B.C. Clinical Document Architecture Implementation Guide

The B.C. Clinical Document Architecture (CDA) Implementation Guide outlines the provincial CDA template standards. These standards facilitate the exchange of clinical documents to care providers across regions and across the continuum of care.  

Scope

The following types of clinical data are included:

  1. Results: Lab, anatomic pathology and diagnostic Imaging result types. 
  2. Clinical Documents: Discharge summaries, procedure notes and various other clinical documents that fall under the category of “unstructured.”

The implementation guide does not define the messaging distribution or transport mechanism. 

Governance

The standards within this implementation guide have been endorsed by the provincial Clinical Messaging Standards Working Group, and by the B.C. Standing Committee of Health Information Management and Information Technology.  

Current Status

Significant analysis and review of documents and specifications were undertaken to make sure the standards developed would be applicable and attainable to the various stakeholder groups. Constraints were developed by reviewing inputs and assessing gaps, feeding into the proposed statements and definitions. The organizational members of the provincial working group, including representatives from health authorities, were consulted on issues where clarification was required around clinical workflow process and data capture to validate the proposed statements and definitions. Wherever possible, content templates defined and reviewed by standards bodies were referenced, and appropriate constraints for the B.C. context applied.

The BC team transitioned some templates from the BC CDA Implementation Guide into the Art Decor tool, with additional templates to follow.  In order to ensure that implementers have the most complete information, both the paper copy of the BC CDA Implementation Guide as well as the Art Decor tool should be consulted.

Version 4.0 of the standard was created in September 2015, and is available for download below.

Maintenance

The content of the standard may require edits, additions and/or maintenance as actual implementations provide the necessary technical validation. Additional adjustments may be required over time to reflect requirements in British Columbia, or to align with emerging pan-Canadian clinical document architecture standard development.  

Download

Download the B.C. Clinical Document Architecture Implementation Guide version 4.0 (PDF, 2.3MB) standard.