ICD-11 and other international health classifications: considerations for Australia

1. ICD-11 and other international health classifications: considerations for Australia Jenny Hargreaves Head, Australian Collaborating Centre for the World Health Organization Family of International Classifications, AIHW

2. This presentation covers • Overview of the World Health Organization’s Family of International Classifications • Brief information on the Australian Collaborating Centre for the WHO’s Family of International Classifications • Information about the development of ICD-11 and WHO’s plans for field trials • Brief information about other WHO classification development • Thoughts about Australian involvement

3. The WHO Family of International Classifications Reference classifications: main classifications on basic parameters of health • International Classification of Diseases (ICD) • International Classification of Functioning, Disability and Health (ICF) • International Classification of Health Interventions (ICHI) (under development) Derived and related classifications (eg ICD-O, ICPC-2, country versions such as ICD-10-AM)

4. WHO Classification development work ICD revision – preparing ICD-11 Updates to ICD-10 Updates to ICF Development of ICHI By WHO; with assistance of the WHO-FIC collaborating centres

5. WHO-FIC Collaborating Centres A dozen or so Centres around the world, working as a collaborative network Work with WHO in the development, dissemination, maintenance and use of the WHO-FIC for statistics, evidence Participate in updating processes for ICD and ICF Work with relevant WHO regional offices (Western Pacific)

6. What is the Australian Collaborating Centre? Network of individuals and organisations throughout Australia who have expertise or interest in health classifications Coordination and information sharing through AIHW Liaison with WHO, contributions to WHO work such as classification development Funding support from Department of Health and Ageing

7. Australian Collaborating Centre members AIHW Australian Bureau of Statistics National Casemix and Classification Centre (UoW) National Centre for Classification in Health (USyd) National Centre for Health Information Research and Training (QUT) Australian ICF Disability and Rehabilitation Research Program (USyd) Family Medicine Research Centre (USyd) Department of Health and Ageing Some state and territory health departments Individual experts New members welcome!

8. Acknowledgment for content in the following slides: Bedirhan Ustun, Head of Classifications, Terminologies and Standards, WHO

9. WHO’s ICD-11 Revision Goals Evolve a multi-purposeand coherent classification Mortality, morbidity, primary care, clinical care,research, public health… Consistency & interoperability across different uses Serve as an internationaland multilingual reference standard for scientific comparability and communication purposes Ensure that ICD-11 will function in an electronic health records environment

10. ICD-11 processes • Overseen by the ICD Revision Steering Group • Development of chapter content by specialist Topic Advisory Groups • WHO coordination and checking • Review by experts worldwide • Review by ‘Cross-cutting’ Topic Advisory Groups – mortality, morbidity, functioning and safety and quality • Field trials

11. ICD-11 Timeline 2011 : Alpha version ( ICD 11 alpha draft) Alpha browser available on-line since May 2011 Commenting facility since about November 2011 2013 : Beta version Field Trials Version +2 YR : Field trials 2015 : Final version for WHA Approval 2015+ implementation

12. THE CONTENT MODELAny 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 • Treatment Properties • 13. Diagnostic Criteria

13. Current Status as of 30 April 2013 • Some Chapters need further work • Neoplasms • Signs & Symptoms • External Causes • Z codes • Other chapters’ structure reported to be complete • Mental Health, Sexual Health, • Sexual health is a new chapter • Definitions • Top level > 50 % • Overall > 35 %

14. Morbidity111 Mort/PCHigh11 Morbidity112 Morbidity121 Mort/PCHigh12 PC – Low 1 Morbidity131 Mort/PCHigh13 Morbidity132 Morbidity133 Morbidity211 Mort/PCHigh21 PC – Low 2 Morbidity221 Mort/PCHigh22 Morbidity222 Morbidity311 Mort/PCHigh31 Morbidity312 PC – Low 3 Morbidity321 Mort/PCHigh32 Mort/PCHigh33 PRIMARY CARE Low Resource Morbidity341 (Verbal Autopsy ?) Morbidity342 Mort/PCHigh34 Morbidity351 Extensions Mort/PCHigh35 National Linearizations Specialty - Research PRIMARY CARE High Resource MORBIDITY MORTALITY International

