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ICD11 Qualiity and Safety TAG 2013 (show)

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This is the ICD Revision Summary presentation made in Quality and Safety Topic Advisory Group meeting in New York, 2-3 April 2013.

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ICD11 Qualiity and Safety TAG 2013 (show)

  1. 1. WHO Quality and Safety Topic Advisory Group 6th Meeting, April 2-3th, 2013, New York, USA Second part of the story T. Bedirhan Üstün World Health Organization Classifications, Terminologies, Standards
  2. 2. 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)
  3. 3. 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
  4. 4. 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 %
  5. 5. Remaining Content Model Parameters• Sign Symptoms• Diagnostic Criteria• Laboratory Tests• Genetic Linkages• Treatment Properties
  6. 6. Information Notes1. ICD Revision Communication 10. Diagnosis Type2. ICD Revision Timelines 11.Main Condition3. TAG Allocation 12.Review Process4. Content Model 13.Mirror Coding5. Foundation Component and Linearizations 14.Modifiers and Qualifiers6. Legacy Linearizations 15.Field Trials7. Code Structure 16.Stability Analysis8. Multidimensional Coding 17.Multilingual ICD Platform9. Index 18.Dagger and Asterisk resolution 19.Multisystem Chapter
  7. 7. Information Notes under development20. Cross-cutting TAG Roles a. Mortality b. Morbidity c. Functioning d. Quality & Safety21. Post-Coordination Principles and Rules22. Residual Categories23. Common Ontology with SCT24. Coding Rules25. National Linearizations in ICD-1126. ICD-11 Definitions
  8. 8. 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 ?
  9. 9. ICD knowledge base• Coding Rules – Mortality – Morbidity• Explanation of classification – Pre-coordination – Post- Coordination• Multiple Coding – Cluster Style – Chain Style
  10. 10. 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
  11. 11. Primary CareFoundation: ICDcategories with Linearizations - Definitions, synonyms - Clinical descriptions Morbidity - Diagnostic criteria - Causal mechanism - Functional Properties Find Term MortalitySNOMED-CT,International Classification of Functioning, 11Disability and Health (ICF)…
  12. 12. Linerization requirements• Classical ICD – Mutually Exclusive MEJE priniciple – Jointly Exhaustive No double counting All categories will be in Residuals: Other (*.8) Unspecified (*.9) should be generated for each linearization
  13. 13. Building Linearizations• Multiple Parenting Allowed – Pneumonia • Lung Disease • Sometimes Infectious Disease• Permanence of meaning across different linearizations – Telescopic principle • Zoom in – zoom out
  14. 14. Morbidity111 Morbidity112 Morbidity121 Morbidity131 Morbidity132 Morbidity133 Morbidity211 Morbidity221 Morbidity222 Morbidity311 Morbidity312 Morbidity321 Morbidity341 Morbidity342 Morbidity351MORBIDITYInternational
  15. 15. PC – Low 1 PC – Low 2 PC – Low 3PRIMARY CARE Low Resource(Verbal Autopsy ?)
  16. 16. Mort/PCHigh 11 PC – Low 1 Mort/PCHigh 12 Mort/PCHigh 13 Mort/PCHigh 21 PC – Low 2 Mort/PCHigh 22 Mort/PCHigh 31 PC – Low 3 Mort/PCHigh 32 Mort/PCHigh 33 Mort/PCHigh 34 Mort/PCHigh 35PRIMARY CARE Low Resource PRIMARY CARE High Resource(Verbal Autopsy ?) MORTALITY
  17. 17. Morbidity111 Mort/PCHigh 11 Morbidity112 PC – Low 1 Mort/PCHigh 12 Morbidity121 Morbidity131 Mort/PCHigh 13 Morbidity132 Morbidity133 Mort/PCHigh 21 Morbidity211 PC – Low 2 Morbidity221 Mort/PCHigh 22 Morbidity222 Morbidity311 Mort/PCHigh 31 PC – Low 3 Morbidity312 Mort/PCHigh 32 Morbidity321 Mort/PCHigh 33 Morbidity341 Mort/PCHigh 34 Morbidity342 Mort/PCHigh 35 Morbidity351PRIMARY CARE Low Resource PRIMARY CARE High Resource MORBIDITY(Verbal Autopsy ?) MORTALITY International
  18. 18. Morbidity111 Mort/PCHigh 11 Morbidity112 PC – Low 1 Mort/PCHigh 12 Morbidity121 Morbidity131 Mort/PCHigh 13 Morbidity132 Morbidity133 Mort/PCHigh 21 Morbidity211 PC – Low 2 Morbidity221 Mort/PCHigh 22 Morbidity222 Morbidity311 Mort/PCHigh 31 PC – Low 3 Morbidity312 Mort/PCHigh 32 Morbidity321 Mort/PCHigh 33 Morbidity341 Mort/PCHigh 34 Morbidity342 Mort/PCHigh 35 Morbidity351PRIMARY CARE Low Resource PRIMARY CARE High Resource MORBIDITY Extensions(Verbal Autopsy ?) MORTALITY International National Linearizations Specialty - Research
  19. 19. ICD Organization• 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• Post- Coordination - extensions • Bicycle Accident • Hit • Role • Context • Activity
  20. 20. X – Chapter: Extension Codes Type 1 Type 2 Type 3Severity Main Condition (types) History ofTemporality Reason for Family History of(course of the condition) encounter/admissionTemporality Main Resource Condition Screening/Evaluation(Time in Life)Etiology Present on AdmissionAnatomic detail Provisional diagnosis Topology Specific Anatomic LocationHistopathology Diagnosis confirmed byBiological Indicators Rule out / DifferentialConsciousnessExternal Causes (detail)Injury Specific (detail)
  21. 21. Multiple Coding Equivalent ExpressionsCluster Style Chain / String Style– Code1* – Code1/Code2/Code3– Code2*– Code3*– ..– * CLUSTERING IND.
