Analysis of CDA R2 testing tools - most requirements are neither tested nor respected.
Publication date: Feb 13, 2015
During the recent IHIC conference IHE Europe published an analysis that shows serious weaknesses in the current CDA validation tools.
When it comes to the validation of CDA documents one can distinguish a number of steps which should form the basis for a full validation of a CDA document:
any CDA document has to be
- well-formed XML,
- valid with respect to the published CDA schema,
- conform with all requirements of the CDA abstract HL7v3 model - inclusive of all of the CDA requirements that aren't expressed as part of the schema, because the schema
language is simply not expressive enough to deal with all of the requirements as expressed in the abstract model,
- conform to the requirements as expressed in a CDA Implementation Guides - more often than not a process where multiple templates
(as defined by the implementation guide) have to be validated.
The object of the analysis by IHE Europe (Abderrazek Boufahja, Eric Poiseau, Guillaume Thomazon and Anne-Gaëlle Bergé) was to examine
to which degree the existing CDA Tools as well as existing national/regional CDA projects meet the requirements of the 3rd validation step.
The authors identified 160 requirements which should be tested by any CDA validation tool.
Once they had a list of requirements they tested existing CDA validation tools to see whether those would detect the issues in question, and they
tested example messages defined by national/regional projects to see whether those projects used a strong enough validation process.
Boufahja presenting during the IHIC 2015
Even if the list of 160 requirements should be incomplete, or if some of those requirements are erroneous, the results of the analysis is a clear indication
that more work is needed by all parties concerned:
- The CDA tools that were tested are: Trifolia, MDHT, Eclipse Instance Editor, Art-Decor, the NIST validation tool, and the IHE Gazelle ObjectsChecker tool.
If we exclude the new IHE Gazelle ObjectsChecker tool (which does catch almost all of the 160 requirements) the old
Eclipse Instance Editor (no updates since 2011 - no longer available for download) performed best, the remaining tools have a worse performance.
Now some will argue (as I do) that the aim of some of these tools (e.g. Trifolia, Art-Decor) has never been to deal with the 3rd validation step,
but only to focus on the 4th validation step (templates). Still, the validation strength of MDHT and the NIST validation Tool should be improved upon.
Note that the Everest toolkit hasn't been tested - the tool was unknown to IHE Europe at the time of the analysis.
- They also tested message examples from 10 national/regional projects, the average number of errors found in the example CDA documents ranged between 2 and 44.
So there are projects out there where (on average) a CDA document has 44 known issues. It seems the various CDA projects also have to beef up their testing process.
The list of most frequent errors can be found in the paper, they are more or less the same as the ones we found in
an earlier similar study in 2008 -
which just goes to show that projects should move away from XML based validation and should instead focus on model based validation.
The actual paper (published under the CC-BY-NC-ND license) can be found on the
EJBI website (special 2015 issue related to IHIC),
a scanned copy (PDF) can be found on the
In my opinion this was the most interesting paper presented at the IHIC meeting in Prague earlier this week - toolkit developers as well as national/regional CDA projects should
learn its lessons and beef up their support for stricter CDA validation.
PermaLink to this page: http://www.ringholm.com/column/HL7_CDA_Conformance_testing_tools_analysis.htm
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- Combining the best of IHE XDS with HL7 FHIR (Jun 27, 2019)
- FHIR DevDays and the year in review (Dec 27, 2018)
- Creation and Curation of FHIR Profiles - process and governance (Dec 14, 2017)
- De Algemene Verordening Gegevensbescherming (AVG) in de zorg (Dutch, Sep 19, 2017)
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- FHIR DevDays - UK GP System APIs (Sep 16, 2015)
- IHE XDS - testing and implementation tools (Aug 25, 2015)
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- Why we sponsor the HL7 WGM (May 10, 2015)
- FHIR in Paris (Apr 21, 2015)
- Mapping HL7v2 messages to FHIR. (Apr 13, 2015)
- Analysis of CDA R2 testing tools - most requirements are neither tested nor respected. (Feb 13, 2015)
- HL7 and IHE in Sweden (Feb 08, 2015)
- 2015 FHIR Chiefs Calendar (Jan 07, 2015)
- The Merry FHIR Choir caroling the 12 Days of Christmas (Dec 09, 2014)
- Chicago FHIR Update (Oct 13, 2014)
- Internationalization of HL7 (Sep 25, 2014)
- New XDS Advanced training course on offer by IHE Services and IHE Academy (Jul 14, 2014)
- Recent and Future developments of the DICOM standard (Mar 06, 2014)
- Top 10 HL7 videos watched in 2013 (Jan 02, 2014)
- Report from the HL7 WGM in Cambridge (Oct 16, 2013)
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- Renovate HL7 version 3 (Aug 03, 2012)
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- Lighting the FHIR, HL7s new major interoperability standard (Jun 15, 2012)
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- HL7 Affiliates Meeting in Orlando (Jan 11, 2009)
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Ringholm bv is a group of European experts in the field of messaging standards and systems integration in healthcare IT.
We provide the industry's most advanced training courses and consulting on healthcare information exchange standards.
See http://www.ringholm.com or call +31 33 7 630 636 for additional information.
Rene is the Tutor-in-chief of Ringholm.