COLLABORATION ARRANGEMENT

International Classification of Health Interventions

Outline

• WHO perspective Ustun• AMA perspective

Musacchio• ICHI work to date Madden• Computable Classifications Musen• Content Model Tu & Nyulas • Conclusions All• Question & Answers

Why do we need an Interventions Classification?

• Clinical Documentation• Monitoring and Evaluation• Quality Indicators• Safety Indicators• Efficiency and Effectiveness research• Reimbursement• Resource Allocation Decisions

UNIVERSAL HEALTH COVERAGE…

Global LandscapeWHO SURVEY 2006

Countries without an Intervention Classification: around 130

Countries with an Intervention Classification: 60

Countries using ICD-9-CM Vol 3: 12

Countries using Casemix: 20

OECD: sentinel interventions – Health Accounts 28

5

WHO Family of Classifications

REFERENCE Classifications

I nternationalC lassification of D iseases

I nternationalC lassification of F unctioning, Disability & Health

I nternational C lassification of H ealth I nterventions (under development)

RELATED Classifications

International Classification of External Causes of

Injury (ICECI)

The Anatomical, Therapeutic, Chemical

(ATC) classification system with Defined Daily Doses

(DDD)

ISO 9999 Technical aids for persons with disabilities

– Classification and Terminology

International Classification of Primary Care (ICPC)

DERIVED Classifications

International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

The ICD-10 Classification of Mental and Behavioural

Disorders

Application of the International Classification

of Diseases to Dentistry and Stomatology (ICD-DA)

Application of the International Classification of Diseases to Neurology

(ICD-10-NA)

Current Status - WHO

© Copyright WHO

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Current Status - AMA

© Copyright AMA

FUTURE: AMA + WHO

+ 2018

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ICHI Development Goals

1. Evolve a multi-purpose and coherent classification– 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 ICHI will function in an electronic health records environment.

• Link ICHI logically to underpinning terminologies and

ontologies

Unpacking the Future Classification

1. Ontology Structure

2018

2. Ontology Content

a) CPT…b) ICHI α, β, 2018…

• Ontology (philosophy)NOT meant as the Organization of Reality !!!

• Ontology (computer science) – the explicit – operational description of the

conceptualization of a domain:• Concepts: Entity

Properties Value

• An ontology defines:– a common vocabulary a shared understanding/exchange:

• among software agents ( & people ?) – to reuse data - information– to introduce standards to allow interoperability

What is NOntology?

Knowledge Representationthe triad of things, thoughts and words

(Ogden & Richards, 1923 )

APPLETERM

What is CPT®?

• CPT codes are an organized compilation of standardized descriptions and five character alphanumeric codes that physicians, medical coders and billers use to report healthcare services and procedures to payers for reimbursement

• CPT codes provide a uniform language accurately describing medical, surgical and diagnostic services

• CPT codes serve as an effective means for reliable communications within the U.S. healthcare industry

CPT Brief History

• First published as a 4 digit system in 1966

• Moved to its current 5 digit system in 1977

• Adopted for programs administered by the Centers for Medicare and Medicaid Services in 1983

• Named as a Federal U.S. standard procedure code set for electronic transactions for physician services and other healthcare services in August 2000

• Over 8000, surgical, diagnostic and cognitive procedures

The CPT Editorial Panel Process

• Panel Composition: Broad based and comprised of numerous sectorso 11 physicians representing various medical specialtieso 3 physician payer representativeso 1 hospital association physician representative o 2 non-physician healthcare provider representatives

• Non-voting advisory participants from the health information management and professional coding communities also participate

Collaboration Goal and Objectives

Objectives: Working together in the development of a next-generation ICHI code set that can be

linked to other classification systems, such as ICD and ICF, providing a fully integrated international healthcare classification system

Enable cross-border data aggregation and analysis by deploying the next generation ICHI as an augmenting code set for national health systems

Establish AMA as a credible international partner in the WHO-Family of International Classifications

AMA and WHO are planning to collaborate in order to show global leadership in healthcare information innovation through the development and distribution of integrated, ontology-based

terminologies to expand interoperability and analytical applications of clinical data.

Why The Collaboration Between AMA and WHO Makes Sense Today!

