Second part of the story

T. Bedirhan Üstün

World Health Organization Classifications, Terminologies, Standards

WHO Quality and Safety Topic Advisory Group6th Meeting, April 2-3th, 2013, New York, USA

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)

Overview• ICD-11 progress

– Current status – Vol II ICD knowledge base– Stability Analysis: ICD10 in 11

• QS-TAG work– ICD-11 Reviews – ICD-11 Field testing– Traditional Medicine QS issues

• ICHI

Current Status as of 20 March 2013

• Some Chapters need further work– Infectious Disease A– Neoplasms B,C– Sign & Symptoms R– External Causes and Injury– Z codes

• Other chapters’ structure reported to be complete

• Definitions > 50% – Top level > 70 %

Remaining Content Model Parameters

• Sign Symptoms

• Diagnostic Criteria

• Laboratory Tests• Genetic Linkages

• Treatment Properties

Information Notes

1. ICD Revision Communication

2. ICD Revision Timelines

3. TAG Allocation

4. Content Model

5. Foundation Component and Linearizations

6. Legacy Linearizations

7. Code Structure

8. Multidimensional Coding

9. Index

10.Diagnosis Type

11.Main Condition

12.Review Process

13.Mirror Coding

14.Modifiers and Qualifiers

15.Field Trials

16.Stability Analysis

17.Multilingual ICD Platform

18.Dagger and Asterisk resolution

19.Multisystem Chapter

Information Notes under development

20. Cross-cutting TAG Rolesa. Mortality

b. Morbidity

c. Functioning

d. Quality & Safety

21. Post-Coordination Principles and Rules

22. Residual Categories

23. Common Ontology with SCT

24. Coding Rules

25. National Linearizations in ICD-11

26. ICD-11 Definitions

Identifying Options for Main Diagnosis

• Diagnosis at the time of Admission (T1)• Diagnosis at the time of Discharge (T2)

• Identifying what happened in between:– Was a condition present on admission ?– Has a condition arisen in the meantime ?

• Is it derived from T2 - T1 ?• Is it recorded specifically ?

ICD knowledge base

• Coding Rules– Mortality– Morbidity

• Explanation of classification– Pre-coordination – Post- Coordination

• Multiple Coding– Cluster Style– Chain Style

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

11

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

Linerization requirements

• Classical ICD– Mutually Exclusive– Jointly Exhaustive

No double countingAll categories will be in

Residuals: Other (*.8) Unspecified (*.9)

should be generated for each linearization

MEJE priniciple

Building Linearizations

• Multiple Parenting Allowed– Pneumonia

• Lung Disease• Sometimes Infectious Disease

• Permanence of meaning across different linearizations– Telescopic principle

• Zoom in – zoom out

Morbidity111

Morbidity112

Morbidity121

Morbidity133

Morbidity131

Morbidity132

Morbidity221

Morbidity222

Morbidity211

Morbidity311

Morbidity312

Morbidity321

Morbidity341

Morbidity342

Morbidity351

MORBIDITYInternational

PC – Low 1

PC – Low 2

PC – Low 3

PRIMARY CARE Low Resource

(Verbal Autopsy ?)

