International Statistical Classification of Diseases and ......The Definitions have a standard structure according to a template with standard definition templates and further features

2/6/2016 Introduction | Health Informatics Standards | HI101 Courseware | MedX

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International Statistical Classification ofDiseases and Related Health Problems

Dr. Ryan Banez and Dan Smith

INTRODUCTION

Stan has been diagnosed with Unstable Angina. In the medical world, unstable angina can be

written in many a different ways. Such formats would include:

1. Unstable angina

2. Angina, unstable

3. UA

4. U.A.

5. Ua

6. U.Angina

A health professional may easily recognize such formats and interpret them as unstable angina.

Computers, on the other hand, would need a reference from which unstable angina is

represented by a unique set of characters. In addition, UA can be misinterpreted (even by

humans!) as Uterine Atony, Urinalysis, Upper Arm, Unauthorized Absence, Uric Acid, Umbilical

Artery, or Undifferentiated Arthritis, among others.

Immediately we see the problem. Health professionals have inherent capabilities of

understanding the differences in the way health concepts are presented, but computers do not.

In order for computers to understand the difference between Unstable Angina and Uterine

Atony (and similarly, understand the same meaning of Angina, Unstable and Unstable Angina), a

reference set of terminologies should be used.

ICD

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ICD-10

For diseases, the most commonly used terminology standard is the International Classification

of Diseases, or ICD. The International Classification of Diseases (ICD) is the World Health

Organization’s (WHO) “standard diagnostic tool for epidemiology, health management and

clinical purposes. ICD is designed as a health care classification system, including a system of

diagnostic codes for classifying diseases, symptoms, abnormal findings, complaints, social

circumstances, and external causes of injury or disease.

ICD-9 code are 3-5 digits. The first digit is either numeric or alpha (the letters E or V only) and all

other digits are numeric.



Under ICD-10, diseases and other conditions are classified into major categories of similar

disease or conditions. Each element is assigned an alpha numeric code of up to 7 characters.

ICD is published by WHO and adopted by many countries world-wide for the classification of

medical conditions, for billing and reimbursement, and decision support software. ICD

also serves to aggregate health information from varied sources around the world including the

collection, processing, classification and presentation of statistical data. The most commonly

seen use of ICD standards is the filling up of disease entries for insurance purposes. Insurance

companies use ICD to map the patient’s disease with their corresponding reimbursement rates.

Research is also done by determining the most common disease entities, resulting to

adjustment of reimbursement rates in an evidence-based manner.

ICD is currently in its 10th revision and is periodically revised by WHO. While many countries

have adopted ICD-10, some like the US are still primarily based on ICD-9 an older version. This is

because when ICD reached popularity in the United States, it was on the ninth edition. Hospitals

and clinics in the US were quick to adopt ICD-9 and eventually, data became populated with

ICD-9 codes.

When ICD-10 was introduced, the rest of the world has just begun to appreciate the value of

ICD, while the US has continued to populate their data with ICD-9 codes. Because of the huge

amount of data that the US hospitals and clinics have already entered in their databases, the

cost to migrate those codes into the 10th version became way too high. It was only in recent

years that the US hospitals and clinics were able to convert codes into the tenth version.

However, some hospitals and clinics decided to stick to the ninth version.

The biggest difference between these is that ICD-10 have many more codes available for subtle

differences in diagnosis. ICD-11 is planned for release in 2015.

WHO is currently in the process of revising ICD with the anticipation of releasing ICD-11 in 2015.

A beta version of this revision was made available in May of 2012. The development is taking

place as a collaboration of the members of WHO, somewhat similar to Wikipedia – but with



more structure and peer review process. The final draft will be approved by the World Health

Assembly, an arm of WHO.

ICD-11 will have definitions that give key descriptions in human readable terms - to guide users

through the coding process. This is an advancement over ICD-10, which had only title headings.

The Definitions have a standard structure according to a template with standard definition

templates and further features exemplified in a “Content Model”. The Content Model therefore

allows computerization (with links to ontologies and SNOMED CT (Links to an external site.)).

Each ICD entity can be seen from different dimensions or “parameters”. For example, there are

currently 13 defined main parameters in the Content Model (see below) to describe a category

in ICD.

1. ICD Entity Title - Fully Specified Name

2. Classification Properties - disease, disorder, injury, etc.

3. Textual Definitions - short standard description

4. Terms - synonyms, other inclusion and exclusions

5. Body System/Structure Description - anatomy and physiology

6. Temporal Properties - acute, chronic or other

7. Severity of Subtypes Properties - mild, moderate, severe, or other scales

8. Manifestation Properties - signs, symptoms

9. Causal Properties - etiology: infectious, external cause, etc.

10. Functioning Properties - impact on daily life: activities and participation

11. Specific Condition Properties - relates to pregnancy etc.

12. Treatment Properties - specific treatment considerations: e.g. resistance

13. Diagnostic Criteria - operational definitions for assessment

ICD exists in 41 Languages in electronic versions and its expression in multiple languages will be

systematically pursued in ICD11.

