ICD Revision has entered into the final phase. It will be submitted to the World Health Organization's governing bodies in 2018. What is the current situation? Peer Review - Field Test. Do we need additional detail for Internal Medicine?

1. World Health Organization Classifications, Terminologies, Standards
ICD Revision:
JLMMS Finalization
for REVIEW & Field Tests
WHAT DOES THIS MEAN for the IM TAG ?
2018

2. Overview
• ICD Revision: JLMMS Finalization
– JLMMS Task Force
– JLMMS Properties
– Coverage & Stability of ICD11 Beta 2015
• how dissimilar to ICD10 – ICD10 xMs
– Next Steps:
• Finishing the “JLMMS” – between now and Nov 2015
• Issues for IM TAG
• Peer Review
• Field Tests
• DO YOU NEED a SPECIALTY LINEARIZATION? ?

3. 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

4. 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.

5. 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

6. 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

10. 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

11. Linearizations:
Zoom-in Zoom-Out

12. Linearizations:
PC short PC Intermediate JLMMS

13. 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

14. Zooming Problems
• PC high + / JLMMS – 36 items
• PC low + / PC High – 16 items
• PC low + / JLMMS – 19 items
• PC high + / PC low – 1160 items

15. 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

16. 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

17. 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

18. Multiple Coding
Equivalent Expressions
Chain / String Style
JH6.100/ XT0.???/ XD0.100
STEMI - posterior wall – confirmed by EKG
Cluster Style
• JH6.1001 Myocardial Infarction
with ST Elevation
• XT0.???1 Posterior wall of heart
• XD0.1001 Diagnosis Confirmed
by EKG
• 1 CLUSTERING indicator.

19. 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

20. • 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

21. 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

22. Background 1:
National Linearization(s)
level 3
- JLMMS
level 4
National Linearization(s)
- Morbidity only !
- Mortality will use JLMMS
Specialty Linearizations
- Morbidity only
- Research
25
3 4

23. 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

24. Background 3:
Sanctioning Tables
27
• 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

25. National Linearizations
• Countries who adopt ICD-11
– Use “as is”: ICD WHO version: JLMMS
– 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
28

26. 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 ?)
• 1: nested 2: non-nested approaches are possible
• Both methods would use by post-coordination & sanctioning rules
• Specialty extension codes should be included in the Foundation
Component
29

27. 1. Should all be reported to WHO and included in the Foundation Component
2. Should not create duplicates to existing JLMMS codes –no violation of mutual
exclusivity
3. May vary from the extension codes ( i.e. severity, staging, types, substances, …)
4. should not be rolled up to “unspecified Z” in JLMMS
5. can be put in:
- Further to any JLMMS code
- “other specified Y” in JLMMS cluster
6. Any changes required for JLMMS hierarchy will have to be approved by WHO ( via RSG-
SEG / URC ).
7. Primary Parenting should comply with JLMMS
8. Cannot violate the sanctioning rules for JLMMS - Morbidity
Additional “NL /SL“ codes from ICD 11

28. National Linearizations
/ Specialty Linearizations
• May choose to pre-coordinate their
linearizations, or use post coordination
mechanism

29. National Linearizations
Specialty Linearizations
• Copyright and Intellectual Property Rights will be regulated by the Member
State (MS) and WHO in a standard way.
– Serve as an international public good
– Avoid misuse and unauthorized duplication
– Regulate commercial use
• Benefits to MS will be:
– the use of Foundation Component – infrastructure, services (software, URI, Translations…)
– Collective international input – scientific updates
– Updating mechanism
– Linkages to standard terminologies- SNOMED-CT, ICF, …

30. Mapping Tool

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

32. 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?

33. 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

34. 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?

35. 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

36. Inter-rater reliability
• The Case information
• live
• medical record
• Coded using ICD11 by at
least two different people
• Agreement rates
measured

37. Bridge Coding
• The Case information
• live
• medical record
• Coded using
• ICD10
• ICD11
• Agreement rates
measured

38. ICD-10
• Annual Revision
Conferences
• Focus on mortality
statistics
• Produced manually
• Produced in English
• NO field tests
• Update mechanism
built in later
ICD-11
• Continuous web platform
+ meetings
• Focus on ALL statistical
use cases
• Produced digitally
– w/ information model
• Multilingual development
• Field tests done before
• Continuous update –
revision mechanism

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