icd revision and primary care versions

Dr. T. Bedirhan ÜstünWorld Health Organization

Classifications, Terminologies, Standards

WHO on ICD and Health Information

KEY MESSAGES:1. ICD-11 should be simplified 2. ICD-11 should be computerized 3. ICD-11 should be fit for purpose4. ICD-11 should be easy to teach, implement5. ICD-11 should speak the same language in PC and Specialty

All efforts on ICD-10 and ICD-11 should converge

SIMPLICITYIs theUltimateSophistication

Shepherdingsimple requirements

1. Count your sheep• How many born ? • How many dead ?

Reporting of Mortality in the World

Source WHO 2014

Information ParadoxInformation Paradox

0

100000000

200000000

300000000

400000000

500000000

600000000

700000000

800000000

1 2 3 4

YL

Ls

VR countries vs No VR

Burden of Mortality

Carpet burnt

Shepherdingsimple requirements

1. Count your sheep• How many born ? • How many dead ?

2. Don’t cry wolf !

Genealogy of ICD 1664

350years

ICD Revisions

139

161

179

189

205

214

200

954

965

1,0

40

1,1

64 8

,173

1,9

67 1

4,4

73

1

10

100

1000

10000

100000

Farr

/d'E

spin

e

Bert

illo

n

ICD

1

ICD

2

ICD

3

ICD

4

ICD

5

ICD

6

ICD

7

ICD

8

ICD

9

ICD

-9-M

ICD

10

ICD

-10-M

1853 1893 1900 1909 1920 1929 1938 1948 1955 1968 1975 1979 1993 1993

Placing WHO Classifications in HIS & IT

Population Health• Births • Deaths • Diseases• Disability • Risk factors

e-Health RecordSystems

ICD

ICF

ICHI

Classifications

LinkagesKRs

Terminologies

Clinical• Decision Support• Integration of care• Outcome

Administration• Scheduling• Resources • Billing

Reporting• Cost• Needs• Outcome

ICD-11 Revision Goals1. Evolve a multi-purpose and coherent classification

• Mortality, morbidity, primary care, clinical care, research, public health…• Consistency & interoperability across different uses

2. Serve as an international and multilingual reference standard for scientific comparability and communication purposes

3. Ensure that ICD-11 will function in an electronic environment.• ICD-11 will be a digital product• Support electronic health records and information systems

• Link ICD logically to underpinning terminologies and ontologies (e.g. SNOMED, GO, …)• ICD Categories “defined” by "logical operational rules" on their associations and details

Construction of ICD-10: Revision Process in 20th Century

• 8 Annual Revision Conferences (1982 - 89)

• 17 – 58 Countries participated• 1- 5 person delegation

• Manual curation• List exchange• Index was done later

• "Decibel" ? Method of discussion

• Output: Paper Copy

• Work in English only

• Limited testing in the field

Construction of ICD-11: Revision Process in the 21st Century

• Internet-based permanent platform • All year round • Open to all people in a structured way• Content experts focus

• Digital curation• Wiki enabled collaboration• Ontology based

• Enhanced discussion & peer review • TAGs serve as the editorial group

• Electronic copy print version

• Work in multiple languages

• Planned field tests • Based on Use Cases

How do we go from Here to 21st Century?

Sharing Meaning

YOU• Think• wish to express• think you have just

expressed• you expressed• …

OTHER ONE• wants to hear• Actually hears• wishes to understand• understands• …

Knowledge Representationthe triad of

things, thoughts and words (Ogden & Richards, 1923 )

APPLETERM

Ontology (philosophy)– the Organization of Reality

Ontology (computer science) – the explicit – operational

description of the conceptualization of a domain:

An ontology defines:– a common vocabulary a shared

understanding/exchange:among peopleamong software agentsbetween people and software

– to reuse data - information– to introduce standards to allow

interoperability

What is Ontology?

iCAT• Open and Collaborative Platform

• Web based

• Like WIKI • But

• by the Content Model • with

• by the TAGs , and scientific peers

iCATCollaborative Authoring Tool

for ICD Revision

structured

Editorial Oversight

ICD11 βetahttp://www.who.int/classifications/icd/revision

• Beta – Browser & Print 10 look & feel + descriptions – code structure !

• ICD-11 Beta draft is NOT FINAL • updated on a daily basis•NOT TO BE USED for CODING except for agreed FIELD TRIALS

βeta

The ICD Foundation Component

• is a collection of ALL ICD entities like diseases, disorders...

• It represents the whole ICD universe.

• In a simple way, the foundation component is similar to a “store” of books, songs, lego pieces.

