icd revision and primary care versions
TRANSCRIPT
Dr. T. Bedirhan ÜstünWorld Health Organization
Classifications, Terminologies, Standards
WHO on ICD and Health Information
KEY MESSAGES:1. ICD-11 should be simplified 2. ICD-11 should be computerized 3. ICD-11 should be fit for purpose4. ICD-11 should be easy to teach, implement5. ICD-11 should speak the same language in PC and Specialty
All efforts on ICD-10 and ICD-11 should converge
SIMPLICITYIs theUltimateSophistication
Shepherdingsimple requirements
1. Count your sheep• How many born ? • How many dead ?
Reporting of Mortality in the World
Source WHO 2014
Information ParadoxInformation Paradox
0
100000000
200000000
300000000
400000000
500000000
600000000
700000000
800000000
1 2 3 4
YL
Ls
VR countries vs No VR
Burden of Mortality
Carpet burnt
Shepherdingsimple requirements
1. Count your sheep• How many born ? • How many dead ?
2. Don’t cry wolf !
Genealogy of ICD 1664
350years
ICD Revisions
139
161
179
189
205
214
200
954
965
1,0
40
1,1
64 8
,173
1,9
67 1
4,4
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100000
Farr
/d'E
spin
e
Bert
illo
n
ICD
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ICD
2
ICD
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ICD
4
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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ICD
-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
LinkagesKRs
Terminologies
Clinical• Decision Support• Integration of care• Outcome
Administration• Scheduling• Resources • Billing
Reporting• Cost• Needs• Outcome
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
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
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
How do we go from Here to 21st Century?
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• …
Knowledge Representationthe triad of
things, thoughts and words (Ogden & Richards, 1923 )
APPLETERM
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 peopleamong software agentsbetween people and software
– to reuse data - information– to introduce standards to allow
interoperability
What is Ontology?
iCAT• Open and Collaborative Platform
• Web based
• Like WIKI • But
• by the Content Model • with
• by the TAGs , and scientific peers
iCATCollaborative Authoring Tool
for ICD Revision
structured
Editorial Oversight
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
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
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
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
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.
Inpatients
Outpatients
PHC - Recognized
PHC - Attenders
The Community
Where Do People Seek Help ?
1
5
25
50
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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
Halfdan MahlerWHO Director General. 1973-1988
ICD can only be a door stopper in Primary Care
… RENEWAL … NEW WAYSPHC
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.
ICD-10 PCICD-10 PC
ICD-10 PC for Mental Health 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
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
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 …
… BUILDING BLOCKS OF HEALTH INFORMATION …
CLASSIFICATIONS
EVALUATION: Do Classifications increase ...EVALUATION: Do Classifications increase ...
• … recognition ?• … diagnosis ?• … accuracy of diagnosis? • … treatment ?
— prescription ?— compliance ?
• … referral ?• … outcome ?• … patient satisfaction ?
• … recognition ?• … diagnosis ?• … accuracy of diagnosis? • … treatment ?
— prescription ?— compliance ?
• … referral ?• … outcome ?• … patient satisfaction ?
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.
Real Time Public HealthRule-based Aggregation @ Individual, Facility, Population levels
Public Health, Epi & Surveillance
Findings InterventionsEvents
Clinical Information
ReimbursementResource Management
… RENEWAL … NEW WAYSPHC
Every programme,project, partnerhas a separate M&E plan
Every M&E planfocuses on indicatorsbut not on the systemfor generating them
Need for Integration Need for Integration
Clinical Use Case: Exploration of Cough
Fever
386661006
COUGH
49727002
WET COUGHsputum
28743005
Hemoptisia
Blood in Sputum
207069003
• X-ray : Tbc? • Culture
399208008
104184002
• Diagnosis: Tuberculosis 154283005A 15.0
• Treatment: DOTs { 324453004 }
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
Why is this Sooooo important ?
GIGO: Garbage In
Gold Out ?
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
Grade 3 hypertension
Grade 2 hypertension
Grade 1 hypertension
High normal
normal
optimal
120 130 140 150 160 170 180
Systolic pressure
Dia
stol
ic p
ress
ure
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Knowledge Representation
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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.
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)
• 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
Coding Tool
Coding Tool
Transcoding tables ICD-10 to ICD-11 in excel
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
ICD Translation Tool: French
ICD Translation Tool: Japanese
ICD11 Translation Tool: Chinese
… RENEWAL … NEW WAYSPHC
ICPC within WHO-FIC
Millenium Development Goals
What do we do with our “time” ?
Global Village … It takes a village…
It takes the whole globeto share data