ICD-10 IN THE HOSPITAL SETTING

After knowing the historical and descriptive perspectives of ICD-10, it’s time to look into how it is

being used in the hospital. Consider Stan’s situation of being diagnosed with Unstable Angina.

http://en.wikipedia.org/wiki/SNOMED_CT



Most hospitals require ICD-10 codes in the filling up of disease information in insurance

reimbursement forms. The health professional in charge of filling the form, usually the

physician-in-charge, would have a nearby ICD-10 book, from which he will look for the ICD-10

code for unstable angina. The health professional would see the following terms in an ICD-10

(note: the section below has been adapted from the WHO ICD-10 online browser, located at

http://apps.who.int/classifications/icd10/browse/2010/en#/I20.0 (Links to an external site.)):

Ischaemic heart diseases

(I20-I25)

Note:

For morbidity, duration as used in categories I21, I22,I24 and I25 refer to the interval elapsing between

onset of the ischaemic episode and admission to care. For mortality, duration refers to the interval

elapsing between onset and death.

Incl.:

with mention of hypertension (I10-I15 (Links to an external site.))

Use additional code, if desired, to identify presence of hypertension.

I20Angina pectoris

I20.0Unstable angina

Angina:

crescendo

de novo effort

worsening effort

Intermediate coronary syndrome

Preinfarction syndrome

I20.1Angina pectoris with documented spasm

Angina:

angiospastic

Prinzmetal

http://apps.who.int/classifications/icd10/browse/2010/en#/I20.0 (Links to an external site.)http://apps.who.int/classifications/icd10/browse/2010/en#/I10



spasm-induced

variant

I20.8Other forms of angina pectoris

Angina of effort

Stenocardia

I20.9Angina pectoris, unspecified

Angina:

NOS

cardiac

Anginal syndrome

Ischaemic chest pain

The health professional would copy the code I20.0 to the field in the reimbursement form that

asks for ICD-10 code. Should Stan have more than one disease, the health professional would

look for the codes of those diseases and encode them appropriately following the I20.0 input.

It is worth noting, however, that some insurance companies would consider the first code as the

primary diagnosis of the patient, hence would be the major basis of reimbursement. Thus, it is

important to determine what the primary problem of the patient is, otherwise the patient’s

reimbursement may get affected.

Other uses of the ICD-10 would be for entry of causes of disease in death certificate forms. This

information creates value when aggregation is done by the ministry of health, and later on

publish aggregated health statistics in the country, state, or municipality. Aggregated health

information is a statistically-sound evidence that decision makers can use to direct health

programs that they implement. Without standards such as ICD-10, all decisions by key leaders

are done on basis of presumptions only, and that can be dangerous in a community.

INFORMATICS SOLUTIONS FOR ICD-10



ICD-10 is itself a solution to the huge disorganized dataset of clinical information. However,

advances in information and communications technology provide users with tools that aid in

the use of ICD-10 codes for patient diseases.

WHO ICD-10 browser

WHO ICD-10 browser can be accessed

at http://apps.who.int/classifications/icd10/browse/2010/en#/ (Links to an external site.)

Figure 1: World Health Organization ICD-10 online browser

The World Health Organization provides a comprehensive tool to search for diseases and their

corresponding ICD-10 codes. In this manner, instead of looking for a code in a book (or even

yet, waiting in line to have a chance to use the ICD-10 book), one may opt to access the ICD-10

browser online and type the desired diagnosis on the search field.

http://apps.who.int/classifications/icd10/browse/2010/en#/ (Links to an external site.)



Figure 2: ICD-10 search result for Unstable Angina

ICD 10 mobile application

ICD 10 codes also exist in a mobile app format, enabling users to have access to ICD-10 codes

even without a stable Internet connection. In the example below, a simplified ICD-10 code

search interface is seen, where a user can browse through the ICD-10 codes, or find a code

through a search function. Note that the application shown below runs on an Android mobile

operating system, but there are versions also that run on Apple IOS and other mobile OS. There

are also apps that come free of charge, as the one seen below, and those that can be purchased

for a minimal fee. The price differences are accounted for by the different functionalities

available in the different applications, although for the most parts, the free apps would satisfy

the browse and search needs.