The ICD Linearizations• A linearization is a subset of the foundation

component, that is: • Fit for a particular purpose: reporting mortality, morbidity, or other uses• Jointly Exhaustive of ICD Universe (Foundation Component) • Composed of entities that are Mutually Exclusive of each other• Each entity is given a single parent

Skin

Neoplasms

ICD11 Components: Linearizations

Foundation: ICD categories with

- Definitions, synonyms- Clinical descriptions- Diagnostic criteria- Causal mechanism- Functional Properties

Find Term

SNOMED-CT, International Classification of Functioning, Disability and Health (ICF)…

Linearizations

Mortality

Morbidity

Primary Care

Linearizations:Zoom-in Zoom-Out

Linearizations:PC short PC Intermediate

JLMMS

1361 2504 15,473

Title Primary C. Joint Lin. Ophthalm.Cataract code code code

Age-related cataract code code codeCortical age-related cataract other other codeNuclear age-related cataract other other codeCataracta brunescens other other codeNuclear sclerosis cataract other other codeCapsular and Subcapsular age-related cataract other other codeCapsular age-related cataract other other codeAnterior subcapsular polar age-related cataract other other codePosterior subcapsular polar age-related cataract other other codeIncipient age-related cataract other other code

Coronary age-related cataract other code codePunctate age-related cataract other code code

Water clefts other other codeAdvanced or mature age-related cataract other other code

Mature age-related cataract other code code Subtotal advanced or mature age-related cataract other other code

Advanced or mature age-related cataract, total cataract other other codeMorgagnian age-related cataract other other codeCalcified age-related cataract other other codeCombined forms of age-related cataract other other code

DIGITAL ZOOMING

APN Hamamatsu Meeting - 2009

1. A Primary Care classification must be short and simple.2. There should be no redundancy between coding systems. ICD-11 and ICPC should be compatible.3. Classification rubrics in primary care are heterogeneous ranging from ; there may be many different factors important to each case.

There needs to be a proper decision of what factors are to be defined in classification.4. Primary care does not exist on its own, but within an overall health system. Primary care should not be approached as if there is no

secondary or tertiary care. This must be considered when designing the PC Classifications and appropriate collaboration systems built between primary, secondary and tertiary care systems.

5. It is important that Primary Care Classification revision be well coordinated for different types of providers and consumers. There needs to be efficient sharing of information between all stakeholders.

6. The Primary Care Classifications should be based on established terminologies/ontologies. This will be the basis for linking with health records and assuring quality assurance. This underpinning systems will enlight how different coding systems interact with each other.

7. There must be incentives for the users of Primary Care Classification. Primary Care Practitioners will classify if they are given reasons to do so, and classification systems should be developed with this in mind. One incentive for use of the system may be the management guidance.

8. In many countries it is not possible to have a second layer of coders in addition to the practitioners. Methods should be developed for primary care providers allowing code themselves.

9. PC classifications should be tested in the real world to identify issues of feasibility, reliability and these tests should be used to improve their user-friendliness.

10. PC classifications should be of at least two levels of complexity: (a) resource poor settings; (b) resource rich settings.. PC Classification systems should be usable electronically and on paper.

Inpatients

Outpatients

PHC - Recognized

PHC - Attenders

The Community

Where Do People Seek Help ?

1

5

25

50

100

Data Collected But Not Used

the information YOU -

₋ have is not what you want

₋ want is not what you need

₋ need is not what you can have

Finagle's Law of Information have

want

need

In other words there is always a gap between what you have, need or want

Halfdan MahlerWHO Director General. 1973-1988

ICD can only be a door stopper in Primary Care

… RENEWAL … NEW WAYSPHC

WHO-FIC in Primary Care

• WHO FIC elements are not currently suitable for use in primary care:• They are complex,• Too detailed• No reward to the user.

• WHOFIC for Primary Care should be • Concise• Focused on frequent and important conditions in Primary Care• Should be treatable in Primary Care• Providers should be able to code the information.

ICD-10 PCICD-10 PC

ICD-10 PC for Mental Health ICD-10 PC for Mental Health

Diagnostic Guidelines• Presenting Complaints• Diagnostic Criteria• Differential Diagnosis

Management Guidelines• What to say to patient and family• What sort of psychological counseling • Prescription: what, when, how ...?• When and how to refer a specialist

Diagnostic Guidelines• Presenting Complaints• Diagnostic Criteria• Differential Diagnosis

Management Guidelines• What to say to patient and family• What sort of psychological counseling • Prescription: what, when, how ...?• When and how to refer a specialist

Future work

• Selection criteria for ICD categories• ICF-PC disability categories• ICHI-PC intervention categories• Signs - symptoms (Chapter R) • Contextual factors (Chapter Z)• Reason for Encounter use• Other …

… BUILDING BLOCKS OF HEALTH INFORMATION …

CLASSIFICATIONS

EVALUATION: Do Classifications increase ...EVALUATION: Do Classifications increase ...

