To code or Not to Code. Managing Health Information in the 21st Century Dr. T. Bedirhan stn Coordinator, Classifications, Terminologies, Standards. World Health Organization

To CODE or not to CODE

Plot: Health Information Management Context in the 21st Century Health care is a very high information-intensive sector Multidimensional: deaths, diseases, disability, risk factors, treatments, costs Complex: genes, patient care, population health Accurate information for life-long continuity of care Health information sources are fragmented: integration is needed Health care information is of vital importance Multipurpose: Patient Safety, Population health & well being Policy decisions: how to make invest money in health Health care information is worth a lot Most countries spend 5-15% of their GDP on their health care People value health care in political choices External demands IT sector, economics, governments, international regulations Multiple stakeholders are involved / a common language is needed Policymakers; Providers; Clients Health Information Systems & Standards need to be built jointly

Genealogy of HIMs 1664

100 10 1 1,967 14,473 100000 ICD-10-M ICD 10 ICD-9-M 1,164 ICD 9 200 ICD 5 1,040 214 ICD 4 ICD 8 205 ICD 3 965 189 ICD 2 ICD 7 179 ICD 1 ICD 6 161 Bertillon 8,173 10000 954 139 1000 Farr/d'Espine ICD Revisions 1853 1893 1900 1909 1920 1929 1938 1948 1955 1968 1975 1979 1993 1993 6

Health Information Management in the 21st Century The 21st century CHANGE Change 2000 10 last 10years > Change 1900 - 2000 last century Countries managers professions are not ready for this change

Why was transition to ICD-10 in the Wonderland delayed? Aint it broke, dont fix it! +Y2K + WHO developed ICD-9 in 1975 USA implemented ICD-9-CM in 1979 4 years WHO developed ICD-10 in 1990 USA will implement ICD-10-CM in 2013 23 years WHO will develop ICD-11 in 2015 USA will implement ICD-1(CM) in 20?? ?? years

Everything is linked Encoding software, Case mix systems, Medical record abstracting, Billing systems, Registration and scheduling systems, Accounting systems, Decision support systems, Clinical systems, Utilization management, Quality management, Case management, Clinical protocols, Test ordering systems, Clinical reminder systems, Performance measurement systems, Medical necessity software, Disease management systems Provider profiling systems

It is written on the WALL

ICD 9 -10 -11 Dancing in the USA ICD-10 ICD-9 75 79 4 ICD-11 13 90 ?? 15 23 ICD - 2019 ICD - 2018 ICD - 2017 ICD - 2016 2015

Why is this SOOOO important ?

Health Systems & Information Systems: Analog to Digital How do we optimize our health services

Health Professionals Coders Bridge-Coding Data Structures GEMS Codes Coding Guidelines Updates on Codes and Coding Guidelines Health Information Root Operations: Coder Training Manual Clinical Documentation Improvemen Assessments Computer Assisted Coding Summit Data Mapping in Electronic Health Records (online training) Turnkey Solutions for Enterprise-Wide ICD-10 Training Academy for ICD-10-CM/PCS seminars/webinars on ICD-10-CM/PCS CDI in Preparation for ICD-10-CM/PCS (on-line course) SNOMED-CT Mapping Modeling

AHIMA assets Knowledge Association Organization Network Potential Capacity Coding Health Information Management Quality Accuracy Timeliness Reproducable Complete Responsibility

I want to be a Health Information Manager Just like my Mom

Problems with ICD-10 1. Driven by mortality and billing use cases 2. Used in 117 out of 193 countries for official statistics 3. Limited web presence 4. Does not interoperate with electronic health records 5. "Frozen historical accidents" 6. Is just "a laundry list " no definitions 18

Key points on transitioning to ICD-10 1. ICD-9-CM is obsolete and the new version is ready for implementation 2. ICD-10 is needed to improve the quality of health information 3. ICD-10 is needed to support interoperable EHRs and a NHIN 4. ICD-10 is more precise and improves coding accuracy 5. The benefits of ICD-10 outweigh the costs.

Key points on transitioning to ICD-11 1. ICD-10-CM is obsolete and the new version is ready for implementation 2. ICD-11 is needed to improve the quality of health information 3. ICD-11 is needed to support interoperable EHRs and a NHIN 4. ICD-11 is more precise and improves coding accuracy 5. The benefits of ICD-11 outweigh the costs.

