1. The WHO Revision Process Morbidity Kerry Innes Manager Australian Centre for Clinical Terminology and Information Towards ICD-11 for Australia University of Sydney, 1 July 2011

2. Page  2 The morbidity committees  Morbidity Reference Group (MbRG) – a WHO-FIC committee – Update and Revision Committee (URC) ICD-10  Morbidity Topic Advisory Group (MbTAG) – an ICD-11 Revision committee – Revision Steering Group (RSG)

3. Page  3 Governance - MbTAG

4. Page  4 MbTAG membership Donna (co-chair)PickettUSA Syed (co-chair)AljunidMalaysia BernardBurnanSwitzerland LynHanmerSouth Africa KerryInnesAustralia QinJiangChina RafaelLozanoMexico MarionMendelsonFrance LoriMoskalCanada WansaPaoinThailand

5. Page  5 MbTAG – work to date 1.Review and comment on options for replacing the dagger/asterisk convention 2.Review and comment on options for code structure 3.Review of the Safety and Quality TAG paper on ‘clustering’ codes 4.Definition of main condition and review of the Safety and Quality TAG comments on same 5.Consideration of diagnosis-type

6. Page  6 MbTAG – work to date 6. Consider maintenance of a symptom/signs chapter 7. Multisystem disease chapter? 8. Severity 9. Anatomy (chapter)? 10. Precoordination 11. Use of eponyms

7. Page  7 ICD rules task force  Review of ICD rules, such as: –Main condition recording –Reselection of main condition –Presenting problem and underlying cause –Multiple codes for one clinical concept –One code for multiple clinical concepts –Late effects/sequelae

8. Page  8 MbTAG – code structure options 1.01BA1B.-, referring to chapter 1, block B, sub-block A, category number 1B. 2.BA1B.-, referring to block B, sub-block A, category 1B. The chapter information would be omitted, in this case (as has always been the case in ICD). 3.01BA01.- referring to chapter 1 block B, sub-block A, category number 01 4.Keep the old code structure and add one letter in front to expand the code range. Do not include block information in the code

9. Page  9 MbTAG – clustering – S&Q TAG proposal The current version of ICD (ICD-10) has conventions in place for linking diagnostic concepts. These are constrained in scope, and not consistently considered in the development of code structures across ICD-10 chapters. –Use additional code L23.3 Allergic contact dermatitis due to drugs in contact with skin Use additional external cause code (Chapter XX), if desired, to identify drug. –Injury and external cause Where a code from this section(external cause of morbidity) is applicable, it is intended that it shall be used in addition to a code from another chapter of the Classification indicating the nature of the condition.

10. Page  10 MbTAG – clustering – S&Q TAG proposal Dagger/asterisk A02.2+ Localised salmonella infections M01.3* Arthritis in other bacterial diseases classified elsewhere

11. Page  11 MbTAG – clustering – S&Q TAG proposal  The Q&S TAG unanimously supports the notion that a new clustering system will need to be developed for ICD-11, especially given the decision taken regarding the dagger-asterisk system (i.e., that it will be abolished).  The Q&S TAG also recognizes that there is some urgency to developing the new clustering system, because this will influence the entire structure of ICD-11. Further chapter-specific work in iCAT is somewhat constrained in the absence of a decision being taken on clustering.

12. Page  12 MbTAG – clustering – S&Q TAG DiagnosisCluster Diuretic overdose1 Hypokalemia1 Arrhythmia1 Diabetes2 Hypoglycemia3 Insulin overdose3 Medication error (Ch 20)3

13. Page  13 MbTAG – diagnosis typing: S&Q TAG  One of the notable limitations of coded hospital discharge data is the inability to distinguish diagnoses present at admission from diagnoses arising some time after a hospital stay has begun.  Develop a harmonized diagnosis-type indicator system that key stakeholder countries agree to.  Recommend global implementation in all countries that have resources and infrastructure in place for the collection of detailed hospital discharge data.

14. Page  14 MbTAG – diagnosis typing: S&Q TAG  This proposal is brought forward to the Q&S TAG for second discussion at the TAG meeting in February 2011, after which it will be forwarded to the WHO-FIC network for consideration.  Note: a more sophisticated approach to this issue would be ‘time- and date-stamping’ of individual diagnoses. Such an approach could be undertaken in systems that have the coding and health information resources to support uptake.

15. Page  15 Dagger/asterisk  Inconsistency in new revisions by various TAG/WGs –Retirement of asterisk codes –Kept asterisk codes as asterisk codes –Kept asterisk codes as single codes –Need a consistent decision

16. Page  16 Dagger/asterisk  Current dagger: A18.8 Tuberculosis of other specified organs  Current asterisk: E35.0 Disorders of thyroid gland in diseases classified elsewhere  Proposed new concept: Tuberculosis of thyroid gland  Add this as a new class at A18.8  Add a new parent at E35.0  To be reviewed by TAGs/WGs

17. Page  17 Main condition – ICD -11 ICD-10 The main condition is defined as the condition, diagnosed at the end of the episode of health care, primarily responsible for the patient’s need for treatment or investigation. If there is more than one such condition, the one held most responsible for the greatest use of resources should be selected

18. Page  18 Main condition – ICD -11 Rule MC1 Record as the main condition the condition that is determined to be the reason for admission or contact with a health service, established at the end of the episode of health care. Rule MC2 If there is more than one reason for admission: Record as main condition the reason for admission/contact with a health service that required the greatest use of resources during the episode of health care

19. Page  19 Main condition – ICD-11 Rule MC3 If a condition arose during the episode of health care that: a)consumed more resources than any of the reasons for admission/contact with a health service and b) was not a consequence of any of the reasons for admission/contact with a health service (neither the condition itself nor its treatment) Record as main condition the condition that arose during the episode of health care

20. Page  20 Main condition – S&Q TAG comments ‘The model certainly does elegantly present the decision- making that needs to occur for optimal implementation of a resource consumption coding rule.’ ‘There was, however, recognition that many countries that use a reason-for-admission coding rule for main condition will not want to abandon their current approach. (The same may be true for those that use a resource consumption definition.)’

21. Page  21 Main condition – S&Q TAG comments  Develop a new system in which two diagnosis fields are designated as the fields for the main condition. The first of these is for the diagnosis that led to the hospitalization. The second is then for the diagnosis that leads to the greatest consumption of resources.  We anticipate that such a system would meet the objectives of countries that want a reason-for-admission coding rule, while also meeting the objectives of countries that want a resource consumption coding rule (of relevance to case-mix systems). 