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State of the WHO Family of International Classifications -2015

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This is the last speech of Dr. Bedirhan Ustun on the WHO FIC. It is not a swan-song but a transition/handover speech to the WHO Community on the continuation of ICD and ICF work

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State of the WHO Family of International Classifications -2015

  1. 1. Dr. T. Bedirhan Üstün World Health Organization Classifications , Terminologies, Standards State of the WHO FIC 2015
  2. 2. History of Disease & Health in the World • 243 BC: plague in China • 800 s : smallpox in Japan • 1090s: dysentery in Palestine • 1340s: "Black Death" in Europe • 1830s: cholera worldwide • 1917–19: influenza worldwide • … • … • 1976-2015 Ebola
  3. 3. Genealogy of ICD  1664
  4. 4. William Farr to • Farr developed the first national vital statistics system as a instrument for epidemiologic studies. • to crafted a disease nosology usable by vital statisticians and epidemiologists led to the creation of the ICD • The structure of the ICD derives from Farr's 1860 proposal. 150 year later WHO shares the vision of Farr to implement it further in the digital health space
  5. 5. 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 1990 1993
  6. 6. Reporting of Mortality in the World
  7. 7. Information Paradox 0 100000000 200000000 300000000 400000000 500000000 600000000 700000000 800000000 1 2 3 4 YLLs VR countries vs No VR Burden of Mortality
  8. 8. Shepherding simple requirements 1. Count your sheep • How many born ? • How many dead ? 2. Don’t cry wolf !
  9. 9. Millenium Development Goals
  10. 10. 20 October: WORLD STATISTICS DAY 2015
  11. 11. 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
  12. 12. Finagle's Law of Information In other words there is always a gap between what you have, need or want
  13. 13. Health Information needs Health Informatics Computational Processing Knowledge INPUTS Analytical process OUTPUT • Mechanisms • Interventions • Policies • Statistics • Aggregation • Ontologies • Data • Information
  14. 14. GIGO: Garbage In Out ?
  15. 15. Can we build the Big Intelligence ?
  16. 16. Why is this Sooooo important ?
  17. 17. How do we optimize our health services E-he@lth Health Information Systems: Analog to Digital
  18. 18. Placing WHO Classifications in HIS & IT Population Health • Births • Deaths • Diseases • Disability • Risk factors e-Health Record Systems ICD ICF ICHI Classifications KRs Terminologies Clinical • Decision Support • Integration of care • Outcome Administration • Scheduling • Resources • Billing Reporting • Cost • Needs • Outcome
  19. 19. 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
  20. 20. Ontology (philosophy) the Organization of Reality  !!!  Ontology (computer science) – the explicit – operational description of the conceptualization of a domain • Entities • Atributes • Values • 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 “NOntology” ?
  21. 21. Knowledge Representation the triad of things, thoughts and words (Ogden & Richards, 1923 ) APPLE TERM
  22. 22. THE CONTENT MODEL Any Category in ICD is represented by: 1. ICD Concept Title 1.1. Fully Specified Name 2. Classification Properties 2.1. Parents 2.2 Type 2.3. Use and Linearization(s) 3. Textual Definition(s) 4. Terms 4.1. Base Index Terms 4.2. Inclusion Terms 4.3. Exclusions 5. Body Structure Description 5.1. Body System(s) 5.2. Body Part(s) [Anatomical Site(s)] 5.3. Morphological Properties 6. Manifestation Properties 6.1. Signs & Symptoms 6.2. Investigation findings 7. Causal Properties 7.1. Etiology Type 7.2. Causal Properties - Agents 7.3. Causal Properties - Causal Mechanisms 7.4. Genomic Linkages 7.5. Risk Factors 8. Temporal Properties 8.1. Age of Occurrence & Occurrence Frequency 8.2. Development Course/Stage 9. Severity of Subtypes Properties 10. Functioning Properties 10.1. Impact on Activities and Participation 10.2. Contextual factors 10.3. Body functions 11. Specific Condition Properties 11.1 Biological Sex 11.2. Life-Cycle Properties 12. Treatment Properties 13. Diagnostic Criteria
  23. 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 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)
  24. 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. 25. 36 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
  26. 26. • Open and Collaborative Platform • Web based • Like WIKIPEDIA • But • by the Content Model • with • by the TAGs , and scientific peers
  27. 27. 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
  28. 28. ICD-11 Features Internet Based Platform Content Model Multi Lingual Representations Definitions Input from all Stakeholders ‫لعربية‬ Arabic 官话 Chinese English English Français French Русский язык Russian Español Spanish Deutsch German Português Portuguese Field Trials for Use Cases Electronic Health Record Ready
  29. 29. Level Name Use Case Size Pre –Post Coordination 1 SHORT Linearization  Primary Care – Low Resource o {Short Mortality - Verbal Autopsy ?} ~ 1500 categories Pre- coordinated 2 Intermediate Linearization  Primary Care – High Resource ~ 3000 categories Pre- coordinated 3 Common Linearization  Joint Linearization for Mortality and Morbidity Statistics Volume I tabular list 15,000 categories Pre-coordinated (mortality) Pre + Post Coordinated (morbidity) 4 Extension Linearizations  National Linearizations  Specialty Linearizations > 15,000 categories Pre + Post Coordinated
  30. 30. Linearizations: Zoom-in Zoom-Out
  31. 31. Linearizations: PC short PC Intermediate JLMMS
  32. 32. Current Status • Frozen May 2015 … JLMMS • iCAT continues real time… BROWSER • Linearization errors < 274 (from 10K) • Duplicates < 269 (from 3K) • Definitions • Top level > 75 % ~ 10,000 definitions
