How can ICD-11 possibly help you enhancing your casemix ? What Can ICD11 offer systematically? A systematic meaningful integrated system of clinical conditions - (not only for DRGs … ) Better clinical description Better severity grading Better coding of co-morbidity Inherent functional information (key ICF classes) Integrated information system between ICD, ICF, ICHI Deconstructing Diagnosis into subgroups Computerized information processing

1. ICD Developments
How can ICD-11 possibly help you enhancing your casemix ?
Dr. T. Bedirhan Üstün
World Health Organization
Classifications, Terminologies, Standards

2. How can ICD Revision enhance PCS ?
• ICD follows current clinical thinking and scientific updates
• the clinical documentation will be accurately coded
• meaningful patient information is captured.
• ICD is an opportunity to review and align the classification to:
• current clinical thinking, morbidity and other use cases
• PCS, Casemix, DRGs etc
• Computerization:
• Deconstruction into data elements
• Meta data
2018

3. What is wrong with ICD-10?
• It is produced in 1990 – with 1980s scientific input
• An update mechanism was built in 1998 and still functions but updates are restricted to system
boundaries
• Digital representation is not up to todays IT needs
• Classification logic, rules and applications contains errors and gaps
• Limited use:
• in mortality in 110 countries
• in morbidity beyond 30 countries
• Translations limited and not quality assured
• No OFFICIAL PRIMARY CARE VERSION
• National Modifications exist without international coordination
• Specialty Adaptations exist without international coordination

4. 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

5. Genealogy of ICD  1664
350
years

6. 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

7. 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

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

9. How do we
optimize our
health
services
Health Systems & Information Systems:
Analog to Digital

10. 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 software agents
• between people and software
– to reuse data - information
– to introduce standards to allow
interoperability
 among people
What is “NOntology” ?

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

12. 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

13. 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

14. What is available:
• ICD-11 Beta version 2015 for review and field trials
• Maps between ICD versions 10 – and 11
• For longitudinal data analysis
• 10 DRGs: can they be re-built in 11?
• Can we build better DRGs using extra features in ICD11?

15. 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.

16. 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

17. What is a Casemix System
or DRGs ?
• a set of classes of patient treatment episodes
which are relatively homogenous in:
• clinical characteristics
• resources used
• Used for:
• Budgeting/Funding
• Reimbursement /Paying the health care providers
• Cost control
• Quality control
• Benchmarking
Efficiency
Quality
Better Information
Better Decision-making

18. 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

22. 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

23. Linearizations:
Zoom-in Zoom-Out

24. Linearizations:
PC short PC Intermediate JLMMS

25. 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

26. 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

27. What Can ICD11 offer systematically?
A systematic meaningful integrated system of clinical conditions
(not only for DRGs … )
• Better clinical description
• Better severity grading
• Better coding of co-morbidity
• Inherent functional information (key ICF classes)
• Integrated information system between ICD, ICF, ICHI
• Deconstructing Diagnosis into subgroups
• Computerized information processing

28. • 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

29. Mapping Tool

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

31. Diff Files

32. Diff Files

33. 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

34. 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

35. 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)

36. 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

37. 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.

39. 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

40. • 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

42. Multiple Coding
Equivalent Expressions
Cluster Style
• Code1*
• Code2*
• Code3*
• ..
• * CLUSTERING IND.
Chain / String Style
• Code1/Code2/Code3

43. 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.

44. 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

45. Background 1:
National Linearization(s)
level 3
- JLMMS
level 4
National Linearization(s)
- Morbidity only !
- Mortality will use JLMMS
Specialty Linearizations
- Morbidity only
- Research 48
3 4

46. 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

47. Background 3:
Sanctioning Tables
50
• 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

48. • 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

49. 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

50. 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?

51. 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

52. 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?

53. 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

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

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

56. 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)

57. Separate Classification of
Disease and Disability
+ = case
Diagnosis Disability => better
formulation
of caseness

58. 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

59. FUTURE: AMA + WHO
+ =
62
2018
alpha

60. It is YOU
who is going to build the WHO FIC

61. SNOMED : Old and Current
Former
SNOMED
Enterprise
College
American
Pathologists
Global
Network
Overall Health Care

62. Why work together?
– WHO & IHTSDO
– Coverage & Adequacy
– Quality – Reliability - Utility
– MultiLingual Applicability
– Interoperability
– Sustainability
– Member States:
Enable health care delivery and
compile health information
SNOMED & WHO Classifications
are synergistic and not antagonistic

63. Myths to debunk
• If you use SNOMED you don’t need ICD
• ICD is for statistics only

64. The «Common Ontology»
Purpose
• To provide a common formal knowledge representation structure to
enable interoperability between:
• ICD-11 and SNOMED CT.
• a shared semantics

65. Ultimate “Turing-like” Test
If common ontology
achieved

66. Cerebrovascular disease
http://mitel.dimi.uniud.it/whotools/mappingTools/mappet/

67. 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
70

68. Rewriting ICD Using SNOMED
example of Depressive Disorder F32.0
A. Low mood {41006004}
Loss of interest {417523004 }
Low energy {248274002}
1. Appetite (decrease, increase) {64379006, 72405004}
2. Body weight (decrease, increase) {89362005, 8943002}
3. Sleep (decrease, increase) {59050008, 77692006}
4. Psychomotor (decrease, increase) {398991009, 47295007}
5. Libido loss {8357008}
6. Low self esteem {286647002, 162220005}
7. Guilt, self blame {7571003}
8. Thoughts of death …
9. Suicide Ideation {102911000, 6471006}
B.

69. Beyond
Semantic Interoperability for HIS
• Search using Concepts above Words
• How many patients do have diabetes mellitus type II?
• Extraction of Concepts from Health Records
• Automated extraction of Hb1Ac 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

70. Interoperability

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