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

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
uncertaintyOfPresenceS ?! I0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
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
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
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)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
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

id0..1string
extensionI0..0Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
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 K50
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90
    Include 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 K50
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K50
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K51
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA K52
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M30
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M31
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M32
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M33
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M34
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M35
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA M36
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D80
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D81
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D82
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D83
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D84
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D86
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D89
    Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA D90
    Include 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"
}