• … recognition ?• … diagnosis ?• … accuracy of diagnosis? • … treatment ?

— prescription ?— compliance ?

• … referral ?• … outcome ?• … patient satisfaction ?

• … recognition ?• … diagnosis ?• … accuracy of diagnosis? • … treatment ?

— prescription ?— compliance ?

• … referral ?• … outcome ?• … patient satisfaction ?

Primary Care Classifications• Comprehensive - not a single chapter-oriented• Brief - yet covering all common disorders• User-friendly and flexible with different modules• Emphasis on Doctor-Patient relationship• Management-oriented “Treatment Guidelines” ? • Dual function: used both for training and in daily practice• Culture-oriented: can be applied in many different cultures• extensive implementation and evaluation process• endorsed by WHO, WONCA, APN and multiple parties • Creating a network (or integrating into existing ones) between primary care physicians and

psychiatrists.

Real Time Public HealthRule-based Aggregation @ Individual, Facility, Population levels

Public Health, Epi & Surveillance

Findings InterventionsEvents

Clinical Information

ReimbursementResource Management

… RENEWAL … NEW WAYSPHC

Every programme,project, partnerhas a separate M&E plan

Every M&E planfocuses on indicatorsbut not on the systemfor generating them

Need for Integration Need for Integration

Clinical Use Case: Exploration of Cough

Fever

386661006

COUGH

49727002

WET COUGHsputum

28743005

Hemoptisia

Blood in Sputum

207069003

• X-ray : Tbc? • Culture

399208008

104184002

• Diagnosis: Tuberculosis 154283005A 15.0

• Treatment: DOTs { 324453004 }

From David Werner and David Sanders. Questioning the Solution. The Politics of Primary Health Care and Child Survival with an in-depth critique of Oral Rehydratation Therapy. Palo Alto: Health Rights, 1997.

The Power of ORS

Why is this Sooooo important ?

GIGO: Garbage In

Gold Out ?

Beyond

• Search using Concepts above Words• How many patients do have diabetes mellitus type II?

• Extraction of Concepts from Health Records• Automated extraction of HbA1c results of selected patients with DM type II from lab

reports within last year

• Statistical Index on Community Collections• Calculation of coverage gap for treatment need for diabetes mellitus

• Concept Navigation across Collections• Comparison of region A with region B etc

50

Grade 3 hypertension

Grade 2 hypertension

Grade 1 hypertension

High normal

normal

optimal

120 130 140 150 160 170 180

Systolic pressure

Dia

stol

ic p

ress

ure

172

102

110

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100

95

90

85

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Knowledge Representation

51

Uniform Resource Identifiers

URI: //id.who.int/….

• enable links to other established terminology, ontologies

• allow impact analysis possible via W3C• e.g. where on the world these are used or not used

• Useful for translations: • the concepts will indicate a language-independent construct

and translations will refer to the unique source concept.

Current Status

• Frozen June 2015• iCAT continues real time… BROWSER

• JLMMS is frozen for review

• Definitions • Top level > 75 % ~ 10,000 definitions

• Linearization errors < 344 (from 10K) • Duplicates < 651 (from 3K)

• 2015 : Beta version & Field Trials Version (June /September 15) • 2016 : World Health Assembly Information Presentation

Field trials

• 2018 : Final version for WHA Approval• 2018+ implementation• Continuous Annual Cycles

• ICD 2019• ICD 2020• ICD 2021

ICD-11 Timeline

Coding Tool

Coding Tool

Print Versions

Transcoding tables ICD-10 to ICD-11 in excel

ICD-10 ICD-11 correspondence• 3 character – 1183 (w/o ECI & Residuals)

• 951 Equivalent• 191 mapped to a larger entity in 11

• with post coordination many have equivalent maps• 41 not mapped

• 4 character - 6635• 4343 Equivalent• 2207 mapped to a larger entity in 11

• with post coordination many have equivalent maps• 85 not mapped

ICD Translation Tool: French

ICD Translation Tool: Japanese

ICD11 Translation Tool: Chinese

… RENEWAL … NEW WAYSPHC

ICPC within WHO-FIC

Millenium Development Goals

What do we do with our “time” ?

Global Village … It takes a village…

It takes the whole globeto share data

Questions & Answers

ustunb@who.int

@ustunb

bedirhan-ustun