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ICD DevelopmentsHow can ICD-11 possibly help you enhancing your casemix ?
Dr. T. Bedirhan ÜstünWorld Health Organization
Classifications, Terminologies, Standards
How can ICD Revision enhance PCS ? • ICD follows current clinical thinking and scientific updates
• the clinical documentation will be accurately coded • meaningful patient information is captured.
• ICD is an opportunity to review and align the classification to: • current clinical thinking, morbidity and other use cases• PCS, Casemix, DRGs etc
• Computerization:• Deconstruction into data elements • Meta data
2018
What is wrong with ICD-10?• It is produced in 1990 – with 1980s scientific input• An update mechanism was built in 1998 and still functions but updates are restricted to system boundaries
• Digital representation is not up to todays IT needs• Classification logic, rules and applications contains errors and gaps
• Limited use:• in mortality in 110 countries• in morbidity beyond 30 countries
• Translations limited and not quality assured
• No OFFICIAL PRIMARY CARE VERSION
• National Modifications exist without international coordination• Specialty Adaptations exist without international coordination
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
Genealogy of ICD 1664
350years
ICD Revisions
139
161
179
189
205
214
200
954
965
1,04
0
1,16
4 8,17
3
1,96
7 14,4
73
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100000
Farr/
d'E
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ICD
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ICD
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ICD
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ICD
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ICD
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ICD
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ICD
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ICD
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ICD
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ICD
-9-M
ICD
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-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
KRs
Terminologies
Clinical• Decision Support• Integration of care• Outcome
Administration• Scheduling• Resources • Billing
Reporting• Cost• Needs• Outcome
How do we go from Here to 21st Century?
How do we optimize our health services
Health Systems & Information Systems:Analog to Digital
Ontology (philosophy)the Organization of Reality !!!
Ontology (computer science) – the explicit – operational description of the
conceptualization of a domain• Entities • Atributes • Values
• An ontology defines:– a common vocabulary – a shared understanding / exchange:
• among software agents• between people and software
– to reuse data - information– to introduce standards to allow
interoperability
among people
What is “NOntology” ?
iCAT• Open and Collaborative Platform
• Web based
• Like WIKIPEDIA• But
• by the Content Model • with
• by the TAGs , and scientific peers
iCATCollaborative Authoring Tool
for ICD Revisionstructured
Editorial Oversight
THE CONTENT MODELAny Category in ICD is represented by:
1. ICD Concept Title1.1. Fully Specified Name
2. Classification Properties2.1. Parents2.2 Type2.3. Use and Linearization(s)
3. Textual Definition(s)
4. Terms4.1. Base Index Terms4.2. Inclusion Terms4.3. Exclusions
5. Body Structure Description 5.1. Body System(s) 5.2. Body Part(s) [Anatomical Site(s)]5.3. Morphological Properties
6. Manifestation Properties6.1. Signs & Symptoms 6.2. Investigation findings
7. Causal Properties7.1. Etiology Type7.2. Causal Properties - Agents7.3. Causal Properties - Causal Mechanisms 7.4. Genomic Linkages7.5. Risk Factors
8. Temporal Properties8.1. Age of Occurrence & Occurrence Frequency8.2. Development Course/Stage
9. Severity of Subtypes Properties
10. Functioning Properties10.1. Impact on Activities and Participation10.2. Contextual factors10.3. Body functions
11. Specific Condition Properties11.1 Biological Sex11.2. Life-Cycle Properties
12. Treatment Properties
13. Diagnostic Criteria
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
What is available:• ICD-11 Beta version 2015 for review and field trials
• Maps between ICD versions 10 – and 11• For longitudinal data analysis• 10 DRGs: can they be re-built in 11?
• Can we build better DRGs using extra features in ICD11?
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
What is a Casemix System or DRGs ?
