1. ICD
Dr. T. Bedirhan Üstün Coordinator, Classifications, Terminologies, Standards. World Health Organization

2. Background WHO +International Standards  ICD Classification
Common language for definitions:
Applications:
Mortality: Counting the dead
Morbidity: Monitoring & Evaluation
Primary Care: Diagnosis  Management
Research: Epi, Genetics, Pharma…

3. 1666  2011

4. ICD Revisions

5. ICD-10 Medical Devices associated with adverse incidents in diagnostic and therapeutic use
Y70 Anaesthesiology devices associated with adverse incidents
Y71 Cardiovascular devices associated with adverse incidents
Y72 Otorhinolaryngological devices associated with adverse incidents
Y73 Gastroenterology and urology devices associated with adverse incidents
Y74 General hospital and personal-use devices associated with adverse incidents
Y75 Neurological devices associated with adverse incidents
Y76 Obstetric and gynaecological devices associated with adverse incidents
Y77 Ophthalmic devices associated with adverse incidents
Y78 Radiological devices associated with adverse incidents
Y79 Orthopaedic devices associated with adverse incidents
Y80 Physical medicine devices associated with adverse incidents
Y81 General- and plastic-surgery devices associated with adverse incidents
Y82 Other and unspecified medical devices associated with adverse incidents

6. WHO Family of Classifications
REFERENCE Classifications
DERIVED Classifications
International Classification of Diseases for Oncology, Third Edition (ICD-O-3)
The ICD-10 Classification of Mental and Behavioural Disorders
Application of the International Classification of Diseases to Dentistry and Stomatology, Third Edition
(ICD-DA)
Application of the International Classification of Diseases to Neurology
(ICD-10-NA)
ICF, Children & Youth Version (ICF -CY)
RELATED Classifications
International Classification of Primary Care (ICPC)
International Classification of External Causes of Injury (ICECI)
The Anatomical, Therapeutic, Chemical (ATC) classification system with Defined Daily Doses (DDD)
ISO 9999 Technical aids for persons with disabilities – Classification and Terminology
I nternational
C lassification of
D iseases
F unctioning,
Disability & Health
H ealth
I nterventions
(under development)

7. WHO Classifications in HIS
ICD
ICF
ICHI
Classifications
Population Health
Births
Deaths
Diseases
Disability
Risk factors
Reporting
Cost
Needs
Outcome
Clinical
Decision Support
Integration of care
Outcome
Administration
Scheduling
Resources
Billing

8. Placing WHO Classifications in HIS & IT
Linkages
KRs
Terminologies
e-Health Record
Systems
ICD
ICF
ICHI
Classifications
Population Health
Births
Deaths
Diseases
Disability
Risk factors
Reporting
Cost
Needs
Outcome
Clinical
Decision Support
Integration of care
Outcome
Administration
Scheduling
Resources
Billing

9. Health Information Systems: Analog to Digital
How do we optimize our health services
A Health Information System
is an information system
(i.e. a system of computer equipment, programs, procedures and personnel designed, constructed, operated, and maintained to collect, record, process, retrieve and display information)
specific to the health care domain.
A Health Information System can be considered as:
An integrated (to a greater or lesser degree) collection of a number of different Information Systems in use in a health care context,
2. A generic label for different types of Information Systems used in Health Care. 

10. ICD-11 Revision Goals
Evolve a multi-purpose and coherent classification
Mortality, morbidity, primary care, clinical care, research, public health…
Consistency & interoperability across different uses
Serve as an international and multilingual reference standard for scientific comparability and communication purposes
Ensure that ICD-11 will function in an electronic health records environment.
Link ICD logically to underpinning terminologies and ontologies (e.g. SNOMED, GO, …)
ICD Categories “defined” by "logical operational rules" on their associations and details 10

11. Construction of ICD-10: Revision Process in the 20th Century
8 Annual Revision Conferences ( )
17 – 58 Countries participated
1- 5 person delegations
mainly Health Statisticians
Manual curation
List exchange
Index was done later
"Decibel" Method of discussion
Output: Paper Copy
Work in English only
Limited testing in the field

12. Construction of ICD-11: Revision Process in the 21st Century
Internet-based permanent platform
All year round
Open to all people in a structured way
Content experts focus
Digital curation
Wiki enabled collaboration
Ontology based
Enhanced discussion & peer review
TAGs serve as the Editorial Group
Electronic copy  print version
Work in multiple languages
Planned field tests
Based on Use Cases

