Fact-of-Death Data Exchange Using Clinical Document Architecture

The electronic health record (EHR) has been noted to improve health care, with the obvious advantages of retrieving information faster and easier, with greater legibility, and meeting and enabling auditing and legal requirements. Clinicians often use natural language when describing observations, diagnoses, and other biomedical concepts. This can make translation into machine-level semantics more complicated. To allow for documents to be read by computerized systems, a standard method of representing data would be preferred. Health Level 7 (HL7) has created standards for representing clinical documents, and for information exchange, usually implemented in extensible markup language (XML). The HL7 Clinical Document Architecture (CDA) is made up of these document standards (Dolin, et al., 2001). Clinical documents must conform to standards if the free text in clinical notes is to be utilized in an efficient, effective manner. There exists a need to create a CDA-compliant message specification for 'fact of death' for the purposes of notifying institutions connected to a health information exchange (HIE) about the death of a person.