Mort/PCHigh 11

Mort/PCHigh 12

Mort/PCHigh 13

Mort/PCHigh 21

Mort/PCHigh 22

Mort/PCHigh 31

Mort/PCHigh 33

Mort/PCHigh 34

Mort/PCHigh 32

Mort/PCHigh 35

PRIMARY CARE High Resource

PC – Low 1

PC – Low 2

PC – Low 3

PRIMARY CARE Low Resource

(Verbal Autopsy ?) MORTALITY

Mort/PCHigh 11

Mort/PCHigh 12

Mort/PCHigh 13

Mort/PCHigh 21

Mort/PCHigh 22

Mort/PCHigh 31

Mort/PCHigh 33

Mort/PCHigh 34

Mort/PCHigh 32

Mort/PCHigh 35

Morbidity111

Morbidity112

Morbidity121

Morbidity133

Morbidity131

Morbidity132

Morbidity221

Morbidity222

Morbidity211

Morbidity311

Morbidity312

Morbidity321

Morbidity341

Morbidity342

Morbidity351

PRIMARY CARE High Resource MORBIDITY

PC – Low 1

PC – Low 2

PC – Low 3

PRIMARY CARE Low Resource

(Verbal Autopsy ?) MORTALITY International

Mort/PCHigh 11

Mort/PCHigh 12

Mort/PCHigh 13

Mort/PCHigh 21

Mort/PCHigh 22

Mort/PCHigh 31

Mort/PCHigh 33

Mort/PCHigh 34

Mort/PCHigh 32

Mort/PCHigh 35

Morbidity111

Morbidity112

Morbidity121

Morbidity133

Morbidity131

Morbidity132

Morbidity221

Morbidity222

Morbidity211

Morbidity311

Morbidity312

Morbidity321

Morbidity341

Morbidity342

Morbidity351

PRIMARY CARE High Resource MORBIDITY

PC – Low 1

PC – Low 2

PC – Low 3

PRIMARY CARE Low Resource

(Verbal Autopsy ?) MORTALITY International National LinearizationsSpecialty - Research

Extensions

• 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

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)   

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 EKG

Cluster Style

• JH6.1001 Myocardial Infarction with ST Elevation

• XT0.???1 Posterior wall of heart

• XD0.1001 Diagnosis Confirmed by EKG

• 1 CLUSTERING indicator.

• Ensure a seamless transition between ICD-10 and ICD-11 – national – international levels

• CrossCutting TAGs review and confirm continuity between ICD-10 and ICD-11

• Represent knowledge gained from national clinical modifications in the revised ICD.

Stability Analysis

Objectives

• Mortality• Morbidity

– ICD-10-WHO with ICD-11-WHO– ICD-10&11-WHO with ICD-10-GM– ICD-10&11-WHO with ICD-10-AM– ICD-10&11-WHO with ICD-10-CM– ICD-10&11-WHO with ICD-10-CA

Stability Analysis

Types & Methodology

Age-adjusted death rates for nephritis, nephrotic syndrome, and nephrosis:

United States, 1968-2005

QS-TAG work agenda• Papers

– QS specific issues • Overview Paper :QS-TAG & ICD revision • PSI for ICD 10 and ICD 11

– broader morbidity related issues • coordinate with Mb-TAG

• Main Condition issue • Dx timing indicators • Number of Dx fields

• Field trials

ICHI

• ICHI linkages– ICHI derived DRG list– ICHI Development Management Group

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

Review Process

• The review process :– the content

• Definitions• Content model parameters

– The structure - of the linearization (s) • Mortality• Morbidity• Primary Care

• The reviewers: – scientific peers

Initial Review

1. Linearization Review

2. Content Review

Linearization Review

1. Mortality Linearization Review

2. Morbidity Linearization Review

3. Primary Care Linearization Review

4. Mirror-Coding Review

5. Quality & Safety TAG review

Linearization Review

1. Review Unit is the whole linearization in question– e.g. Four-character Codes in MORTALITY– Review the results of Stability Analysis– Mark-up in iCAT– Review restricted to the relevant TAG only

• e.g. M TAG for Mortality Linearization

Morbidity Linearization

1. Review of Five or more character codes

2. Results of the Stability Analysis

3. Results of the resolution of Dagger-Asterisk resolution

Primary Care Linearization(s)

• Expect to produce two different linearizations– Low resource PC linearization

• Fewer categories – large groupings

– High resource PC linearization• Frequent health conditions in PC with high

resources (same as Morbidity linearization in resolution, but representing only PC relevant cases)

Initial Review

• Initial Review of the current Beta draft:– Linearization Structure(s) (e.g. Mortality and Morbidity or Primary

Care)– Content

• Review Units: may include individual entities or groups of entities at any level, such as:

Structure Review Units– Entire Linearization– Chapter– Subchapter– Clusters– Use Cases– Other structure groupings, as selected

Content Review Units

– Chapter– Subchapter– Clusters– Individual entities– Other groups of entities, as selected

Content Review

1. Initial review:– Selected sections of ICD-11 where

• work has been completed

– specific review is needed– there is special interest

• Accuracy• Scientific quality• Completeness• Clinical or Public Health Utility

Content Review

• Proposal Generation Phase– When proposals are mature (decide how) – Submit to 5 reviewers – Obtain 3 complete reviews– Generate combined statement– Submit to TAG in a combined list– Implement results– Submit conflicts to RSG

