IG:HL7 diagnosis

Representation of Diagnosis based on the Clinical Document Architecture Rel.2 for Healthcare in Germany

Version 1.1

Representation of Cancer Diagnosis

Introduction

In this chapter, diagnostic aspects in documentation of tumor diseases will be discribed. Different aspects of diagnostical discriptions of tumor diseases are discribed by ICD-O (Oncology) and by further classifications to constitute the determination of expansion respectivly of the diseases stage.

Last one is mostly classified by the TNM-System.

Especially for hemato oncological diseases (Leukemias and Lymphomas), other systems (e.g. Ann-Arbor-Classification) are used. TNM-System discribes:

• Expansion of primary tumor (extent repectivly spread in distant organs)
• Affection of lymph nodes in lymph flow area
• Exisistence of distant metastasis.

For not by TNM – System classifiable diseases or in addition to TNM-System there are a number of further classification systems:

• Ann Arbor
• Rai
• Binet
• CML-Phasen
• FAB
• Durie and Salmon
• Gleason-Score

Discriptions can be found here: http://www.med.uni-giessen.de/akkk/gtds/grafisch/doku/bd5f.htm http://www.tumorzentren.de/tl_files/dokumente/adt_basis.pdf

This list probably will be always incomplete because of the medical progress.

ICD-O

Third Edition of ICD-O [DIMDI, WHO] is the topical one. ICD-O consists of two axes, Topography- and Morphology-Axis. In ICD-O, tumor can be classified by

• Site
• Tissue Structure (Histology)
• Biological behaviour (Dignity)
• Tissue grading (mostly in two or four stages)

In this case, tissue structure and tissue grading is redundant. Precisely: The first four digits of morphology-code describe tissue-type. The fifth one describes biological behaviour (dignity-code):

• /0 = benign
• /1 = neoplasm with uncertain or unknown behaviour
• /2 = Cancer in situ
• /3 = malignant, primary tumor
• /6 = malignant, metastasis (not used in tumor documentation)
• /9 = malignant, uncertain wether primary tumor or a metastatic

The sixth digit describes grading, differentiation or phenotype (Histology/Pathology):

• 1 = Grade I, well differentiated (Low grade)
• 2 = Grade II, moderately differentiated (Intermediate grade)
• 3 = Grade III, poorly differentiated (High grade)
• 4 = Grade IV, undifferentiated (High grade)
• 9 = Grade IX, grade cannot be assessed

For Leukemias and Lymphomas, the sixth digit signifies the immunophenotype

• 5 = T-Cell
• 6 = B-Cell, Pre-B-Cell, B-Ancestor-Cell
• 7 = Null-Cell, Not-T-Cell-Not-B-Cell
• 8 = NK-Cell, Natural Killer Cell
• 9 = Determination of Cell Type was not accomplished, not specified or not applicable

TNM System describes

• Expansion of primary tumor (extent repectivly spread in distant organs)
• Affection of lymph nodes in lymph flow area
• Exisistence of distant metastasis

For the topography axis, there exists an (hierarchical) enlargement, the ‘localisation key’ (Wagner, G. (HRSG.): Tumorlokalisationsschlüssel, 5. Auflage, Springer Verlag, Berlin, Heidelberg, New York, Tokyo 1993), which can supply at some positions clinical relevant differentiation. The morphology axis is composed of a four-digit code for tissue basic structure, a characteristic number for dignity and an additional grading item. The key itself does not contain all possible combinations of histology and dignity, but points out those ones, for whome exist special discriptions. Vice versa not all combinations of basic structure and dignity are possible (so there is no ‘benign leukemia’). Not either there is a grading system available for all kinds of tumor. For some ones, additional information (for Example ‘Cell-line’) is used at the corresponding position.

Tumor Localization

For Tumor-Coding first of all, the site is important. It will be classified by the Topography -Axis of ICD-O. Topographical -Codes of ICD-10 are based on chapter II (Neoplasm –C 00 – C 97) of ICD-10. However, some of the topographical Codes of ICD-10 (Codes) are not used, because their content is discribed by histology- and digit-Codes of ICD-O. (e.g. Differentiation in situ/ infiltrated, melanoma vs. scin cancer).

Tumor Histology and Dignity

Furthermore, in ICD-O, tumor morphology i.e. tissue structure (histology) and biological behavior (dignity) is discribed by special Codes. Tumor histology is coded by a four-digit number, which is assumed of the morphology-axis of Standardized Nomenclature of Patholoy (SNOP). Dignity-Code is attendant on morphology-Code, seperated by /. Examples:

• 8060/0 squamous epithelium - papillomatose
• 8070/2 squamous epithelium – cancer in situ undifferentiated
• 8070/3 squamous epithelium – cancer undifferentiated
• 8070/6 squamous epithelium – cancer metastasis undifferentiated

Tumor Grading

Grading is derived from the comparison of primary tissue with the neoplasm of this tissue. There are five grading-degrees (s.o.) and further three degrees for Malignant Lymphoma. Registration of tumor grading is also provided in TNM.

