture (CDA)

CDA Clinical Document Architecture (CDA) is the standard format for eHealth Messages in Australia. Communicare can send and receive CDA documents.

Receiving CDA Documents

CDA documents sent to Communicare through Secure Messaging or File Drop are listed with all other documents in Documents and Results > Received Documents tab. Received CDA documents are read-only. You can open received CDA documents and assign them to patients as you would for any other received document.

Common Data

All CDA documents contain the following sections:
  • Custodian:
    • The organisation in charge of maintaining the document, that is, the steward that is entrusted with the care of the document.
    • Every CDA document can only have one custodian.
    • The Custodian field is populated with data from the organisation and requires that the organisation has a valid HPI-O. See Organisational Parameters - General.
  • Author:
    • The healthcare provider who composed the CDA Document.
    • Every CDA document can have only one author.
    • The Author field is populated with the details of the current provider and requires that the provider has a valid HPI-I (see Edit Provider) and the encounter place has a valid HPI-O (see Edit Encounter Place).
  • Subject of care:
    • Identifies the person for whom the healthcare event, encounter or clinical interaction has been captured or interchanged, that led to the creation of the document. In other words, the subject of the information.
    • Every CDA document can have only one subject of care.
    • The subject of care is populated with the details from the patient's biographic record and requires that the patient has a valid IHI. See Patient Biographics.

Upload to My Health Record

You can upload the following CDA document to a patient's My Health Record:
  • eReferrals
  • Discharge Summaries
  • Event Summaries
  • Shared Health Summaries

Upload to a Private Repository

Some large health organisations may choose to upload the following CDA documents to a private repository instead of a patient's My Health Record:
  • Event Summaries
  • Shared Health Summaries

Sending Documents Securely

You can send eReferrals and Discharge Summary CDA documents securely via Secure Messaging. In the Document view window, click 'Send Secure'.

Saving a CDA Document

Whenever you upload a CDA document to My Health Record, or send via Secure Messaging, the document is automatically saved. However, you can also manually save eReferrals and Discharge Summaries.

In the Document view window, click 'Save'.

Saved documents are listed in a patient's Clinical Record, on the 'Detail' tab.

Security

  • The My Health Record security model does not support Communicare's Viewing Rights. Granting access to the My Health Record to users with limited Viewing Rights may result in those users viewing restricted information in the My Health Record.
  • Care should be taken when submitting documents to the My Health Record to ensure that sensitive data is not uploaded by mistake.
  • Communicare recommends that users who access the My Health Record should have full Viewing Rights.

National E-Health Transition Authority (NEHTA) Compliance

Communicare is compliant with NEHTA for unpacking and rendering CDA documents, packaging CDA documents, and producing Event Summaries, eReferrals, Shared Health Summaries and eDischarge Summaries.