WHO and AMA have organizational missions that are closely aligned and focus on the overall betterment of healthcare

WHO Mission

To provide leadership on global health matters, shaping the health research

agenda, setting norms and standards, articulating evidence-based policy options,

providing technical support to countries and monitoring and assessing health

trends.

AMA Mission

To promote the art and science of medicine and the betterment of public

health through the strategic focus areas of improving health outcomes, accelerating

change in medical education, and increasing professional satisfaction and

practice sustainability

Collaboration Group

– Expert Group ~ 12 members– appointed by AMA and WHO in equal numbers and with joint agreement.

• Richard Madden and Mark Musen will be the co-chairs of the group• 4 management members of current ICHI will be included on the board

– AMA and WHO will appoint one Staff Member each to represent them in the Advisory Group as ex-officio members.

• Bob Musacchio and Bedirhan Ustun

– The group will be advisory to AMA and WHO and will oversee the project work according to the Project Plan appended to this agreement.

Project Plan

• Objectives• Streams of work• Deliverables• Timelines• Budget

Financial Aspects

• AMA will provide the financial resources to WHO in support of the development of the ICHI to cover Project costs:

• For five years– Central project management: WHO Project Staff– Meetings: Expert Group, other work groups – Consultants– Contracts – Development, Field Trials, Reports – Other

ICHI Development Background

 

1978: WHO International Classification of Procedures in Medicine (ICPM)

1988: ICPM not maintained

Many national classifications developed: US, UK, Australia, Germany, ... Focus on medical/surgical interventions, hospital in-patients Duplication, not comparable

Many countries with no classification

Use of U.S. and Australian classification in other countries

Broad scope for ICHI

ICHI planned to include Medicine, surgery, diagnostics Primary care Allied health and provision of support Mental health Nursing interventions Public health

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Structure of ICHI

Finalised in 2010 Multi-dimensional, based on European standard for

classification of surgical interventions: France and Canada had followed this approach

Definition– A health intervention is an activity performed for, with or on behalf

of a person or a population whose purpose is to improve, assess or modify health, functioning or health conditions.

• 5648 interventions across medical and surgical, functioning and other environmental and behaviour areas– 4346 - Interventions on body systems and functions (incl ~ 1790

functioning interventions)– 707 - Interventions on activities and participation domains – 595 - Interventions to improve the environment and health

behaviour

• ncch/sydney.edu.au/health-sciences/ncch/resources.shtml

ICHI Alpha-2 content - interventions

• TARGET n = 633• ACTION n = 131• MEANS n = 59

• New hierarchical grouping of TARGET axis – with subchapters for body parts and for types of activity.

ICHI content - axes

New Target groups provides the tabular list with an additional level of hierarchy.

Extract from the Tabular list illustrating the additional level of hierarchy.

• ICD-9-CM was included in the foundation (original base) for ICHI

• Maps to ICD-9-CM were maintained

• An ICHI subset has been identified that can replace ICD-9-CM

ICD 9 CM Volume 3 and ICHI

Current ICHI Content Model

An Intervention in ICHI is represented by:

Title of Entity: Name of intervention1. Textual definition2. Hierarchy – Type – Use3. Synonyms - Inclusion – Exclusion - Index terms- Notes

Descriptive characteristics1 TargetA Body Part / Anatomical site D EnvironmentB Body Function E BehaviourC Activities and Participation

Current ICHI Content Model (II)

2 ActionA Diagnostic C ManagingB Therapeutic D Preventing

3 Means A Approach C MethodB Technique D Sample

Other relevant informationA Extension codesB Device: Assistive Devices: ISO9999 (proprietary)

Implanted devices: GMDN (proprietary)C Chemical substance: ATCD Objective: ICD, ICF

WHO - 2018

+ =

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2018

International Classification of Diseases and Disorders

=2017

ICD-11JLMMS.