• a set of classes of patient treatment episodes
which are relatively homogenous in:
• clinical characteristics• resources used
• Used for: • Budgeting/Funding• Reimbursement /Paying the health care providers• Cost control• Quality control• Benchmarking
EfficiencyQualityBetter InformationBetter Decision-making
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
Level Name Use Case Size Pre –PostCoordination
1 SHORT Linearization
Primary Care – Low Resource
o {Short Mortality -Verbal Autopsy ?}
~ 1500 categories Pre-coordinated
2 Intermediate Linearization
Primary Care – High Resource
~ 3000 categories Pre-coordinated
3 Common Linearization
Joint Linearization for Mortality and Morbidity Statistics Volume I tabular list
15,000 categories Pre-coordinated(mortality)Pre + Post Coordinated (morbidity)
4 Extension Linearizations
National Linearizations Specialty Linearizations
> 15,000 categories
Pre + Post Coordinated
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
Current Status • Frozen May 2015 … JLMMS
• iCAT continues real time… BROWSER
• Linearization errors < 274 (from 10K) • Duplicates < 269 (from 3K)
• Definitions • Top level > 75 % ~ 10,000 definitions
What Can ICD11 offer systematically?
A systematic meaningful integrated system of clinical conditions (not only for DRGs … )
• Better clinical description• Better severity grading• Better coding of co-morbidity
• Inherent functional information (key ICF classes) • Integrated information system between ICD, ICF, ICHI
• Deconstructing Diagnosis into subgroups• Computerized information processing
• Mortality
• Morbidity• ICD-10-WHO with ICD-11-WHO• ICD-10&11-WHO with ICD-10-GM• ICD-10&11-WHO with ICD-10-CA• ICD-10&11-WHO with ICD-10-AM• ICD-10&11-WHO with ICD-10-CM
Stability AnalysisTypes & Methodology
Mapping Tool
Transcoding tables ICD-10 to ICD-11 in excel
Frozen Diff Files
Frozen Diff Files
ICD-10 ICD-11 correspondence• 3 character
w/o ECI & Residuals• 930 Equivalent• 189 mapped to a larger entity in 11
• with post coordination many have equivalent maps• 6 not mapped 1125 TOTAL
• 4 character• 3980 Equivalent• 1108 mapped to a larger entity in 11
• with post coordination many have equivalent maps• 4 not mapped• 5092 TOTAL
ICD-10 ICD-11 correspondence• 3 character
w/o with ECI & Residuals• 930 1412 Equivalent• 189 615 mapped to a larger entity in 11
• with post coordination many have equivalent maps• 6 112 not mapped 1125 2249 TOTAL
• 4 character• 3980 5262 Equivalent• 1108 3769 mapped to a larger entity in 11
• with post coordination many have equivalent maps• 4 43 not mapped• 5092 9074 TOTAL
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)
What can a ICD11 CODE represent?
1 2 3 4Service Contacts
Episode of Care
Inpatient Community Residential Ambulatory
1 2 3 54
CourseA
B
CD
IllnessA B
Multiple CodingEquivalent Expressions
Chain / String Style
JH6.100/ XT0.???/ XD0.100
STEMI - posterior wall – confirmed by EKGCluster Style
• JH6.1001 Myocardial Infarction with ST Elevation
• XT0.???1 Posterior wall of heart
• XD0.1001 Diagnosis Confirmed by EKG
• 1 CLUSTERING indicator.
Defusing the exploding bicycle:500 codes in pieces
• 10 things to hit…• Pedestrian / cycle / motorbike / car / HGV / train / unpowered vehicle / a tree / other
• 5 roles for the injured…• Driving / passenger / cyclist / getting in / other
• 5 activities when injured…• resting / at work / sporting / at leisure / other
• 2 contexts…• In traffic / not in traffic
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
• 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
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 EKGCluster Style
• JH6.1001 Myocardial Infarction with ST Elevation
• XT0.???1 Posterior wall of heart
• XD0.1001 Diagnosis Confirmed by EKG
• 1 CLUSTERING indicator.