Figure 3: Diseases Codes ICD-10 by Trofo systems

Integrated ICD-10 browser in an Electronic Health Record

Computerized hospital information systems provide, as part of their service, a mechanism to

search for ICD-10 codes from within the computer terminals that access the information

system. Some information systems would have a separate application that they would have to

launch in order to browse the codes. These applications support the “Copy” feature and enable

users to paste the codes to the information system that they are using.

For more advanced information systems, the ICD-10 feature is inherently available and can be

well appreciated in the input of diagnosis. In HarmoniMD, for example, typing the diagnosis on

the field provided will automatically search for the diagnosis coupled with its ICD-10 code (see

Figure 4). The benefit of which, as compared to other methods of determining the ICD-10 code,

is that it eliminates the possibilities of errors resulting from wrong encoding of the disease into

the field provided.

Figure 4: Integrated ICD-10 search function in a cloud-based EHR HarmoniMD



HISTORICAL SYNOPSIS

ICD started out way back when computers have come out of existence. The first major attempt

at classifying disease was accomplished by Dr. Jacques Bertillon, a French physicians of the late

1800s in his treatise Bertillon Classification of Causes of Death, which was introduced at the

International Statistical Institute in Chicago in 1893. Subsequent updates included a synthesis of

German, English and Swiss medical classifications with a resulting 161 titles. The first

international conference to revise ICD as it came to be known was in 1900 with revisions

happening every 10 years thereafter. Until the release of ICD-6, most updates were minor in

nature. The most common versions of ICD that are being used today are ICD-9 and 10, the

details of which are described below.

ICD-9

At the 1975 meeting of WHO in Geneva, Switzerland, there was much debate about the

structure of ICD including the calls for more detail and the organization of conditions based on

the organs affected. Wikipedia reports: 'The final proposals presented to and accepted by the

Conference retained the basic structure of the ICD, although with much additional detail at the level

of the four digit subcategories, and some optional five digit subdivisions. For the benefit of users not

requiring such detail, care was taken to ensure that the categories at the three digit level were

appropriate. For the benefit of users wishing to produce statistics and indexes oriented towards

medical care, the Ninth Revision included an optional alternative method of classifying diagnostic

statements, including information about both an underlying general disease and a manifestation in a

particular organ or site. This system became known as the dagger and asterisk system and is retained

in the Tenth Revision.'

ICD-10

Work on ICD-10 started in 1983 and was approved in 1990 at the 43rd World Health Assembly

with the latest version coming into use starting in 1994. This classification allows for more than

155,000 different codes and added many new diagnosis and procedures, a significant

expansion of the 17,000 code available in ICD-9. Interestingly, most of the world adopted ICD-10

readily while the US remains mostly on ICD-9 with a proposed change over date of October 1,

2013.

ADVANTAGES AND SOLUTIONS

Advantages



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ICD has become an important tool for fast aggregation of health data coming from different

hospital and clinic data sets. Imagine if the ministry of health would have to tally each disease

entity and create statistical analysis from those tally sets, as compared to having a database

that can output real-time information about the current health situation in the country, or

specific regions, towns, and municipalities.

Another advantage of having ICD-10 is compatible health data for a much wider analysis of

community health. By using the same coding set as that of other countries, the global health

situation is assessed in a faster rate.

Limitations

ICD, whether its ninth or tenth edition, is limited only to classifying diseases discussed and

included in their respective versions. Because of the complexities of other systems, such as

dermatology, oncology, psychiatry, among others, only the common and general term

descriptions of diseases from the mentioned specialties are included. There are special versions

of the ICD which caters to further classification of diseases for psychiatry and oncology, while

there is a Dermlex standard for further details on dermatological diseases. Notwithstanding the

intricacies of the different subspecialties, ICD is enough to cover the most common diseases, as

well as less common ones but only to a certain degree of granularity.

There are likewise disease terms unique to countries which are not necessarily included in the

ICD. Certain diseases from countries like the Philippines, furthermore, have descriptions that

are needed to be included in the terminology, but are not necessarily included in the ICD.

Because of this, the Philippines has decided to produce an ICD-10 with Philippine modifications

that would directly address the need to further classify and organize information on certain

diseases like Tuberculosis.

As of this writing, the Philippine modifications are still being used in the country, and this

immediately causes possible conflicts. For one, ICD-10 Philippine codes cannot be compared to

international health data. More than that, incompatibilities may exist once ICD-11 is released.

Patients may have Philippine codes which may have a possible same ICD-11 code, consequently

affecting the management and could be detrimental to the health of the patient. It is important

that while the Philippine modification may address the problems today, it could pose a very

complex problem to solve in the future.

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International Statistical Classification of Diseases and ......The Definitions have a standard structure according to a template with standard definition templates and further features