Review Units

1. Linearizations

2. Chapters – Sub Chapters – Code clusters

3. Single categories– Initial selection from:

• Completed content• Hot Categories – with differential aspects in XMs.• Public Health Importance

4. Set of Content Model parameters across multiple categories– e.g. Lab findings , genomics, etc.

Review Software

A. Process manager– Identify Review Units– Identify Reviewers– Send invitations

• Letter• Review questions

– Send reminders, if necessary– Compile results

Reviewers

• Content Reviewers: Pool of specialist experts to review in their area of expertise, similar to quality assessment in peer-reviewed journals.

• Structure Reviewers: Morbidity TAG and Mortality TAG

• TAG and WG members :– will act as a scientific journal editorial board.– should NOT be nominated as reviewers.

Call for Reviewers

• WHO Requests all TAGs and WGs to provide nominations of reviewers for the next step in the Beta Phase.

•  Please send the following information to WHO (robinsonm@who.int) and copy the message to Bedirhan (ustunb@who.int) :– Name of the nominee– Email address– Area(s) of expertise (content they are qualified to review)– CV of the nominee (preferred)– Linked-In or other professional profile link (if available)

Reviewers

1. WHO search– From PUBMed, Google Scholar– WHO expert database

2. TAG Nominations

3. ICD-11 Web-site– Self-nomination

4. Solicited Reviews– NGOs ( e.g. WONCA etc ) – Genetics institutions

Contributor - Reviewer Acknowledgement

• WHO is currently creating a list to acknowledge all participants:

– ICD website– Print version of the ICD-11.

• Please include all with participant contact information.

The following individuals will be acknowledged:

– RSG– RSG-SEG– TAG– TAG WGs

– Managing Editors

– NGOs– Other Contributors – WHO-FIC Collaborating Centres– WHO Staff

Incentives for Reviewers

Content Review – Schedule

3rd Wave– Musculoskeletal– Mental Health– Neurology– Rare Diseases– Circulatory

4th Wave– Dermatology– Hematology– Respiratory– Neoplasms– Infectious Diseases– Pediatrics

1st Wave• GURM• TM (Disorders)• Gastroenterology• Nephrology• Hepato-pancreatobiliary

2nd Wave• External Causes and Injuries• Ophthalmology• Dentistry• Rheumatology• Endocrinology

ICD11 Field Trials

• Basic aims– To test the “fitness of ICD-11 for multiple purposes”

• Mortality coding• Morbidity coding• Quality & Safety • Other use cases

– To ensure the comparability between ICD-10 and ICD-11– To increase consistency, identify improvement paths, and reduce errors

.

• Key Assessments:

• Applicability – feasibility easy to use

• Reliability - consistency gives same results in the hands of all

• Utility - added value renders useful information

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

Core Studies

• Study One: – Feasibility and Reliability for live Cases and Case

Summaries coding with • ICD-10 an 11

• Study Two: – Basic Questions

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

Basic Questions

Consensus Conference ApproachEach field trial centre will conduct at least one consensus conference to discuss the basic questions. The results of the consensus conference will be summarised in a report and forwarded to WHO Geneva.

Individual Response ApproachResponses to the basic questions should be collected by each field trial centre from multiple individuals who have expertise in the area of TM coding. Each person should provide a written response to the basic questions on the Response Form provided in the protocol. The field trial centre will collect these responses and provide a summary using the same format as for the Consensus Conference.

– Plan for field trials• Essential components• Additional components

– Methodology– Timelines

– Possible Participants

– Data collection – Analysis - Publications

Field Trials Work Plans

Transition Strategy

75 79 90 13 15 ??

ICD-9 ICD-10 ICD-11

4 23

2015

ICD

- 2016

ICD

- 2017

ICD

- 2018

ICD

- 2019

• TAG serving as an Editorial Board• Reviews

• Organizing Field testing• Feasibility• Quality assurance• Reliability

Roadmap during Beta Phase

ICD Revision

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Don’t follow in the footsteps of the old poets, seek what they sought先人言葉に盲従せず、その考え方に学べ

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