Clinical Document Specification

Ontario Clinical Document Specification Download

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Some file names in the downloaded ZIP file are long and therefore the ZIP file should be extracted to c:\ (or similar). The extraction process will create a folder called 'Ontario CDS' in which the specification artifacts will be located.

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One of eHealth Ontario’s newest projects, the Clinical Document Specification (CDS), targets the standards-based exchange of clinical documents.  eHealth Ontario has developed a standards-based CDS to facilitate and expedite the wider electronic availability and transfer of clinical documents between and among hospitals, physicians, Community Care Access Centres (CCACs) and other health care organizations in Ontario. The CDS has been developed with the intention of realizing a pan-Ontario standard for clinical documents; it is aligned with prior Ontario specifications such as e-Referral and Discharge Summary, as well as existing pan-Canadian specifications and international document standards.

Scope

Development work has been supported by engaging with a wide array of clinicians, organization and agencies.  Several eHealth Ontario Delivery Partners – cGTA (LHINs 5 to 9) and LHINs 10 and 11 - will use the CDS to inform the document requirements for their respective clinical data repositories. Specific clinical documents supported by the CDS include:

  • Assessment and
  • Consult Report

Process

The eHealth Ontario Standards team has created an Interim Release of the CDS based on Ontario requirements (e.g. samples of contemporary clinical reports reflecting clinical, business and technical requirements) as well as a thorough review of existing standards such as pan-Canadian specifications, HL7 Clinical Document Architecture (CDA), and other relevant international standards.

The CDS Specification was validated with numerous Ontario stakeholder groups from Nov 2010, to Jan 2011, as follows:

  • CDS  Steering Committee (November 9, 2010,  December 2, 2010 & Feburary 16, 2011)
  • CDS Business Review Group (November 22 & 24, 2010)
  • CDS Technical Review Group (December 14 & 15, 2010, February 7, 2011)
  • Public Review (Jan 5 – Jan 28, 2011)

The three week Public Review of the Clinical Document Specification was completed on January 28, 2011. Two hundred and twenty-five individuals e.g. vendors and organizations, attended 4 webcasts, which provided an overview of the CDS and how to participate in the review. Close to 100 individual comments were received. Thanks to all participants.

Additional Information

If you have any questions on the specification, please do not hesitate to contact eHealth Standards at ehealthstandards@ehealthontario.on.ca.