15. ICD ~ SNOMED-CT Common Ontology Core subset of ICD Foundation Component & SNOMED CT • Shared concepts: • fully specified names; definitions; synonyms • Same parent-child relationships • Actual scope yet to be specified • Likely to include at least the 15,000 concepts in ICD • First ‘experiment’ is to develop a small slice of common ontology for cardiovascular disease

16. Information Notes • ICD Revision Communication • ICD Revision Timelines • TAG Allocation • Content Model • Foundation Component and Linearizations • Legacy Linearizations • Code Structure • Multidimensional Coding • Index • Diagnosis Type • Main Condition • Review Process • Mirror Coding • Modifiers and Qualifiers • Field Trials • Stability Analysis • Multilingual ICD Platform • Dagger and Asterisk resolution • Multisystem Chapter

17. Information Notes under development • Cross-cutting TAG Roles • Mortality • Morbidity • Functioning • Quality & Safety • Post-Coordination Principles and Rules • Residual Categories • Common Ontology with SCT • Coding Rules • National Linearizations in ICD-11 • ICD-11 Definitions • Synchronization of Update and Revision Process

18. Stability Analysis • Mortality • Morbidity • ICD-10-WHO withICD-11-WHO • ICD-10&11-WHO withICD-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 • Potentially a very useful resource

19. ReviewProcess • 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

20. ReviewProcess • The coverage: • the content • Definitions • Content model parameters • The structure - of the linearization (s) • Mortality • Morbidity • Primary Care • The reviewers: • scientific peers • Contributors being sought

21. ICD-11 Field Trials: overall objectives Systematically test the ICD-11 before its use to • increase consistency, • identify improvement paths, and • reduce errors

22. ICD-11 Field Trials: Basic aims • To test the “fitness of ICD-11 for multiple purposes” • Mortality coding • Morbidity coding including DRG effects • Other use cases • In different health settings • Primary care (high resource and low resource settings) • General health care, and specialised care settings • Research settings – epidemiology and population health, and clinical research • To ensure the comparabilitybetween ICD-10 and ICD-11

23. ICD-11 Field Trials: Key Assessments • Applicability – feasibility  easy to use • Reliability - consistency  gives same results in the hands of all • Utility - added value  renders useful information

24. Management of Field trials • Field trials Structure • WHO (central organization) • Field Trial Centres (WHO FIC CC, others?) • Field Trial Sites • Roles & Responsibilities • Coder/rater • Site coordinator & assistant • Centre coordinator & assistant

25. Field Trial Studies • Core Studies (mandatory) • Study One: • Basic Questions • Study Two: • Reliability & Feasibility • Study Three: • Bridge Coding • Additional Studies – eg testing index

26. Possible Basic Question topics Needfor ICD-11 – clinical care, statistics, reimbursement, research Uses for ICD-11 Characteristics of ICD-11 Diseases conceptions & delineation Terminology principles Coding Coverage issues ICD-11 and other WHO FIC Other

27. Basic Question Components • Consensus Conference Approach • Individual Response Approach

28. Study on reliability & feasibility • The Case information • Case Summaries (CS) • Live Cases (LC) • Other (e.g. Video Cases) • Coded using ICD-11 Chapters by at least two different people • Agreement rates measured • Processes of joint discussion of differences

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

30. Field trial data management & issues • Data management • Infrastructure • (web-base software (multilingual) & Paper and pencil • Workflow • Entry, check/validation/submission • Ethics review (e.g. WHO ERC, national ERC) • As required

31. Field trials timing • Currently in consolidation phase at WHO • A draft classification to be delivered to mortality and morbidity Topic Advisory Groups in late June • Field trials starting end of June, for two years • Pilot testing and more planning over coming months

32. ICD-11 Field trials in Australia? • Monitor and contribute to current planning? • Participate in field trials • Acute care • Other – primary care? Population health? Research? • Early in the process? Late? Both? • Extend to test effects on DRGs? On coder resource requirements? On information requirements? • To help shape final ICD-11 product to suit Australia’s needs, particularly if we want to consider not having a national modification, or having a minimal national modification

33. Infectious diseases: change for field testing? • An expansion of content on organisms, as first axis • Should the chapter continue with focus on epidemic and generalised infections? For public health purposes; not appropriate in other chapters? • Or focus on manifestation, with aetiology post-coordinated? • Or will the new structure work? (Thanks to OlafrSteinham from the Nordic WHO-FIC Collaborating Centre)