Health Information Standards ICD 1948 ICD-6 1990 ICD -10 2014 ICD-11 International Nomenclature Regulations All Member States agree to use WHO Classifications by treaty (1967) ICD -11 is being produced Joint Authoring Review Field testing Multiple Languages USE CASES BUSINESS Applications

WHO Classifications in HIS ICD ICF Knowledge Representations Mappings e-Health Record Systems ICHI Classifications Terminologies Population Health Clinical Births Deaths Diseases Disability Risk factors Administration Reporting Decision Support Scheduling Integration of care Resources Outcome Billing Cost Needs Outcome

Interoperability

SNOMED : Old and Current Former SNOMED Enterprise College Network American Global Pathologists 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

Rewriting ICD Using SNOMED example of Depressive Disorder F32.0 A. Low mood {41006004} Loss of interest {417523004 } Low energy {248274002} 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 B. 1. {102911000, 6471006}

Digital Models New business models e-bay e-trade New products e-health e-banking Existing products e-media (music/video) Existing business models

Sharing Ontologies: Knowledge Representation "One day I read a book and whole my life changed " Common sense/intuition Disciplined definitions Orhan Pamuk, Nobel Literature Laurate, 2006 SALT LAKER

What is NOntology ? 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 people among software agents between people and software to reuse data - information to introduce standards to allow interoperability

Computers are S T U P I D ? They cannot ask questions They may if you enable them - only give you answers. Pablo Picasso

Definition of Disease a set of dysfunction(s) in any of the body systems including: with a known pattern of signs, symptoms & findings symptomatology - manifestations probably with an underlying explanatory mechanism etiology a distinct pattern of development over time course and outcome a known pattern of response to interventions treatment response with linkage to underlying genetic factors genotypes, phenotypes and endophenotypes with linkage to interacting environmental factors

THE CONTENT MODEL Any Category in ICD is represented by: 1. ICD Concept Title 1.1. Fully Specified Name 2. Classification Properties 2.1. Parents 2.2 Type 2.3. Use and Linearization(s) 3. Terms 7.1. 7.2. 7.3. 7.4. 7.5. 8. 4.1. Base Index Terms 4.2. Inclusion Terms 4.3. Exclusions 5. Body Structure Description 5.1. Body System(s) 5.2. Body Part(s) [Anatomical Site(s)] 5.3. Morphological Properties 6. Manifestation Properties 6.1. Signs & Symptoms 6.2. Investigation findings Causal Properties Etiology Type Causal Properties - Agents Causal Properties - Causal Mechanisms Genomic Linkages Risk Factors Temporal Properties 8.1. Age of Occurrence & Occurrence Frequency 8.2. Development Course/Stage Textual Definition(s) 4. 7. 9. Severity of Subtypes Properties 10. Functioning Properties 10.1. Impact on Activities and Participation 10.2. Contextual factors 10.3. Body functions 11. Specific Condition Properties 11.1 Biological Sex 11.2. Life-Cycle Properties 12. Treatment Properties 33 13. Diagnostic Criteria

ICD11 Components 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) Primary Care Linearizations Morbidity Mortality 34

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)

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 The linearization is similar to the classical print version of ICD Tabular Lists (e.g. volume I of ICD-10 or other previous editions). Various linearizations could be built at different granularity, use case or other purposes such as for Primary Care, Clinical Care or Research. The linkage from the foundation component to a particular linearization will ensure consistent use of the ICD. The ICD Entities are represented in a content model which has 13

Search as you type

Browsing ICD Entities

Advanced Search

Linearizations

OpenID Logon

User Profile

Threaded Comments

Single Assessment Questions

Suggesting Definitions

Construction of ICD-10: Revision Process in 20th Century 8 Annual Revision Conferences (1982 - 89) 17 58 Countries participated 1- 5 person delegations mainly Health Statisticians Manual curation List exchange Index was done later "Decibel" ? Method of discussion Output: Paper Copy Work in English only Limited testing in the field

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

It is YOU who is going to build the ICD

What difference does it make? Coding cycling accident in ICD-10 V12.24 Pedal cyclist injured in collision with two- or threewheeled motor vehicle, unspecified pedal cyclist, nontraffic accident, while resting, sleeping, eating or engaging in other vital activities

The history of cycling codes 1972 ICD-9 (E826): 8 codes READ-2 (T30..): 81 codes READ-3: 87: 82 codes 1999 ICD-10: 587 codes

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

Conceptual Lego it could be... Goodbye to picking lists Structured Data Entry File Edit Help Cycling Accident What you hit Your Role Activity Location

AHIMA Tools for ICD-10 Implementation

asymmetry Information in HEALTH CARE From www.research.vt.edu/.../images/Asymmetry.jpg

Post Salt Lake City : WHO AHIMA collaboration ICD Revision Joint Authoring Review Field testing Multiple Languages USE CASES BUSINESS Applications Coding clinical information Classification Linkages with SNOMED Get the EHR right