Download - ICD11 Qualiity and Safety TAG 2013 (show)
Second part of the story
T. Bedirhan Üstün
World Health Organization Classifications, Terminologies, Standards
WHO Quality and Safety Topic Advisory Group6th Meeting, April 2-3th, 2013, New York, USA
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 or songs.
• From these elements we build a selection as a linearization.
• This analogy may however be misleading because there are many links between the ICD entities (like parent-child relations and other).
• The ICD entities in the Foundation Component:
• are not necessarily mutually exclusive• allow multiple parenting ( i. e. an entity may be
in more than one branch, for example tuberculosis meningitis is both an infection and a brain disease)
Overview• ICD-11 progress
– Current status – Vol II ICD knowledge base– Stability Analysis: ICD10 in 11
• QS-TAG work– ICD-11 Reviews – ICD-11 Field testing– Traditional Medicine QS issues
• ICHI
Current Status as of 20 March 2013
• Some Chapters need further work– Infectious Disease A– Neoplasms B,C– Sign & Symptoms R– External Causes and Injury– Z codes
• Other chapters’ structure reported to be complete
• Definitions > 50% – Top level > 70 %
Remaining Content Model Parameters
• Sign Symptoms
• Diagnostic Criteria
• Laboratory Tests• Genetic Linkages
• Treatment Properties
Information Notes
1. ICD Revision Communication
2. ICD Revision Timelines
3. TAG Allocation
4. Content Model
5. Foundation Component and Linearizations
6. Legacy Linearizations
7. Code Structure
8. Multidimensional Coding
9. Index
10.Diagnosis Type
11.Main Condition
12.Review Process
13.Mirror Coding
14.Modifiers and Qualifiers
15.Field Trials
16.Stability Analysis
17.Multilingual ICD Platform
18.Dagger and Asterisk resolution
19.Multisystem Chapter
Information Notes under development
20. Cross-cutting TAG Rolesa. Mortality
b. Morbidity
c. Functioning
d. Quality & Safety
21. Post-Coordination Principles and Rules
22. Residual Categories
23. Common Ontology with SCT
24. Coding Rules
25. National Linearizations in ICD-11
26. ICD-11 Definitions
Identifying Options for Main Diagnosis
• Diagnosis at the time of Admission (T1)• Diagnosis at the time of Discharge (T2)
• Identifying what happened in between:– Was a condition present on admission ?– Has a condition arisen in the meantime ?
• Is it derived from T2 - T1 ?• Is it recorded specifically ?
ICD knowledge base
• Coding Rules– Mortality– Morbidity
• Explanation of classification– Pre-coordination – Post- Coordination
• Multiple Coding– Cluster Style– Chain Style
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
11
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
Linerization requirements
• Classical ICD– Mutually Exclusive– Jointly Exhaustive
No double countingAll categories will be in
Residuals: Other (*.8) Unspecified (*.9)
should be generated for each linearization
MEJE priniciple
Building Linearizations
• Multiple Parenting Allowed– Pneumonia
• Lung Disease• Sometimes Infectious Disease
• Permanence of meaning across different linearizations– Telescopic principle
• Zoom in – zoom out
Morbidity111
Morbidity112
Morbidity121
Morbidity133
Morbidity131
Morbidity132
Morbidity221
Morbidity222
Morbidity211
Morbidity311
Morbidity312
Morbidity321
Morbidity341
Morbidity342
Morbidity351
MORBIDITYInternational
PC – Low 1
PC – Low 2
PC – Low 3
PRIMARY CARE Low Resource
(Verbal Autopsy ?)
