ICD 10 to ICD 11. Zafar Ahmed MBBS, MBA, M Econ. PhD International Center for Casemix and Clinical Coding, National University of Malaysia

Transcription

1 ICD 10 to ICD 11 Zafar Ahmed MBBS, MBA, M Econ. PhD International Center for Casemix and Clinical Coding, National University of Malaysia / zafar.he@gmail.com

2 Faculty of Medicine and Hospital UKM

3 Acknowledment Dr.T. BedirhanÜstün Coordinator, Classifications, Terminologies, Standards. World Health Organization All the members of Morbidity Technical Advisory Group (TAG)

4 Presentation Overview Clinical Documentation Disease Classification and ICD 10 Problems with ICD 10 Objectives of Developing ICD 11 ICD 11 Revision Process icat ICD 11 Features Difference between ICD 10 and ICD 11 Conclusion

5 Hospitals are Data Hungry Institutions

6 Medical Record Department The Nerve Center

7 Documentation of Clinical Information The documentation of patient information Clinical Notes (case notes, or patient history notes) Written by doctors for clinical staff Written in the free text

8 Free text Documentation Most precise way for describing the patient specific information Problems; Hand written No standardization of the language used Abbreviation, short terms, etc

9 Disease terminology Standardization When we want to compile patient data at community level When we need patient level data for planning or forecasting purposes When we want to compare patients

10 What is Disease Classification? System whereby diseases are grouped or classified following pre-determined criteria and according to standard rules and guidelines The International Classification of Diseases (ICD) is the global standard to report and categorize diseases in order to compile health information related to deaths, illness and injury.

11 What is ICD 10? International Classification of Disease version 10 Developed and maintained by World Health Organization (WHO) Objective is to provide a standardized way for documenting the Disease related information

12 Problems with ICD "Frozen historical accidents 2. Is just "a laundry list " no definitions 3. Used in 117 out of > 200 countries for official statistics 4. Driven by mortality and billing use cases 5. Limited web presence 6. Does not interoperate with electronic health records

13 Solution Develop a newer version of ICD The ICD 11 Objective of developing ICD 11 Multipurpose and Coherent Classification International multilingual reference standard Fit for Electronic Record Environment

14 It all starts with the revision process ICD 10 Revision Process 20 th Century process 8 Annual Revision Conferences ( ) Countries participated 1-5 person delegations mainly Health Statisticians Manual curation List exchange Index was done later Output: Paper Copy Work in English only Limited testing in the field

15 ICD 10 Revision Process 21 st Century process Internet-based permanent platform All year round Open to all people in a structured way Content expertsfocus Digital curation Wiki-likecollaboration Enhanced discussion & peer review Electronic copyprint version Work in multiple languages Planned field tests Based on Use Cases

16 ICD Revision Organizational Structure WHO Health Informatics and Modelling TAG (HIM TAG) icat Software Team Morbidity TAG Mortality TAG Functioning TAG Quality & Safety TAG Cross-Sectional TAGs Revision Steering Group Internal Medicine TAG Paediatrics TAG Dentistry TAG Dermatology TAG Rare Diseases TAG External Causes and Injuries TAG Maternal, Neonatal and Urogenital TAG Mental Health TAG Musculoskeletal TAG Neoplasms TAG Neurology TAG Ophthalmology TAG Gastroenterology WG Cardiovascular WG Hepatology & Pancreatobiliary WG Nephrology WG Endocrinology WG Rheumatology WG Haematology WG Respiratory WG Working Groups Traditional Medicine TAG

17 How do we go from Here to 21 st Century? 17

18 What is icat? ICD-11 Collaborative Authoring Tool (icat), adopted to facilitate the revision process icat is n Internet-based platform icatconsist of; ICD-11 Browser; ( sections with authoring access allow the TAGs and the WHO to work collaboratively The platform includes information for the foundation component of ICD-11 and its linearisationsand uses the content model for ICD-11

19 icat

20 ICD-11 Features Internet Based Platform Input from all Stakeholders Content Model Definitions Field Trials for Use Cases Electronic Health Record Ready Multi Lingual Representations ر Arabic 官话 Chinese English English Français French Русский язык Russian Español Spanish Deutsch German Português Portuguese

21 Differences in ICD 10 and ICD 11 ICD-11: A dynamic classification for the information age, Jenny Hargreaves and JodeeNjeru: HIM-INTERCHANGE Vol4 No ISSN (PRINT) ISSN

22 Conclusion Clinical Documentation is the basis of the Clinical data WHO ICDs plays an important role in clinical data standardization in the disease environment ICD 11 overcomes the shortcomings of the ICD 10 both in term of scale and scope icatplays an important role in the development of ICD 11

23 PREGUNTAS?