Term | Definition | Source |
CDA Standard | The HL7 Version 3 Clinical Document Architecture (CDA®) is a document markup standard that specifies the structure and semantics of "clinical documents" for the purpose of exchange between healthcare providers and patients. It defines a clinical document as having the following six characteristics: 1) Persistence, 2) Stewardship, 3) Potential for authentication, 4) Context, 5) Wholeness and 6) Human readability.
A CDA can contain any type of clinical content -- typical CDA documents would be a Discharge Summary, Imaging Report, Admission & Physical, Pathology Report and more. The most popular use is for inter-enterprise information exchange, such as is envisioned for a US Health Information Exchange (HIE). | CDA Release 2 Description |
Custodian | Responsible for maintaining the record/care plan | HL7 Care Plan Definition |
Data Provenance | The term “data provenance” in the context of Health IT refers to evidence and attributes describing the origin of health information as it is captured in a health system. | Data Provenance Charter |
EHR | An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. | HealthIT.gov |
Health IT | Health IT, shorthand for “health information technology,” is a broad concept that encompasses an array of technologies. Health IT is the use of computer hardware, software, or infrastructure to record, store, protect, and retrieve clinical, administrative, or financial information. | HealthIT.gov |
HIE | Health Information Exchange | |
Life Cycle (Record Entry) | Lifecycle occurs over time and at one or more Events during the Entry Lifespan, starting with the Entry creation/origination Event and ending with the Entry destruction/erasure Event. Intervening Lifecycle Events may include Entry amendment, attestation, access/view, translation, disclosure/transmission, de-identification, encryption, archival. | ISO/HL7 10781 EHR System Functional Model Release 2 |
Life Span (Record Entry) | Lifespan is the period starting when the Entry (instance) is created/originated and ending when that Entry (instance) is destroyed/permanently erased - typically after a retention period specified according to scope of practice, organizational policy and/or jurisdictional law. | ISO/HL7 10781 EHR System Functional Model Release 2 |
PHR | Personal Health Record | |
W3C | World Wide Web Consortium |