ICD Revision: Quality Safety Meeting 2013 September 9-10

World Health Organization Classifications, Terminologies, Standards

ICD Revision: Where Are We?

Overview1. ICD-11 progress

– Current status of progress

– Vol II ICD knowledge base

– Review Process– Field Trials

2. Issues and Solution Plans

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Current Status:

• All input from Vertical TAGs received– Minor exceptions: sexual disorders, some GURM, Mental Health, Neurology…

• ICD 2013 Beta for Review

Mortality Linearization

Morbidity Linearization• Linearizations relatively stable

– constant updates– Together with Stability Analyses

» For review by mTAG and MbTAG» Q&S TAG – PS Indicators» fTAG – mirror codes

– Sept Review Process started– Sept Community Proposals started

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OutlineICD2013 Beta for Review

• Mortality Package: 1. Mortality Linearization

2. Mortality Stability Tables

3. Annotation Document

4. Other documentation ( Electronic/Print Index files; updated rules )

• Morbidity Package: 1. Morbidity Linearization

2. Morbidity Stability Tables

3. Annotation Document

4. Other documentation ( Electronic/Print Index files; updated rules )

• Other TAGs– Shoreline Documents for each chapter – Current Status for Definitions, Content Model and Residuals

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Critical Timelines

• Current Packages mTAG, MbTAG– Updates in September

• Webex or Live Meetings with vertical TAGs to resolve issues– August - September

• First review results of mTAG, MbTAG – in Beijing WHOFIC Annual Network Meeting October 2013– Discussion of future steps

• Scientific Peer Review of Vertical Chapters starting in September

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ICD 2013 BetaInfrastructure is ready for:

1. Linearization generation• Index Generation (Print + Electronic)• Post Coordination modeling + sanctioning tables

2. NEW PROPOSAL GENERATION • by public

3. REVIEW mechanism • by selected Scientific Peers

4. Multi-lingual presentation

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ShorelineBoundary between Pre- and Post-Coordination

– Mortality Linearization is always Pre-coordinated

– Morbidity Linearization is both Pre- and Post-Coordinated

Post-Coordination : uses X- R- and Other Chapters

» Specialty Linearizations may use:

» Post-Coordination and other extensions

General Rules for (Pre- and Post-) Coordination

• Items at ICD-10 three-character level would be pre-coordinated – unless there is compelling reason in the contrary

• Items at ICD-10 four character level and higher will be mostly post-coordinated – unless evidence or use case requirement indicate otherwise

Pre-coord. Pre- or Post-coordination Post-coordination

1 2 3 4 5 6

STEM Code

Mostly Post–coordination;Can be Pre-Coordinated depending on evidence

Post-coordination space (X, R, other chapters..) PRE COORDINATION by Exception

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ICD10 levels

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General criteria for determining pre-coordination

• What to keep in the “Mortality – Morbidity” Linearizations?

1. Legacy (esp. if used previously in Mortality linearization)

2. Scientific evidence

3. Consistency according to Taxonomical and ontological rules

4. Utility

a) Clinical – treatment grouping etc

b) Public Health - reportable disease etc

5. “Use Case specific”:

A. Frequency in practice setting for a given linearization

( e.g. Primary Care, Verbal Autopsy…)

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Digital Telescoping (Russian Dolls)

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Digital Telescoping (Russian Dolls)

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

MORBIDITY

PC – Low 1

PC – Low 2

PC – Low 3

PRIMARY CARE Low Resource

(Verbal Autopsy ?) MORTALITY National LinearizationsSpecialty - Research

Extensions 12

1 234

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Mortality Linearization

– Will include all ICD-10 entities have legacy for appropriate time series analysis:• Infant & Child Mortality• Maternal Mortality• General Mortality• Global Burden of Disease • Other major sources - e.g. Verbal Autopsy

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Mortality Linearization

• Mortality Linearization is a proper subset of Morbidity Linearization

• There should not be any items that are in the mortality and are not expressed in the morbidity linearization

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Mortality Linearization

• Mortality Linearization should only contain items relevant causes of death

• Each entity to be examined for its relevance in mortality statistics (internationally and nationally) – “Is it used?” – “What is the frequency among its parent category

and its children?”