POST COORDINATION MECHANISM• Extension codes are implemented in iCAT• Sanctioning tables are being generated
• REQUIRED• ALLOWED• DISALLOWED
• First target group is the REQUIREDa. ICD-10 categories which have equivalence with ICD11 STEM + X codes
(around 1000 codes) b. other
Background 1:
National Linearization(s)
level 3 - JLMMS
level 4National Linearization(s)- Morbidity only !- Mortality will use JLMMS
Specialty Linearizations- Morbidity only- Research 48
3 4
Background 2:STEM CODES & Extension codes
• Precoordinated ICD-11 codes are called STEM CODES
• STEM CODES give the basic classification tree structure
• Additional details are added to STEM CODES by EXTENSION CODES
Pre-coord. Post-coordination1 - 3 / 4 5 – 6
STEM Code
EXTENSION CODES
ICD11 levels
Background 3:Sanctioning Tables
50
• Not all extension codes could be used for a given STEM CODE
• Applicable extensions for a stem code will be specified in SANCTIONING TABLES
• Sanctioning tables will identify each relevant item as:• Required
(this set is essential for JLMMS – Morbidity)
• Applicable
• Non-applicable
• 2015 : Beta version for Review & Field Trials • +2 YR : Field trials
• 2016 : Information Session at WHA
• 2018 : Final version for WHA Approval• 2019+ implementation• Continuous Annual Cycles
• ICD 2019• ICD 2020
ICD-11 Timeline
Achievements• Good foundation – linearization mechanism
• Joint Linearization for Mortality and Morbidity Statistics• Model for Multiple Linearizations ( Primary Care1, Others)• Model for retrofitting: ICD-10, ICD-10-CM or others…• Model for future updates and maintenance
• Stability with ICD-10 with Transcoding and Crosswalk tables• Definitions• Content Model – allow semantic web properties• Quality Check mechanisms• Annotations for reasons for changes • Post-coordination Mechanism• Proposal Mechanism• Review Mechanism• Computerized Index• CODING TOOL• Multilingual Presentation: Computer-assisted crowd sourced Translations• SNOMED Linkages: • > 4000 New Codes
Still To Do…• Continue improvements… JLMMS vs Clinical • Finalization of key linearizations: JLMMS first
• National linearizations -• Specialty linearizations –
• Continuous Review Process• Improvement of INDEX• Continuation: RSG URC
• URIs - web services• Automated Coding Tools for Mortality ? • DRG groupers?
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
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
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
ICD-10 B24 HIV disease B24 HIV disease
ICF activity limitations performance restriction in:
Moving around (d455.44) Washing (d510.33) Education (d830.44)
…
Almost fully functional
moderate participation restriction in
Higher education (d830.03)
Separate Classification of Disease and Disability
+ = case
Diagnosis Disability => better formulation of caseness
Added Value of Disability InformationPredictive power
13%8%
19%28%
100%100%
150%123%
OR 1
OR 1
OR 1
OR 14
OR 4
OR 15
Functioning Information
62
FUTURE: AMA + WHO
+ = 2018
alpha
It is YOU who is going to build the WHO FIC
SNOMED : Old and Current
FormerSNOMED
Enterprise
College
American
Pathologists
Global
Network
Overall Health Care
Why work together?– WHO & IHTSDO
– Coverage & Adequacy– Quality – Reliability - Utility– MultiLingual Applicability– Interoperability– Sustainability
– Member States: Enable health care delivery and
compile health information
SNOMED & WHO Classifications are synergistic and not antagonistic
Myths to debunk• If you use SNOMED you don’t need ICD• ICD is for statistics only
The «Common Ontology» Purpose• To provide a common formal knowledge representation structure to
enable interoperability between:• ICD-11 and SNOMED CT. • a shared semantics
Ultimate “Turing-like” Test
?≡
If common ontology achieved
Cerebrovascular diseasehttp://mitel.dimi.uniud.it/whotools/mappingTools/mappet/
Grade 3 hypertension
Grade 2 hypertension
Grade 1 hypertension
High normal
normal
optimal
120 130 140 150 160 170 180
Systolic pressure
Dias
tolic
pre
ssur
e
172
102
110
105
100
95
90
85
80
Knowledge Representation
70
Rewriting ICD Using SNOMEDexample of Depressive Disorder F32.0
A. Low mood {41006004}
Loss of interest {417523004 }
Low energy {248274002}
1. Appetite (decrease, increase) {64379006, 72405004}
2. Body weight (decrease, increase) {89362005, 8943002}
3. Sleep (decrease, increase) {59050008, 77692006}
4. Psychomotor (decrease, increase) {398991009, 47295007}
5. Libido loss {8357008}
6. Low self esteem {286647002, 162220005}
7. Guilt, self blame {7571003}
8. Thoughts of death …
9. Suicide Ideation {102911000, 6471006}
B.
Beyond Semantic Interoperability for HIS
• Search using Concepts above Words• How many patients do have diabetes mellitus type II?
• Extraction of Concepts from Health Records• Automated extraction of Hb1Ac 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
Interoperability