Mort/PCHigh 11
Mort/PCHigh 12
Mort/PCHigh 13
Mort/PCHigh 21
Mort/PCHigh 22
Mort/PCHigh 31
Mort/PCHigh 33
Mort/PCHigh 34
Mort/PCHigh 32
Mort/PCHigh 35
PRIMARY CARE High Resource
PC – Low 1
PC – Low 2
PC – Low 3
PRIMARY CARE Low Resource
(Verbal Autopsy ?) MORTALITY
Mort/PCHigh 11
Mort/PCHigh 12
Mort/PCHigh 13
Mort/PCHigh 21
Mort/PCHigh 22
Mort/PCHigh 31
Mort/PCHigh 33
Mort/PCHigh 34
Mort/PCHigh 32
Mort/PCHigh 35
Morbidity111
Morbidity112
Morbidity121
Morbidity133
Morbidity131
Morbidity132
Morbidity221
Morbidity222
Morbidity211
Morbidity311
Morbidity312
Morbidity321
Morbidity341
Morbidity342
Morbidity351
PRIMARY CARE High Resource MORBIDITY
PC – Low 1
PC – Low 2
PC – Low 3
PRIMARY CARE Low Resource
(Verbal Autopsy ?) MORTALITY International
Mort/PCHigh 11
Mort/PCHigh 12
Mort/PCHigh 13
Mort/PCHigh 21
Mort/PCHigh 22
Mort/PCHigh 31
Mort/PCHigh 33
Mort/PCHigh 34
Mort/PCHigh 32
Mort/PCHigh 35
Morbidity111
Morbidity112
Morbidity121
Morbidity133
Morbidity131
Morbidity132
Morbidity221
Morbidity222
Morbidity211
Morbidity311
Morbidity312
Morbidity321
Morbidity341
Morbidity342
Morbidity351
PRIMARY CARE High Resource MORBIDITY
PC – Low 1
PC – Low 2
PC – Low 3
PRIMARY CARE Low Resource
(Verbal Autopsy ?) MORTALITY International National LinearizationsSpecialty - Research
Extensions
• Pre-coordination - fixed names
V12.24 Pedal cyclist injured in collision with two- or three-wheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities
ICD Organization
• Post- Coordination - extensions• Bicycle Accident
• Hit • Role• Context• Activity
X – Chapter:
Extension Codes Type 1 Type 2 Type 3
Severity Main Condition (types) History of
Temporality (course of the condition)
Reason for encounter/admission
Family History of
Temporality (Time in Life)
Main Resource Condition Screening/Evaluation
Etiology Present on Admission
Anatomic detail TopologySpecific Anatomic Location
Provisional diagnosis
Histopathology Diagnosis confirmed by
Biological Indicators Rule out / Differential
Consciousness
External Causes (detail)
Injury Specific (detail)
Multiple CodingEquivalent Expressions
Cluster Style
– Code1*– Code2*– Code3*– ..– * CLUSTERING IND.
Chain / String Style
– Code1/Code2/Code3
Multiple CodingEquivalent Expressions
Chain / String Style
JH6.100/ XT0.???/ XD0.100
STEMI - posterior wall – confirmed by EKG
Cluster Style
• JH6.1001 Myocardial Infarction with ST Elevation
• XT0.???1 Posterior wall of heart
• XD0.1001 Diagnosis Confirmed by EKG
• 1 CLUSTERING indicator.
• Ensure a seamless transition between ICD-10 and ICD-11 – national – international levels
• CrossCutting TAGs review and confirm continuity between ICD-10 and ICD-11
• Represent knowledge gained from national clinical modifications in the revised ICD.