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Mortality Linearization

ICD 2013 Beta Mortality Linearizationas of 29 August

• 1,039 categories at ICD10 3 Character-equivalent level

• 3,892 categories at all levels (up to 7 ICD-10 Character level)

Problems

1. Final Verification ongoing – Some 100 are not directly included out of a total of about

1000 codes either: • relevant part of major tabulations• frequent 95% of cases

– They need to be explained in stability analysis

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Morbidity Linearization(s)

• The main international reference for reporting and data exchange:– hospital discharge summaries – case mix groupings– reimbursement – …

• Morbidity Linearization– comprehensive enough – avoid unnecessary detail

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Morbidity Linearization(s)

1. International WHO Morbidity Linearization

2. National Morbidity Linearization(s)

3. Specialty Linearizations

STEM CODES• Precoordinated ICD-11 codes are called ‘STEM CODES’

• STEM CODES give the basic classification tree structure

• Additional details are added to STEM CODES by EXTENSION CODES

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Pre-coord. Pre- or Post-coordination Post-coordination1 - 4 5 6

STEM Code

Mostly Post–coordination;Can be Pre-Coordinated depending on evidence

Post-coordination space (X, R, other chapters..) PRE COORDINATION by Exception

ICD11 levels

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Sanctioning Tables

• Not all extension codes could be used for a given STEM CODE

• Applicable extensions for a stem code will be specified in SANCTIONING TABLES

• Sanctioning tables will identify each relevant item as:– Applicable– Required – Non-applicable

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National Linearizations• Countries who adopt ICD-11

– Use as is: ICD WHO version– May generate their own “National Linearizations”

• National Linearizations will require:– extension items are in the foundation component

(drawn from or if absent will be added to foundation)– Identify the mechanism of how they are linearized

• Foundation – National Linearizations:– provides an enhanced coordination mechanism – avoids non-standard development– ensures comparability

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Specialty Linearizations

• Further detail for specialty care could be done in two ways:

1. Extensions of the Morbidity Linearization

2. New groupings from the Foundation Component (Research Linearizations ?)

• Both methods would use by post-coordination & sanctioning rules

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

Stability Analysis

Types & Methodology

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

United States, 1968-2005

Overall Evaluation

+• Solid Digitalization

– iCAT– Browser– Proposal Mechanism– Linkage to SNOMED– URIs

• Engagement of Partners– TAGs

• Review Mechanism• Field Trials

- / ?• Project Management• Remaining Time • Communication

• Funding– Japan, EU, TM – PS

ICD-11 Timeline

• 2013 : Beta version & Field Trials Version – +2 YR : Field trials

• 2015 : Final version for WHA Approval– 2015+ implementation

ICD-11 Timeline

• WHA Adoption and Implementation dates are separate – Member States adopt ICD at their own

convenience – WHA adoption enables official use for

countries who wish to switch

Transition Strategy

75 79 90 14 15 ??

ICD-9 ICD-10 ICD-11

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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-11 administrative data use case:

• Quality - Patient Safety indicators • Case-mix groupings• Data – Meta data standards, documentation

• Diagnostic algorithms • Chart-Database comparison studies• "True" gold standards• International Morbidity comparisons• …

ICD Revision use cases

Advanced computerised safety systems:

– Identification of common patterns in safety-relevant events.

– New tools for prediction, detection and monitoring of adverse

events and other relevant information.

– Use ICD in innovative data mining and integration techniques of

existing databases and specific applications

• like electronic health record systems,

• decision support systems,

• adverse event reporting systems.

– Include validation leading to quantitative benefits.

Issues

• Is the remaining time sufficient for 2015– Translations No– Implementation Preparation No– Proper wide scale testing No– Completing Reviews Yes– Producing a better usable ICD Yes

ICD-11 Timeline

• 2015 : Final version for WHA Approval– 2015+ implementation

• 2016 : WHA Approval– More time for Review and FT

• 2017 : WHA Approval– More time for Review , Field Trial and

Translations

ICD-11

• International Public Good– Openly Accessible– Free for WHO Member States

• Available in multiple formats:– Printed Book editions– Internet-edition – Various computerized tools