The presentation multiple code sets ( aka linearizations) that are used in ICD11 and its different use cases: Primary Care, Mortality statistics, Morbidity Statistics. Use for Primary Care should be simple short and user friendly. It should have incentives for the providers and compatible with ICD11 Joint Linearizations.

1. Dr. T. Bedirhan Üstün
World Health Organization
Classifications, Terminologies, Standards
WHO on
ICD and Health Information

2. KEY MESSAGES:
1. ICD-11 should be simplified
2. ICD-11 should be computerized
3. ICD-11 should be fit for purpose
4. ICD-11 should be easy to teach, implement
5. ICD-11 should speak the same language in PC and Specialty
 All efforts on ICD-10 and ICD-11 should
converge

3. SIMPLICITY
Is the
Ultimate
Sophistication

4. Shepherding
simple requirements
1. Count your sheep
• How many born ?
• How many dead ?

5. Reporting of Mortality in the World
Source WHO 2014

6. Information Paradox
0
100000000
200000000
300000000
400000000
500000000
600000000
700000000
800000000
1 2 3 4
YLLs
VR countries vs No VR
Burden of Mortality

9. Carpet burnt

10. Shepherding
simple requirements
1. Count your sheep
• How many born ?
• How many dead ?
2. Don’t cry wolf !

11. Genealogy of ICD  1664
350
years

12. ICD Revisions
139
161
179
189
205
214
200
954
965
1,040
1,164
8,173
1,967
14,473
1
10
100
1000
10000
100000
Farr/d'Espine
Bertillon
ICD1
ICD2
ICD3
ICD4
ICD5
ICD6
ICD7
ICD8
ICD9
ICD-9-M
ICD10
ICD-10-M
1853 1893 1900 1909 1920 1929 1938 1948 1955 1968 1975 1979 1993 1993

13. Placing WHO Classifications in HIS & IT
Population Health
• Births
• Deaths
• Diseases
• Disability
• Risk factors
e-Health Record
Systems
ICD
ICF
ICHI
Classifications
Linkages
KRs
Terminologies
Clinical
• Decision Support
• Integration of care
• Outcome
Administration
• Scheduling
• Resources
• Billing
Reporting
• Cost
• Needs
• Outcome

14. ICD-11 Revision Goals
1. 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

15. 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

16. 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

17. How do we go
from Here to 21st Century?

18. 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
• …

19. Knowledge Representation
the triad of
things, thoughts and words
(Ogden & Richards, 1923 )
APPLE
TERM

20. 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 people
among software agents
between people and software
– to reuse data - information
– to introduce standards to allow
interoperability
What is
Ontology?

21. • Open and Collaborative Platform
• Web based
• Like WIKI
• But
• by the Content Model
• with
• by the TAGs , and scientific peers

22. ICD11 βeta
• http://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

23. 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.

24. 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

25. 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

29. Linearizations:
Zoom-in Zoom-Out

30. Linearizations:
PC short PC Intermediate JLMMS

31. Title Primary C. Joint Lin. Ophthalm.
Cataract code code code
Age-related cataract code code code
Cortical age-related cataract other other code
Nuclear age-related cataract other other code
Cataracta brunescens other other code
Nuclear sclerosis cataract other other code
Capsular and Subcapsular age-related cataract other other code
Capsular age-related cataract other other code
Anterior subcapsular polar age-related cataract other other code
Posterior subcapsular polar age-related cataract other other code
Incipient age-related cataract other other code
Coronary age-related cataract other code code
Punctate age-related cataract other code code
Water clefts other other code
Advanced 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 code
Morgagnian age-related cataract other other code
Calcified age-related cataract other other code
Combined forms of age-related cataract other other code
DIGITAL ZOOMING

32. 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.

33. Inpatients
Outpatients
PHC - Recognized
PHC - Attenders
The Community
Where Do People Seek Help ?
1
5
25
50
100

34. Data Collected But Not Used

35. 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

36. Halfdan Mahler
WHO Director General. 1973-1988
ICD can only be a door stopper
in Primary Care

37. PHC … RENEWAL … NEW WAYS
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.

38. ICD-10 PC

39. 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

41. 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 …

42. CLASSIFICATIONS … BUILDING BLOCKS OF HEALTH INFORMATION …
EVALUATION:
Do Classifications increase ...
• … recognition ?
• … diagnosis ?
• … accuracy of diagnosis?
• … treatment ?
— prescription ?
— compliance ?
• … referral ?
• … outcome ?
• … patient satisfaction ?

43. 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.

44. Real Time Public Health
Rule-based Aggregation @ Individual, Facility, Population levels
Public Health,
Epi & Surveillance
Findings InterventionsEvents
Clinical Information
Reimbursement
Resource Management

45. PHC … RENEWAL … NEW WAYS
Every programme,
project, partner
has a separate
M&E plan
Every M&E plan
focuses on indicators
but not on the system
for generating them
Need for Integration

46. Clinical Use Case:
Exploration of Cough
Fever
386661006
COUGH
49727002
WET COUGH
sputum
28743005
Hemoptisia
Blood in Sputum
207069003
• X-ray : Tbc?
• Culture
399208008
104184002
• Diagnosis: Tuberculosis 154283005
A 15.0
• Treatment: DOTs { 324453004 }

47. 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

48. Why is this Sooooo important ?

49. GIGO:
Garbage In
Out ?

50. 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

51. Grade 3 hypertension
Grade 2 hypertension
Grade 1 hypertension
High normal
normal
optimal
120 130 140 150 160 170 180
Systolic pressure
Diastolicpressure
172
102
110
105
100
95
90
85
80
Knowledge Representation
51

52. 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.

53. 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)

54. • 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

55. Coding Tool

56. Coding Tool

57. Print Versions

58. Transcoding tables ICD-10 to ICD-11
in excel

59. 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

60. ICD Translation Tool: French

61. ICD Translation Tool: Japanese

62. ICD11 Translation Tool: Chinese

63. PHC … RENEWAL … NEW WAYS
ICPC within WHO-FIC

64. Millenium Development Goals

65. What do we do with our “time” ?

66. Global Village … It takes a village…
It takes
the whole globe
to share data

67. Questions & Answers
ustunb@who.int
@ustunb
bedirhan-ustun