Example of Content Model: ICD

http://www.who.int/classifications/icd/revision/contentmodel/en/

International Classification of Interventions

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=

2018

2018ICHIICPT …

Content Model development process:

• Analyze of ICHI Alpha and CPT sources• Propose prototype Content Model• Review by ICHI/CPT community• Test with “exemplars”• Implement in Protégé• Demonstrate prototype iCAT-ICHI Plus• Refine model• …

ICHI Alpha Source Materials

Conversion of ICHI Alpha to OWL

CPT Source Materials

CPT Developer Tool Kit (DTK)

DTK* formulation of CPT

• 14 axes used to describe procedures

• Formulated in OWL

Intervention Content Model (Partial list)

Create Prototype Content Model

• Align CPT axes and ICHI axes, possibly creating new ones• Determine sources of the value sets of axes• Align CPT and ICHI intervention types• For each intervention type, determine properties used to

describe the intervention• Work out exemplars on paper• Model Content Model in ontology authoring tool

10/15/14

Types of Content Model parameters

• WHO-FIC core parameters– Shared among WHO-FIC classifications

• Descriptive/informational parameters– Classification-specific information “about” a category– Not inherited by derivative categories

• Structural parameters– Axes along which a category can be abstracted or specialized

Content models for WHO-FIC classifications should share core parameters

• Definitional parameters– title, definitions, code (if any)

• Terms– Synonyms– Index terms– Inclusions– Exclusions

10/15/14

WHO-FIC core parameters: Linearization parameters

Fine Needle Aspiration Surgical Procedures

Descriptive/Informational parameters: Taken from CPT and ICHI Alpha

• From CPT– CPT code– Reportable– Short/medium/consumer-friendly/clinical... Descriptor– …

• ICHI Alpha– Inclusion notes?– Exclusion notes?– …

Structural parameter: hasAction

Structural parameter: hasTarget

ICHI Target + CPT Anatomic Site ICD Extension Codes

Structural parameter: hasAssociatedProcedure

• CPT DTK definition: “Specifies the procedure for which a CPT procedure is designated”

• Value Set– ICHI Plus Intervention

Exemplars for Validation

Stanford resident modeled ~80 exemplars

ICHI Meeting, Chicago June 2014

• Attended by ICHI Alpha developers and CPT experts• Plenary as well as smaller groups using provisional CM to model

exemplars– Dissected 3 exemplars together– Two groups

• Dissected 2 common procedures• Group 1: One additional procedure• Group 2: Three additional procedures

– Remarkable consistency

Current Status

• 16 parameters derived or reformulated from ICHI Alpha or DTK axes/parameters

• Value sets need to be defined• Top-level interventions/procedures need to be finalized• Prototype Content Model has been encoded in computable

representation language

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Implication of our modeling approach to WHO-FIC

• We have created an shared core WHO-FIC content model• We cross reference WHO-FIC classification terms• We are using the same post-coordination paradigm across

WHO-FIC classifications (ICD-11 and ICHI)• We will be experimenting with value sets shared across WHO-

FIC classifications (ICD-11 and ICHI)• We use the same iCAT software infrastructure to support the

development of WHO-FIC classifications

Revised 55

Conclusions

Collaboration Timing

Drivers for Change: Interoperability to Manage Health Outcomes Globally

• The lack of interoperability in the healthcare system is holding back needed innovations in quality of care and cost efficiencies

• Most countries have adopted their own standards for classifying procedural data, making it difficult for cross-border integration and analysis

• In light of the growing global disease burden, especially concentrated in developing nations, WHO has forged partnerships across the globe to combat these challenges, enabling greater data exchange across countries would support greater success of these initiatives

Collaboration Strengths

• In direct support of WHO’s and AMA’s missions• Combines the power of the healthcare and terminology leaders• Benefit from ICHI Alpha development and AMA’s CPT content • Leverages WHO’s international prowess and structured classification experience• Leverages AMA’s editorial and implementation prowess• Delivers significant benefits to global healthcare

What does WHO want ?

• Meaningful exchange of health information– Enable aggregation of health information from different sources

• One stop-shop for different users / developers– In multiple languages

• Crystallization spiral for knowledge representation– formalization conceptualization formalization

• Linkages between different domains of health information• Translational research tool + semantic consistency

ICHI - 2018• A reference classification-ontology set

– provision of semantics to enable users to use data in a consistent manner– provision of possible services for:

• classification • terminology • linkages

• For use cases such as:

– Universal Health Coverage

– Billing & Reimbursement

– Casemix and Resource Allocation

– Quality and Safety monitoring

– Comparative Effectiveness Studies