34. X chapter – extension codes • To support multi-dimensional coding or post-coordinated coding • Paired with stem codes from elsewhere in the classification • 3 types: • Type 1 – additional detail eg severity, laterality • Type 2 - administrative eg main condition, present on admission • Type 3 – stem code as reference, eg ‘rule out’, ‘family history of’ • Balance of pre/post coordination still being worked on by WHO

35. X chapter, continued • Extension codes used with ‘cluster codes’ to group codes representing single concepts, eg • CodeA 1 • CodeB 1 • CodeC 1 • Or chain coding: CodeA/CodeB/CodeC 1 • These have equivalent meaning • Impacts on information systems • For field trials, will the required information be available in linkable form? How would it relate to ACS for Additional diagnoses?

36. National modifications • WHO Information Note not yet published – approach not yet known • To be influenced by X chapter arrangements, and stability analyses? • X chapter could accommodate detail currently in national modifications • National modifications could be (largely) choices about use of X chapter features?

37. National modifications, ctd • Links to national information systems/regulations/funding arrangements • Links to update process for ICD-11 • Frequency and timing? Turnaround time? • processes for proposing, considering and approving updates? • Content and construct issues • Specific country needs eg external causes • A balance between international comparability and specific national needs (Thanks to ACC colleagues for discussions on these topics)

38. ICD-11 Australian implementation? • Mortality • Morbidity – acute care, other • Post 2015? • Consider after testing of final ICD-11?

39. International Classification of Functioning, Disability and Health • ICF used in ABS Survey of Disability, Ageing and Carers, and other national health information work • eg AIHW’s current work to develop a ‘standardised disability flag’ module for Community Services Ministers to improve information on people with disability accessing mainstream services • Combining ICF for children and youth into ICF • Combining foundation layer • Development of information model • ICF practical manual • Annual updates for ICF

40. Annual updates for ICF • Australian ICF updates workshop • Repeating last’s year’s successful workshop • Collaborative Australian input into WHO processes • Only France also doing this • A model for how Australia could contribute to ICD updates?

41. International Classification of Health Interventions • Work to date, including Alpha version ‘spearheaded’ by Richard Madden, University of Sydney • Medical, surgical, public health, nursing and functioning interventions • Business plan – uses and users • Detailed project plan • Management committee • For WHO Governing Body endorsement, ultimately

42. International Classification of Health Interventions • Considerations for Australia • A longer term development than ICD-11 • Likely to be developed to link with emerging e-health environment • A replacement for ACHI? More future proof? • Australian involvement?

43. Family Development Committee • More work looking into the future • A Committee of the WHO-FIC Network of Collaborating Centres • Advises WHO on additions and other changes to the Family

44. Family Development Committee • Applications of the WHO-FIC – use of ICD, ICF and ICHI together, and for casemix in particular • Stocktake of current and future use of WHO-FIC in casemix • Principles on which a casemix system should be developed, particularly from a classification perspective • Focal point for ICHI – advice on project management, preparation of a statement of benefits, advice on links to other WHO-FIC members

45. Family Development Committee • Health services classification – role in the Family? Costs and benefits? Priority? Link to OECD system of accounts? Australian hospital peer groups? Australian health expenditure classifications? • WHO-FIC support for the WHO’s Universal Health Coverage initiative - primary care versions of the classifications, reasons for encounter in general practice, presenting problems in emergency departments? Other patient perspectives? Population health measures and risk factors? Alignment with other primary care classifications?

46. Family Development Committee • Integration of the Family: a Family-wide development • What does this mean? At what level? For what purpose? • Alignment or combining of content models • Alignment or combining of foundation layers • Rules for derived and related classifications • Processes for adding and deleting classifications • Alignment of pre-and post-coordination approaches • Identification and filling of gaps • Incorporation of specialist classifications into the reference set • Approaches to mapping between WHO-FIC members and with other classifications and terminologies

47. Considerations for Australia, in summary Ensuring that the Family of International Classifications suits Australia’s purposes into the future? • For both internal Australian purposes - and for international comparability and potential use of international products? Involvement in ICD-11 content preparation Involvement in ICD-11 field trials Involvement in ICD-10 updates (to morph into ICD-11 updates) Involvement in establishment phase for ICHI Involvement in update process for ICF Watching brief on longer term WHO work