  33. 33. • 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
  34. 34. Mapping Tool
  35. 35. Transcoding tables ICD-10 to ICD-11 in excel
  36. 36. Diff Files
  37. 37. Diff Files
  38. 38. ICD-10 ICD-11 correspondence • 3 character w/o ECI & Residuals • 930 Equivalent • 189 mapped to a larger entity in 11 • with post coordination many have equivalent maps • 6 not mapped 1125 TOTAL • 4 character • 3980 Equivalent • 1108 mapped to a larger entity in 11 • with post coordination many have equivalent maps • 4 not mapped • 5092 TOTAL
  39. 39. ICD-10 ICD-11 correspondence • 3 character w/o with ECI & Residuals • 930 1412 Equivalent • 189 615 mapped to a larger entity in 11 • with post coordination many have equivalent maps • 6 112 not mapped 1125 2249 TOTAL • 4 character • 3980 5262 Equivalent • 1108 3769 mapped to a larger entity in 11 • with post coordination many have equivalent maps • 4 43 not mapped • 5092 9074 TOTAL
  40. 40. ICD11 Coding Tool Poster C304
  41. 41. What can a ICD11 CODE represent? 1 2 3 4 Service Contacts Episode of Care Inpatient Community Residential Ambulatory 1 2 3 54 Course A B C D Illness A B
  42. 42. 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 Topology Specific Anatomic Location Provisional diagnosis Histopathology Diagnosis confirmed by Biological Indicators Rule out / Differential Consciousness External Causes (detail) Injury Specific (detail)
  43. 43. Defusing the exploding bicycle: 500 codes in pieces • 10 things to hit… • Pedestrian / cycle / motorbike / car / HGV / train / unpowered vehicle / a tree / other • 5 roles for the injured… • Driving / passenger / cyclist / getting in / other • 5 activities when injured… • resting / at work / sporting / at leisure / other • 2 contexts… • In traffic / not in traffic 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
  44. 44. • 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
  45. 45. POST COORDINATION MECHANISM • Extension codes are implemented in iCAT • Sanctioning tables are being generated • REQUIRED • ALLOWED • DISALLOWED • First target group is the REQUIRED a. ICD-10 categories which have equivalence with ICD11 STEM + X codes (around 1000 codes) b. other
  46. 46. Background 1: National Linearization(s) level 3 - JLMMS level 4 National Linearization(s) - Morbidity only ! - Mortality will use JLMMS Specialty Linearizations - Morbidity only - Research 64 3 4
  47. 47. Background 2: STEM CODES & Extension 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 Pre-coord. Post-coordination 1 - 3 / 4 5 – 6 STEM Code EXTENSION CODES ICD11 levels
  48. 48. Background 3: Sanctioning Tables 66 • 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: • Required (this set is essential for JLMMS – Morbidity) • Applicable • Non-applicable
  49. 49. • 2015 : Beta version for Review & Field Trials • +2 YR : Field trials • 2016 : Information Session at WHA • 2018 : Final version for WHA Approval • 2019+ implementation • Continuous Annual Cycles • ICD 2019 • ICD 2020 ICD-11 Timeline
  50. 50. Achievements • Good foundation – linearization mechanism • Joint Linearization for Mortality and Morbidity Statistics • Model for Multiple Linearizations ( Primary Care1, Others) • Model for retrofitting: ICD-10, ICD-10-CM or others… • Model for future updates and maintenance • Stability with ICD-10 with Transcoding and Crosswalk tables • Definitions • Content Model – allow semantic web properties • Quality Check mechanisms • Annotations for reasons for changes • Post-coordination Mechanism • Proposal Mechanism • Review Mechanism • Computerized Index • CODING TOOL • Multilingual Presentation: Computer-assisted crowd sourced Translations • SNOMED Linkages: • > 4000 New Codes
  51. 51. Still To Do… • Continue improvements… JLMMS vs Clinical • Finalization of key linearizations: JLMMS first • National linearizations - • Specialty linearizations – • Continuous Review Process • Improvement of INDEX • Continuation: RSG  URC • URIs - web services • Automated Coding Tools for Mortality ? • DRG groupers?
  52. 52. • 2015 : Beta version for Review & Field Trials • +2 YR : Field trials • 2016 : Information Session at WHA • 2018 : Final version for WHA Approval • 2019+ implementation • Continuous Annual Cycles • ICD 2019 • ICD 2020 ICD-11 Timeline
  53. 53. Transition Study • What does it take a Member State to make the transition to ICD-11? • Current implementation state • Users & Stakeholders: data generators, data users, implicated groups • Current applications: size, scope, costs- benefits • Health Information needs • How are the health data used? ICD data used? • Gaps? • Plans for future next 5-10-20 years • E-health development policy • Business Plan • Benefits, Costs, Risks
  54. 54. Beta • Comments • Proposals • Field Trials • Review Mechanism
  55. 55. ICD-10 B24 HIV disease B24 HIV disease ICF activity limitations performance restriction in: Moving around (d455.44) Washing (d510.33) Education (d830.44) … Almost fully functional moderate participation restriction in Higher education (d830.03)
  56. 56. Separate Classification of Disease and Disability + = case Diagnosis Disability => better formulation of caseness
  57. 57. Added Value of Disability Information Predictive power 13% 8% 19% 28% 100% 100% 150% 123% OR 1 OR 1 OR 1 OR 14 OR 4 OR 15 Functioning Information
  58. 58. Networking Networks: WHOFIC and WHODAR
  59. 59. Ruy Laurenti David Gray
  60. 60. Socrates says to Crito: “We owe a cock to Asclepius."
  61. 61. IEKYF RQMSI ADXUO KVKZC GUBJ • forbidden fruit • the object that fell on Isaac Newton in legend • Witch’s Apple … • the fruit of the tree of knowledge

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