Stability Analysis
Objectives
• Mortality• Morbidity
– ICD-10-WHO with ICD-11-WHO– ICD-10&11-WHO with ICD-10-GM– ICD-10&11-WHO with ICD-10-AM– ICD-10&11-WHO with ICD-10-CM– ICD-10&11-WHO with ICD-10-CA
Stability Analysis
Types & Methodology
Age-adjusted death rates for nephritis, nephrotic syndrome, and nephrosis:
United States, 1968-2005
QS-TAG work agenda• Papers
– QS specific issues • Overview Paper :QS-TAG & ICD revision • PSI for ICD 10 and ICD 11
– broader morbidity related issues • coordinate with Mb-TAG
• Main Condition issue • Dx timing indicators • Number of Dx fields
• Field trials
ICHI
• ICHI linkages– ICHI derived DRG list– ICHI Development Management Group
Why a Review Process
• The review process will help WHO assure the quality of the Beta Content
• Review focus: – Scientific accuracy– Completeness of each unit– Internal consistency– Utility / Relevance of each unit
Review Process
• The review process :– the content
• Definitions• Content model parameters
– The structure - of the linearization (s) • Mortality• Morbidity• Primary Care
• The reviewers: – scientific peers
Initial Review
1. Linearization Review
2. Content Review
Linearization Review
1. Mortality Linearization Review
2. Morbidity Linearization Review
3. Primary Care Linearization Review
4. Mirror-Coding Review
5. Quality & Safety TAG review
Linearization Review
1. Review Unit is the whole linearization in question– e.g. Four-character Codes in MORTALITY– Review the results of Stability Analysis– Mark-up in iCAT– Review restricted to the relevant TAG only
• e.g. M TAG for Mortality Linearization
Morbidity Linearization
1. Review of Five or more character codes
2. Results of the Stability Analysis
3. Results of the resolution of Dagger-Asterisk resolution
Primary Care Linearization(s)
• Expect to produce two different linearizations– Low resource PC linearization
• Fewer categories – large groupings
– High resource PC linearization• Frequent health conditions in PC with high
resources (same as Morbidity linearization in resolution, but representing only PC relevant cases)
Initial Review
• Initial Review of the current Beta draft:– Linearization Structure(s) (e.g. Mortality and Morbidity or Primary
Care)– Content
• Review Units: may include individual entities or groups of entities at any level, such as:
Structure Review Units– Entire Linearization– Chapter– Subchapter– Clusters– Use Cases– Other structure groupings, as selected
Content Review Units
– Chapter– Subchapter– Clusters– Individual entities– Other groups of entities, as selected
Content Review
1. Initial review:– Selected sections of ICD-11 where
• work has been completed
– specific review is needed– there is special interest
• Accuracy• Scientific quality• Completeness• Clinical or Public Health Utility
Content Review
• Proposal Generation Phase– When proposals are mature (decide how) – Submit to 5 reviewers – Obtain 3 complete reviews– Generate combined statement– Submit to TAG in a combined list– Implement results– Submit conflicts to RSG
Review Units
1. Linearizations
2. Chapters – Sub Chapters – Code clusters
3. Single categories– Initial selection from:
• Completed content• Hot Categories – with differential aspects in XMs.• Public Health Importance
4. Set of Content Model parameters across multiple categories– e.g. Lab findings , genomics, etc.
Review Software
A. Process manager– Identify Review Units– Identify Reviewers– Send invitations
• Letter• Review questions
– Send reminders, if necessary– Compile results
Reviewers
• Content Reviewers: Pool of specialist experts to review in their area of expertise, similar to quality assessment in peer-reviewed journals.
• Structure Reviewers: Morbidity TAG and Mortality TAG
• TAG and WG members :– will act as a scientific journal editorial board.– should NOT be nominated as reviewers.
Call for Reviewers
• WHO Requests all TAGs and WGs to provide nominations of reviewers for the next step in the Beta Phase.
• Please send the following information to WHO ([email protected]) and copy the message to Bedirhan ([email protected]) :– Name of the nominee– Email address– Area(s) of expertise (content they are qualified to review)– CV of the nominee (preferred)– Linked-In or other professional profile link (if available)
Reviewers
1. WHO search– From PUBMed, Google Scholar– WHO expert database
2. TAG Nominations
3. ICD-11 Web-site– Self-nomination
4. Solicited Reviews– NGOs ( e.g. WONCA etc ) – Genetics institutions
Contributor - Reviewer Acknowledgement
• WHO is currently creating a list to acknowledge all participants:
– ICD website– Print version of the ICD-11.
