Rheumatological/immunological diseases


Parameter Case Report Form and Response Options

Does the patient suffer from at least one rheumatological or immunological disease? Yes No Unknown
Inflammatory bowel disease
Rheumatic arteritis
Disorder of connective tissue
Vasculitis
Congenital immunodeficiency disease
Other

This is an example of how the case report form could look like when such a data collection tool is used.


To integrate data from clinical care and research such as clinical trials, the guide relies on FHIR resources for data-exchange from the clinical and diagnostic healthcare process rather than constructing a plain questionnaire.

This profile of a FHIR Condition is derived from the Diagnosis-profile of the Medical Informatics Initiative (MII). The valueset bindings on the Condition.code element have been constrained to solely feature the response options for this particular parameter of the case report form. For the explicitly listed diseases in the case report form, the SNOMED and ICD codes are also explicitly specified in the ValueSets below. Note that for the 'Other' option the ValueSets contain filters that allow a number of other codes for this category that are included in the expansion.

A separate instance of a Condition resource is created for each of the requested diseases.

To represent the presence, absence or uncertainty of findings, use Condition.verificationStatus or uncertaintyOfPresence on Condition.modifierExtension. This is used to map the Yes/No/Unknown scheme from case report forms to the Condition resource. Note the additional constraint on Condition that checks if either verificationStatus or the extension is present:

keyseverityhumanexpression
unk-1errorIf verificationStatus is present, uncertaintyOfPresence-Extension SHALL NOT be present.verificationStatus.exists() != Condition.modifierExtension.where(url = 'https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence').exists()

Profile - Rheumatological or Immunological Diseases

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/rheumatological-immunological-diseases

Snapshot

ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
uncertaintyOfPresenceS ?! I0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
severity0..1CodeableConceptBinding
Mehrfachcodierungs-KennzeichenS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
DiagnosesicherheitS I0..1Extension(Coding)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ I1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
lebensphase-vonS I0..1Extension(CodeableConcept)
lebensphase-bisS I0..1Extension(CodeableConcept)
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Extension - Uncertainty of Presence

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence

Snapshot

extensionI0..0Extension
url1..1System.StringFixed Value
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string


ValueSets

Valuesets are provided with both SNOMED-CT and ICD-10-GM codes.


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/rheumatological-immunological-diseases

ValueSet 'RheumatologicalImmunologicalDiseases'

Version1.0.6
Published byBerlin Institute of Health at Charité (BIH)
StatusActive
ExperimentalFalse

Rheumatological or immunological diseases in the context of Covid-19

Contact Information

Website: https://www.bihealth.org/en/re...

This value set includes codes from the following code systems:

  • The following codes from system: SNOMED_CT

    CodeDisplay
    24526004Inflammatory bowel disease (disorder)
    69896004Rheumatoid arthritis (disorder)
    105969002Disorder of connective tissue (disorder)
    31996006Vasculitis (disorder)
    36138009Congenital immunodeficiency disease (disorder)
    396332003+414029004Rheumatism (disorder) + Disorder of immune function (disorder)
  • Include codes from SNOMED_CT where concept IsA 128139000
  • Include codes from SNOMED_CT where concept IsA 414029004
  • Include codes from SNOMED_CT where concept IsA 81573002
  • Include codes from SNOMED_CT where concept IsA 396332003


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/rheumatological-immunological-diseases-icd

ValueSet 'RheumatologicalImmunologicalDiseasesICD'

Version1.0.6
Published byBerlin Institute of Health at Charité (BIH)
StatusActive
ExperimentalFalse

Rheumatological or immunological diseases in the context of Covid-19 - ICD-10-GM

Contact Information

Website: https://www.bihealth.org/en/re...

This value set includes codes from the following code systems:

  • Include codes from ICD10GM where concept IsA K50Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90Include codes from ICD10GM where child Exists false
  • The following codes from system: ICD10GM

    CodeDisplay
    K52.9Nichtinfektiöse Gastroenteritis und Kolitis, nicht näher bezeichnet
    M06.99Chronische Polyarthritis, nicht näher bezeichnet : Nicht näher bezeichnete Lokalisation
    M35.9Krankheit mit Systembeteiligung des Bindegewebes, nicht näher bezeichnet
    I77.6Arteriitis, nicht näher bezeichnet
    D84.8Sonstige näher bezeichnete Immundefekte
  • Include codes from ICD10GM where concept IsA K50Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K50Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90Include codes from ICD10GM where child Exists false


Examples

Rheumatological or Immunological present
Example condition that is confirmed present

{
    "resourceType": "Condition",
    "id": "rheumatological-immunological-disease-present",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/rheumatological-immunological-diseases"
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed",
                "display": "Confirmed"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410605003",
                "display": "Confirmed present (qualifier value)"
            }
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "display": "Active"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "394810000",
                    "system": "http://snomed.info/sct",
                    "display": "Rheumatology"
                },
                {
                    "code": "408480009",
                    "system": "http://snomed.info/sct",
                    "display": "Clinical immunology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "396332003",
                "system": "http://snomed.info/sct",
                "display": "Rheumatism"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}


Rheumatological or Immunological absent
Example condition that is confirmed absent

{
    "resourceType": "Condition",
    "id": "rheumatological-immunological-disease-congenital-absent",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/rheumatological-immunological-diseases"
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "refuted",
                "display": "Refuted"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410594000",
                "display": "Definitely NOT present (qualifier value)"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "394810000",
                    "system": "http://snomed.info/sct",
                    "display": "Rheumatology"
                },
                {
                    "code": "408480009",
                    "system": "http://snomed.info/sct",
                    "display": "Clinical immunology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "36138009",
                "system": "http://snomed.info/sct",
                "display": "Congenital immunodeficiency disease"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}


Rheumatological or Immunological unknown
Example condition where the presence is unknown

{
    "resourceType": "Condition",
    "id": "rheumatological-immunological-disease-unknown",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/rheumatological-immunological-diseases"
        ]
    },
    "modifierExtension":  [
        {
            "url": "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "code": "261665006",
                        "system": "http://snomed.info/sct",
                        "display": "Unknown (qualifier value)"
                    }
                ],
                "text": "Presence of condition is unknown."
            }
        }
    ],
    "category":  [
        {
            "coding":  [
                {
                    "code": "394810000",
                    "system": "http://snomed.info/sct",
                    "display": "Rheumatology"
                },
                {
                    "code": "408480009",
                    "system": "http://snomed.info/sct",
                    "display": "Clinical immunology"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "69896004",
                "system": "http://snomed.info/sct",
                "display": "Rheumatoid arthritis"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}