ICD Revision: Future

Direction

Lori Moskal, CHIM

Prepared for The International Methodology Consortium for Coded Health Information

Vancouver November 2009

Presentation Overview

• WHO-FIC Network

• ICD -11 development

– Topic Advisory Groups

– Timelines (development & implementation)

– Canada’s role in ICD-11

WHO-FIC Network

• Collaborating centres work with WHO in development,

dissemination, maintenance and use of WHO Family of

International Classifications

• Canada is part of North American Collaborating Centre

(CIHI partners with Statistics Canada)

• Mission is to support national and international health

information systems, statistics and evidence

• Work is based on a Strategy and Work Plan, updated

annually

WHO-FIC Governance

• Work is progressed through committees and reference groups outside annual meeting

• Committees report at annual Network meeting with WHO HQ and regional offices

• Major decisions at meetings referred to WHO for endorsement

• Between annual meetings, Council acts as Exec group meets but defers major decisions to Network

Network Committees

• Executive council (planning committee)

• Implementation Committee

• Update and Revision Committee

• Education Committee

• Electronic Tools Committee

• Family Development Committee

WHO-FIC committees cont’d

• Committee work is focused mainly on the

International Statistical Classification of

Diseases and Related Health Problems (ICD)

and the International Classification of

Functioning, Disability and Health (ICF)

• Family Development Committee ensures that

classifications needed for each health parameter

and setting are identified (ICD-O, ICPC, ICHI)

Reference Groups

• Committees may have working groups

• Examples include:

– Mortality Reference Group

– Morbidity Reference Group

– Functioning and Disabilities Group

CIHI’s Contributions to WHO-FIC

• International Statistical Classification of Diseases and Related Health Problems (ICD-10)

– Update and Revision Committee

– Morbidity Reference Group

– Terminology Reference Group

– Electronic Tools Committee

• International Classification of Functioning, Disability and Health (ICF)

– Functioning and Disabilities Reference Group

– Implementation Committee

– Education committee

CIHI’s contribution to WHO-FIC

• International Classification of Interventions

(ICHI)

– Family Development Committee

– Currently WHO focus is on ICD-11

– Work on ICHI is dependent on availability of WHO-

FIC members

ICD-11WHO’s Mission: “To produce an international

disease classification that is ready for

electronic health records that will serve as a

standard for scientific comparability and

communication”

Construction of ICD-10: Revision Process in the 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

How do we go from Here to 21st Century?

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 health recordsenvironment.

• Link ICD logically to underpinning terminologies and ontologies (e.g. SNOMED,

GO, …)

• ICD Categories “defined” by "logical operational rules" on their associations and

details

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

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

• Ontology (philosophy)

– the Organization of Reality !!!

• Ontology (computer science) – the explicit – operational description

of the conceptualization of a domain:

• Concepts: entity and quality(properties and attributes)

• 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?

THE CONTENT MODELAny Category in ICD is represented by:

Descriptive characteristics

1. Type Disease, disorder, syndrome, injury, sign/symptom, external cause, reason for encounter;

2. Body System(s) (pathophysiology)

3. Body Part(s) (anatomical site)

4. Manifestation Attributes

a. Signs & Symptoms

b. Diagnostic Findings

5. Causal Properties (etiology)

a. Causal Mechanisms /Agents

b. Genomic characteristics

6. Temporal Properties

7. Severity and/or Extent

8. Functional Impact

9. Treatment

TITLE of ENTITY: Name of disease, disorder, or syndrome…1. Textual definition

2. Synonyms - Inclusion – Exclusion - Index terms

Maintenance attributes

A. Unique identifier

B. Subset, adaptation, and special

view flag1. Primary Care

2. Clinical Care

3. Research

4. Special indices (e.g. Public Health

Indices or Resource Groupings)

C. Hierarchical relationshipsparents and children in ICD structure

D. Mapping relationshipsLinkages to other systems like

SNOMED etc.

E. Other rules

Peer ReviewMin 3 reviews – 2 approvals

Managing EditorPostmaster

Life-cycle of a Proposal

RSG

Other

TAGs

Filter

TAG Review

i CAT• Open and collaborative process

– Users are empowered

• Emerging Models:

– Wikipedia

– Commons based production

– Hive-mind

– Wisdom of Crowds

– Ontology

• Wikipedia is freeform text

• Wikipedia is not formally edited by experts

• Wikipedia is about 3 million entries– Any topic

• > 100,000 wikipedians– "digital survival of the fittest"

• ICD has structured content

• ICD will be peer reviewed

– TAG editorial oversight

• ICD will be about 15 thousand

– Diseases, disorders…

• Between 5000 -50,000 contributors

Wikipedia vs. i CAT

i CAT: Possible Concerns

• Accuracy

– addition of incorrect information

• Reliability

• Relevance

• Validity

• Bias and inconsistencies

– Consensus over credentials ?

– undue weight given to popular views

• Vandalism

Tentative Timeline

• 2010 : Alpha version ( ICD 11 alpha draft) – +1 YR : Commentaries and consultations

• 2011 : Beta version & Field Trials Version– +2 YR : Field trials

• 2013 : Final version for public viewing

–2014 : WHA Approval

• 2015+ implementation

ICD Revision Governance

• A workable mix of open consensus building

– Open Transparent Participation Open Access

Expert guided editorial power

– Evidence Curation Scientific Evidence trumps Expert Opinion

Input verification

Aim at interoperability

– Field trials Practical use cases

ICD-11 development

• ICD-11 will have a similar code structure to ICD-

10 (i.e. alphanumeric structure)

• ICD-11 start-up list includes additions done in

national clinical modifications

• Topic Advisory Groups (TAG) made up of

internationally renowned physicians

• Each chapter of ICD will be assigned to a TAG

Topic Advisory Groups

• Planning and coordinating advisory body for

specific issues

• Advise WHO on constitution of working groups

and partners

• Advise in development of various drafts of topic

segments in line with overall production

timelines

• Encourage participation by peer reviewers

Review process of alpha draft

• Following TAG approval of concepts, draft will

be reviewed by classification experts

• Mortality and Morbidity classification experts will

provide review of respective use cases

• Primary care view of ICD-11 yet to be

determined

ICD-11 in Canada

• 2018 is the earliest possible date - implementation is

F/P/T decision

• Would not be implemented in Canada until French

translation available

• WHO preference is to avoid national clinical

modifications—need for an ICD-11-CA will be

determined later

• ICD-10 (and subsequently ICD-10-CA) will continue to

be updated until 2016 to minimize transition to ICD-11

Questions