• Please include all with participant contact information.
The following individuals will be acknowledged:
– RSG– RSG-SEG– TAG– TAG WGs
– Managing Editors
– NGOs– Other Contributors – WHO-FIC Collaborating Centres– WHO Staff
Incentives for Reviewers
Content Review – Schedule
3rd Wave– Musculoskeletal– Mental Health– Neurology– Rare Diseases– Circulatory
4th Wave– Dermatology– Hematology– Respiratory– Neoplasms– Infectious Diseases– Pediatrics
1st Wave• GURM• TM (Disorders)• Gastroenterology• Nephrology• Hepato-pancreatobiliary
2nd Wave• External Causes and Injuries• Ophthalmology• Dentistry• Rheumatology• Endocrinology
ICD11 Field Trials
• Basic aims– To test the “fitness of ICD-11 for multiple purposes”
• Mortality coding• Morbidity coding• Quality & Safety • Other use cases
– To ensure the comparability between ICD-10 and ICD-11– To increase consistency, identify improvement paths, and reduce errors
.
• Key Assessments:
• Applicability – feasibility easy to use
• Reliability - consistency gives same results in the hands of all
• Utility - added value renders useful information
ICD11 Field Trials
• Applicability (Feasibility) – – Is the classification easy to implement in the hands of the real life users (coders,
doctors etc.) ?
• Reliability – – Is the classification used in the same manner by different users? – Do two different users code the same case with the same code? – What are the sources of discrepancy? – What are the factors to improve comparability and consistency?
• Utility – – What is the value of the classification to enhancing data capture and its uses?– Does it improve recognition? – Does it serve for better documentation? – Does it enable re-use? – Does it guide better diagnosis? – Does it allow better resource allocation?
Field Trials• KEY USES:
– Mortality: cause of death coding, verbal autopsy – Morbidity: various morbidity codings – hospital discharge, DRG etc.– Quality – Safety– Other uses
• DIFFERENT SETTINGS: – Primary Care
• High-resource settings• Low-resource settings
– General Health Care• Specialty settings
– Research settings• Use in population studies - epidemiology• Use in clinical research
Core Studies
• Study One: – Feasibility and Reliability for live Cases and Case
Summaries coding with • ICD-10 an 11
• Study Two: – Basic Questions
Inter-rater reliability
• The Case information• live • medical record
• Coded using ICD11 by at least two different people
• Agreement rates measured
Bridge Coding
• The Case information• live • medical record
• Coded using • ICD10• ICD11
• Agreement rates measured
Basic Questions
Consensus Conference ApproachEach field trial centre will conduct at least one consensus conference to discuss the basic questions. The results of the consensus conference will be summarised in a report and forwarded to WHO Geneva.
Individual Response ApproachResponses to the basic questions should be collected by each field trial centre from multiple individuals who have expertise in the area of TM coding. Each person should provide a written response to the basic questions on the Response Form provided in the protocol. The field trial centre will collect these responses and provide a summary using the same format as for the Consensus Conference.
– Plan for field trials• Essential components• Additional components
– Methodology– Timelines
– Possible Participants
– Data collection – Analysis - Publications
Field Trials Work Plans
Transition Strategy
75 79 90 13 15 ??
ICD-9 ICD-10 ICD-11
4 23
2015
ICD
- 2016
ICD
- 2017
ICD
- 2018
ICD
- 2019
• TAG serving as an Editorial Board• Reviews
• Organizing Field testing• Feasibility• Quality assurance• Reliability
Roadmap during Beta Phase
ICD Revision
"Genchi genbutsu"Learn about pines from the pine, and about bamboo from the bamboo.松は松に聞け、竹は竹に聞け
Don’t follow in the footsteps of the old poets, seek what they sought先人言葉に盲従せず、その考え方に学べ
Basho 松尾芭蕉