  22. 22. Multiple Coding Equivalent Expressions STEMI - posterior wall – confirmed by EKG Cluster Style Chain / String Style• JH6.1001 Myocardial Infarction with ST Elevation JH6.100/ XT0.???/ XD0.100• XT0.???1 Posterior wall of heart• XD0.1001 Diagnosis Confirmed by EKG• 1 CLUSTERING indicator.
  23. 23. Stability Analysis Objectives • 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.
  24. 24. Stability Analysis Types & Methodology• 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
  25. 25. Age-adjusted death rates fornephritis, nephrotic syndrome, and nephrosis: United States, 1968-2005
  26. 26. 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
  27. 27. ICHI• ICHI linkages – ICHI derived DRG list – ICHI Development Management Group
  28. 28. 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
  29. 29. 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
  30. 30. Initial Review1. Linearization Review2. Content Review
  31. 31. Linearization Review1. Mortality Linearization Review2. Morbidity Linearization Review3. Primary Care Linearization Review4. Mirror-Coding Review5. Quality & Safety TAG review
  32. 32. Linearization Review1. 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
  33. 33. Morbidity Linearization1. Review of Five or more character codes2. Results of the Stability Analysis3. Results of the resolution of Dagger- Asterisk resolution
  34. 34. 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)
  35. 35. 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  Content Review Units – Entire Linearization – Chapter – Chapter – Subchapter – Subchapter – Clusters – Clusters – Individual entities – Use Cases – Other groups of entities, as selected – Other structure groupings, as selected
  36. 36. Content Review1. 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
  37. 37. 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
  38. 38. Review Units1. Linearizations2. Chapters – Sub Chapters – Code clusters3. Single categories – Initial selection from: • Completed content • Hot Categories – with differential aspects in XMs. • Public Health Importance4. Set of Content Model parameters across multiple categories – e.g. Lab findings , genomics, etc.
  39. 39. Review SoftwareA. Process manager – Identify Review Units – Identify Reviewers – Send invitations • Letter • Review questions – Send reminders, if necessary – Compile results
  40. 40. 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.
  41. 41. 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)
  42. 42. Reviewers1. WHO search – From PUBMed, Google Scholar – WHO expert database2. TAG Nominations3. ICD-11 Web-site – Self-nomination4. Solicited Reviews – NGOs ( e.g. WONCA etc ) – Genetics institutions
  43. 43. 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 – Managing Editors acknowledged: – NGOs – RSG – Other Contributors – RSG-SEG – WHO-FIC Collaborating Centres – TAG – WHO Staff – TAG WGs
  44. 44. Incentives for Reviewers
  45. 45. Content Review – Schedule1st Wave 3rd Wave • GURM – Musculoskeletal • TM (Disorders) – Mental Health • Gastroenterology – Neurology – Rare Diseases • Nephrology – Circulatory • Hepato-pancreatobiliary 4th Wave2nd Wave – Dermatology • External Causes and Injuries – Hematology • Ophthalmology – Respiratory • Dentistry – Neoplasms • Rheumatology – Infectious Diseases • Endocrinology – Pediatrics
  46. 46. 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
  47. 47. 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?
  48. 48. 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
  49. 49. Core Studies• Study One: – Feasibility and Reliability for live Cases and Case Summaries coding with • ICD-10 an 11• Study Two: – Basic Questions
  50. 50. Inter-rater reliability• The Case information • live • medical record• Coded using ICD11 by at least two different people• Agreement rates measured
  51. 51. Bridge Coding• The Case information • live • medical record• Coded using • ICD10 • ICD11• Agreement rates measured
  52. 52. Basic QuestionsConsensus Conference ApproachEach field trial centre will conduct at least one consensus conference todiscuss the basic questions. The results of the consensus conferencewill be summarised in a report and forwarded to WHO Geneva.Individual Response ApproachResponses to the basic questions should be collected by each field trialcentre from multiple individuals who have expertise in the area of TMcoding. Each person should provide a written response to the basicquestions on the Response Form provided in the protocol. The field trialcentre will collect these responses and provide a summary using thesame format as for the Consensus Conference.
  53. 53. Field Trials Work Plans– Plan for field trials • Essential components • Additional components – Methodology – Timelines– Possible Participants– Data collection – Analysis - Publications
  54. 54. Transition Strategy ICD-10 ICD-11 ICD-975 79 90 13 15 ?? 4 23 ICD - 2016 ICD - 2018 ICD - 2019 ICD - 2017 2015
  55. 55. Roadmap during Beta Phase • TAG serving as an Editorial Board • Reviews • Organizing Field testing • Feasibility • Quality assurance • Reliability
  56. 56. ICD Revision "Genchi genbutsu"Learn about pines from the pine,and about bamboo from the bamboo.松は松に聞け、竹は竹に聞けDon’t followin 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 Basho 松尾芭蕉

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