Dr. T. Bedirhan ÜstünCoordinator, Classifications, Terminologies, Standards.

World Health Organization

To code or

Not to Code….Managing Health Information in the 21st Century

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

6

ICD Revisions13

9

161

179

189

205

214

200

954

965

1,04

0

1,16

4 8,17

3

1,96

7 14,4

73

1

10

100

1000

10000

100000

Farr/

d'E

spin

e

Berti

llon

ICD

1

ICD

2

ICD

3

ICD

4

ICD

5

ICD

6

ICD

7

ICD

8

ICD

9

ICD

-9-M

ICD

10

ICD

-10-

M

1853 1893 1900 1909 1920 1929 1938 1948 1955 1968 1975 1979 1993 1993

Health Information Management in the 21st Century

• The 21st century ≡ CHANGE

• Change 2000 – 10 > Change 1900 - 2000

last 10years last century

Countries managers professions are not ready for this change

Why was transition to ICD-10 in the Wonderland delayed?

“Ain’t it broke, don’t fix it!” +Y2K +…

• WHO developed ICD-9 in 1975 • USA implemented ICD-9-CM in 1979

• WHO developed ICD-10 in 1990• USA will implement ICD-10-CM in 2013

• WHO will develop ICD-11 in 2015• USA will implement ICD-1(CM) in 20??

4 years

23 years

?? 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 Dancingin the USA

75 79 90 13 15 ??

ICD-9 ICD-10 ICD-11

4 23

2015

ICD

- 2016

ICD

- 2017

ICD

- 2018

ICD

- 2019

Why is this SOOOO important ?

How do we optimize

our health services

Health Systems & Information Systems:Analog to Digital

Health Information

Health Professionals 

Academy for ICD-10-CM/PCS

seminars/webinars on ICD-10-CM/PCS

CDI in Preparation for ICD-10-CM/PCS (on-line course)

Coders

Clinical Documentation Improvement

Computer Assisted Coding Summit

Turnkey Solutions for Enterprise-Wide ICD-10 Training

Data Mapping in Electronic Health Records (online training)

Data Structures Bridge-CodingGEMS

Updates on Codes and Coding GuidelinesCodes Coding Guidelines

Assessments

Coder Training Manual

Root Operations:

SNOMED-CT®

Mapping

Modeling

AHIMA assets

• Knowledge • Association – Organization – Network • Potential – Capacity

Coding Health Information Management - Quality

AccuracyTimeliness ReproducableComplete

Responsibility

I want to be a

Health Information Manager

Just like my Mom…

18

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

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

Population Health• Births • Deaths • Diseases• Disability • Risk factors

e-Health RecordSystems

ICD ICF

ICHI

Classifications

KnowledgeRepresentations

Mappings

Terminologies

Clinical• Decision Support• Integration of care• Outcome

Administration• Scheduling• Resources • Billing

Reporting• Cost• Needs• Outcome

Interoperability

SNOMED : Old and Current

FormerSNOMED

Enterprise

CollegeAmericanPathologists

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

Rewriting ICD Using SNOMEDexample of Depressive Disorder F32.0A. 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.

Digital Models New business models

Existing business models

New products

Existing products

e-bay e-trade

e-banking e-media (music/video)

e-health

Sharing Ontologies: Knowledge RepresentationCommon sense/intuition Disciplined definitions

"One day I read a book and whole my life changed "Orhan Pamuk, Nobel Literature Laurate, 2006

SALT LAKER

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

What is “NOntology” ?

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 Diseasea 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

33

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 Components

34

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

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 predefined parameters. The information filled in by ICD authors is visible in the alpha browser.

 

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 three-wheeled motor vehicle, unspecified pedal cyclist, non-traffic 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 EntryFile Edit Help

What you hit

Your Role

Activity

Location

Cycling Accident

 AHIMA Tools for ICD-10 Implementation

From www.research.vt.edu/.../images/Asymmetry.jpg

Information asymmetry in HEALTH CARE

• ICD Revision• Joint Authoring• Review• Field testing• Multiple Languages• USE CASES

• BUSINESS Applications • Coding clinical information• Classification Linkages with SNOMED• Get the EHR right

Post Salt Lake City : WHO AHIMA collaboration