ICD Revision and Primary Care Versions
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The document emphasizes the need for a simplified, computerized, and purpose-fit International Classification of Diseases (ICD-11), focusing on consistency across primary and specialty care while being easy to implement and teach. It discusses the evolution of ICD through history, proposes a shift towards digital platforms for classification, and highlights the importance of interoperability in health information systems. The document also addresses the significance of user-friendly and culturally adaptable primary care classifications to enhance health outcomes and data management.
ICD Revision and Primary Care Versions
- 1. Dr. T. Bedirhan Üstün World Health Organization Classifications, Terminologies, Standards WHO on ICD and Health Information
- 2. KEY MESSAGES: 1. ICD-11 should be simplified 2. ICD-11 should be computerized 3. ICD-11 should be fit for purpose 4. ICD-11 should be easy to teach, implement 5. ICD-11 should speak the same language in PC and Specialty All efforts on ICD-10 and ICD-11 should converge
- 4. Shepherding simple requirements 1. Count your sheep • How many born ? • How many dead ?
- 5. Reporting of Mortality in the World Source WHO 2014
- 6. Information Paradox 0 100000000 200000000 300000000 400000000 500000000 600000000 700000000 800000000 1 2 3 4 YLLs VR countries vs No VR Burden of Mortality
- 9. Carpet burnt
- 10. Shepherding simple requirements 1. Count your sheep • How many born ? • How many dead ? 2. Don’t cry wolf !
- 11. Genealogy of ICD 1664 350 years
- 12. ICD Revisions 139 161 179 189 205 214 200 954 965 1,040 1,164 8,173 1,967 14,473 1 10 100 1000 10000 100000 Farr/d'Espine Bertillon ICD1 ICD2 ICD3 ICD4 ICD5 ICD6 ICD7 ICD8 ICD9 ICD-9-M ICD10 ICD-10-M 1853 1893 1900 1909 1920 1929 1938 1948 1955 1968 1975 1979 1993 1993
- 13. Placing WHO Classifications in HIS & IT Population Health • Births • Deaths • Diseases • Disability • Risk factors e-Health Record Systems ICD ICF ICHI Classifications Linkages KRs Terminologies Clinical • Decision Support • Integration of care • Outcome Administration • Scheduling • Resources • Billing Reporting • Cost • Needs • Outcome
- 14. ICD-11 Revision Goals 1. 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
- 15. 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
- 16. 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
- 17. How do we go from Here to 21st Century?
- 18. 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 • …
- 19. Knowledge Representation the triad of things, thoughts and words (Ogden & Richards, 1923 ) APPLE TERM
- 20. 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 people among software agents between people and software – to reuse data - information – to introduce standards to allow interoperability What is Ontology?
- 21. • Open and Collaborative Platform • Web based • Like WIKI • But • by the Content Model • with • by the TAGs , and scientific peers
- 22. ICD11 βeta • http://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
- 23. 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.
- 24. 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
- 25. 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
- 30. Linearizations: PC short PC Intermediate JLMMS
- 31. Title Primary C. Joint Lin. Ophthalm. Cataract code code code Age-related cataract code code code Cortical age-related cataract other other code Nuclear age-related cataract other other code Cataracta brunescens other other code Nuclear sclerosis cataract other other code Capsular and Subcapsular age-related cataract other other code Capsular age-related cataract other other code Anterior subcapsular polar age-related cataract other other code Posterior subcapsular polar age-related cataract other other code Incipient age-related cataract other other code Coronary age-related cataract other code code Punctate age-related cataract other code code Water clefts other other code Advanced 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 code Morgagnian age-related cataract other other code Calcified age-related cataract other other code Combined forms of age-related cataract other other code DIGITAL ZOOMING
- 32. 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.
- 33. Inpatients Outpatients PHC - Recognized PHC - Attenders The Community Where Do People Seek Help ? 1 5 25 50 100
- 34. Data Collected But Not Used
- 35. 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
- 36. Halfdan Mahler WHO Director General. 1973-1988 ICD can only be a door stopper in Primary Care
- 37. PHC … RENEWAL … NEW WAYS 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.
- 38. ICD-10 PC
- 39. 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
- 41. 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 …
- 42. CLASSIFICATIONS … BUILDING BLOCKS OF HEALTH INFORMATION … EVALUATION: Do Classifications increase ... • … recognition ? • … diagnosis ? • … accuracy of diagnosis? • … treatment ? — prescription ? — compliance ? • … referral ? • … outcome ? • … patient satisfaction ?
- 43. 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.
- 44. Real Time Public Health Rule-based Aggregation @ Individual, Facility, Population levels Public Health, Epi & Surveillance Findings InterventionsEvents Clinical Information Reimbursement Resource Management
- 45. PHC … RENEWAL … NEW WAYS Every programme, project, partner has a separate M&E plan Every M&E plan focuses on indicators but not on the system for generating them Need for Integration
- 46. Clinical Use Case: Exploration of Cough Fever 386661006 COUGH 49727002 WET COUGH sputum 28743005 Hemoptisia Blood in Sputum 207069003 • X-ray : Tbc? • Culture 399208008 104184002 • Diagnosis: Tuberculosis 154283005 A 15.0 • Treatment: DOTs { 324453004 }
- 47. 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
- 48. Why is this Sooooo important ?
- 50. 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
- 51. Grade 3 hypertension Grade 2 hypertension Grade 1 hypertension High normal normal optimal 120 130 140 150 160 170 180 Systolic pressure Diastolicpressure 172 102 110 105 100 95 90 85 80 Knowledge Representation 51
- 52. 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.
- 53. 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)
- 54. • 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
- 55. Coding Tool
- 56. Coding Tool
- 57. Print Versions
- 58. Transcoding tables ICD-10 to ICD-11 in excel
- 59. 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
- 60. ICD Translation Tool: French
- 61. ICD Translation Tool: Japanese
- 62. ICD11 Translation Tool: Chinese
- 63. PHC … RENEWAL … NEW WAYS ICPC within WHO-FIC
- 65. What do we do with our “time” ?
- 66. Global Village … It takes a village… It takes the whole globe to share data