Qualifier of Tumor Formular

ICD-O –Codes can be specified by the following qualifier:

Here ICD-O provides additionally the following codes for Lymphoma, which specify the Cell line: B-Cell, T-Cell, Null-Cell Lymphoma. ICD-O uses the Codes 1 – 9. A detailled System is discribed in Chapter 9 under 9.5.2 and 9.53.

Example

GRAPHIC IS MISSING

DisplayName is only available in correlation to qualifiers. According to ICD-O-3 formation rule there are much more discriptions possible as ICD-Catalog proposes.

Terminology

Overview of Value Sets

Value Sets	OID	Short Term	German	English
Tumors	1.2.276.0.76.11.1	uicctumor	ValueSet für Tumore in der Tumordokumentation	ValueSet for tumors in the cancer documentation
Nodes	1.2.276.0.76.11.2	uiccodes	ValueSet für Knoten in der Tumordokumentation	ValueSet for nodes in the cancer documentation
Metastases	1.2.276.0.76.11.3	uiccmetastasen	ValueSet für Metastasen in der Tumordokumentation	ValueSet for metastases in the cancer documentation
ResidualTumor	1.2.276.0.76.11.4	uiccresidualtumor	ValueSet für Residualtumor in der Tumordokumentation	ValueSet for residual tumor in the cancer documentation
Stage Classification	1.2.276.0.76.11.5	uiccstages	ValueSet für die Stadiengruppier ung in der Tumordokumentation	ValueSet for stages in the cancer documentation
Venous Invasion	1.2.276.0.76.11.6	uiccveneninvasion	ValueSet für die Veneninvasion in der Tumordokumentation	ValueSet for venous invasion in the cancer documentation
Lymphatic Invasion	1.2.276.0.76.11.7	uicclymphsysteminvasion	ValueSet für die Lymphsysteminvasion in der Tumordokumentation	ValueSet for the lymphatic system invasion in the cancer documentation
Perineural Invasion	1.2.276.0.76.11.8	uiccneuralscheideninvasion	ValueSet für die Neuralscheideninvasion in der Tumordokumentation	ValueSet for the perineural invasion in the cancer documentation
TNM Qualifier	1.2.276.0.76.11.9	uicctnmqualifier	ValueSet für die TNM-Qualifier in der Tumordokumentation	ValueSet for tnm qualifier in the cancer documentation
TNM Localisation for Tumor Documentation	1.2.276.0.76.11.10	uicclocalisation	ValueSet für die TNM-Seitenlokalisation in der Tumordokumentation	ValueSet for tnm localisation in the cancer documentation

Diagnosis Types In Germany

Code	Meaning
DX	Diagnosis, not specified any further
RFFDX	Referral Diagnosis
ENTDX	Entry Diagnosis
TRFDX	Transfer Diagnosis
ADMDX	Admittance Diagnosis
CDDX	Clinical Department’s Diagnosis
CDXDX	Clinical Department’s extra Diagnosis
CDTDX	Clinical Department’s Treatment Diagnosis
CDDISDX	Clinical Department’s Discharge Diagnosis
CDADMDX	Clinical Department’s Admittance Diagnosis
SUCCDX	Successive Diagnosis (with continuing sick leave)
DISDX	Discharge Diagnosis
TDX	Transfer Diagnosis
PERMDX	Permanent Diagnosis
APERMDX	Anamnestic Permanent Diagnosis
BPERMDX	Treatment-related Permanent Diagnosis
EMERDX	Emergency-related Diagnosis
REIMDX	Reimbursement Diagnosis
POSTOPDX	Post-operative Diagnosis
PREOPDX	Pre-operative Diagnosis
ADR	UAW ­Observed Unwanted Side Effects
ADRPD	UAW Main Disease
ADRCCD	UAW Side Disease
IFSGDX	If–G ­Diagnoses
IFSGSUSPDX	If–G ­Suspicious Diagnoses
IFSGDD	If–G ­Differential Diagnoses
COD	Cause of Death (fatal disease)
CCCOND	Accompanying Diseases
EXTCS	External Cause
NEO	Neoblasts
UAE	Unwanted Medication Event
UAW	Unwanted Medication Effect12
CAREDX	Care Diagnosis
SYMDX	Symptom
OTHDX	Miscellaneous Diagnosis