IG:HL7 diagnosis
Representation of Diagnosis based on the Clinical Document Architecture Rel.2 for Healthcare in Germany
Version 1.1
Inhaltsverzeichnis
- 1 Introduction
- 2 Diagnosis Types
- 3 Common Diagnosis Descriptions
- 4 Diagnosis Model in HL7 V3
- 5 Representation of Diagnosis in specific Codesystems
- 6 Representation of Cancer Diagnosis
- 7 Cancer Diagnosis in HL7 V3
- 8 Representation for specific Use Cases
- 9 Terminology
- 10 Appendix A: Other
- 11 Appendix B: Indices
Introduction
Introduction
Scope
Diagnosis Types
Common Diagnosis Descriptions
Diagnosis Model in HL7 V3
Representation of Diagnosis in specific Codesystems
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.
TNM Classification
Ann Arbor Classification
FIGO Stages
Gleason Score
Papanikolaou
WHO Grading
Conclusion
Cancer Diagnosis in HL7 V3
Representation for specific Use Cases
Terminology
Introduction
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 |
| 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 |