13. Definition of Disease a set of dysfunction(s) in any of the body systems including:
with a known pattern of signs, symptoms & findings
symptomatology - manifestations
probably with an underlying explanatory mechanism
etiology
a distinct pattern of development over time
course and outcome
a known pattern of response to interventions
treatment response
with linkage to underlying genetic factors
genotypes, phenotypes and endophenotypes
with linkage to interacting environmental factors
ICD, although it is a classification of diseases it does not define what a disease is. This is a serious shortcoming. A classification should define its universe. ( i.e. what it consists of). Surely ICD may include other category entries other than disease ( such as sign, symptoms, conditions, syndromes etc.) but all these entities should be explicitly known.
This slide contains a draft definition of a disease. This definition will be tested and improved during the revision process to arrive at a really useful and better definition. An example of a taxonomic rule is given here.
Each entity in ICD is to be defined with the following attributes: is_a disease ( see above ) disorder ( therefore we need to define how disorder is different from disease) syndrome ( similar constellation that may occur as a common final path of various different diseases or disorders) injury ( an external cause has to be identified. level has to be defined to be cell - tissue or higher level - e.g. is x-ray caused deletion in DNA an injury? ) sign, symptom… ( manifestations should be identified consistently ) Part_of ?: site Body system Cardiovascular, Respiratory, etc... Function/Dysfunction_of Body functions ( ICF rubrics is likely to be used) Site: Body structure ( either use ICF or FMA…) Has_signs_of: Manifestations Signs symptoms Causative Agent: External Injury Trauma Pathogenic Internal Genes Autoimmune process ? Origin of: Embryonogenic layer: e.g. ectodermal, mesodermal, endodermal…? Embryological phase: e.g. Neural tube formation Temporal Relations Onset Acute, subacute, chronic… Course Episodic, relapsing, recurring… Severity Progress Spread level Impact Limitations ( ICF A&P) Related Interventions for: Investigation ( Lab, diagnostic examination, ...) Treatment drugs interventions surgical mental other Use in Primary Care Clinical Care Research Special exploration Indices Used in Public Health Indices (mortality, morbidity, disability, risk factor) Used in resource groupings (DRGs, other...) 13

14. What is Ontology? Ontology (philosophy) Ontology (computer science)
the Organization of Reality  !!!
Ontology (computer science)
the explicit – operational description of the conceptualization of a domain:
Concepts: entity and quality (properties and attributes)
An ontology defines:
a common vocabulary  a shared understanding/exchange:
among people
among software agents
between people and software
to reuse data - information
to introduce standards to allow interoperability
•The study of being (Socrates and Aristotle 400–360 BC)
•Co-opted by Computer Science to connote the explicit description of the conceptualization of a domain:
–Concepts
–Properties and attributes of concepts
–Constraints on properties and attributes
–Individuals (often, but not always)
•An ontology defines–a common vocabulary–a shared understanding
Just a beginning  databases  knowledgebases domain specific software applications /guidance
The components of ontologies
•Classes: The primary entities in the worldbeing models (e.g., “organ”)
•Attributes: The properties of classes (e.g.,“shape”, “location”)
•Relations: Statements regarding how oneclass may relate to others (e.g., “the heart” is-a “organ”)
•Axioms: More complex logical statements(e.g., “only paired organs can be left-sided orright-sided”)

15. THE CONTENT MODEL Any Category in ICD is represented by:
TITLE of ENTITY: Name of disease, disorder, or syndrome…
Causal Properties
Etiology Type
Causal Properties - Agents
Causal Properties - Causal Mechanisms
Genomic Linkages
Risk Factors
Temporal Properties
Age of Occurrence & Occurrence Frequency
Development Course/Stage
Severity of Subtypes Properties
10. Functioning Properties
Impact on Activities and Participation
Contextual factors
Body functions
11. Specific Condition Properties
Biological Sex
Life-Cycle Properties
12. Treatment Properties
13. Diagnostic Criteria
ICD Concept Title
Fully Specified Name
Classification Properties
Parents
Type
Use and Linearization(s)
Textual Definition(s)
Terms
Base Index Terms
Base Inclusion Terms
Base Exclusion Terms
Body Structure Description
Body System(s)
Body Part(s) [Anatomical Site(s)]
Morphological Properties
Manifestation Properties
Signs & Symptoms
Investigation findings
Green already exists in ICD-10 either explicitly or implicitly – Content model specifies them in a more systematic way
Orange rubrics are new – they exist in some specialty adaptations already such as oncology, mental health, neurology, dermatology,
Functioning Properties is also new – to allow joint use of ICD and ICF 15 15

16. Collaborative Authoring Tool
iCAT
Open and collaborative process
Users are empowered
Web based
Like WIKI – Trip Advisor
But structured
Editorial Oversight
iCAT
Collaborative Authoring Tool
for ICD Revision

17. iCAT

18. ICD11 Components Foundation: ICD categories with
Linearizations
Mortality
Morbidity
Primary Care
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)… 18

19. Why work together? SNOMED & WHO Classifications
WHO & IHTSDO
Coverage & Adequacy
Quality – Reliability - Utility
MultiLingual Applicability
Interoperability
Sustainability
Member States:
Enable health care delivery and compile health information
Comprehensiveness:
Coverage for all aspects of health care
Adequacy:
Is it fit or purpose – multiple purposes?
Does it have a good information model and ontological basis?
Multilingual applicability
language independent formal concept representation
Representation in multiple languages – more than translation
Utility:
Is it beneficial for:
Care providers : decision making, outcome evaluation
Consumers : participation – ownership – evaluation – risk reduction
Policy/Decision Makers : informed decision making on costs, benefits, efficiency
Reliability:
does it give the same results in different users
Validity:
Does it indicate the right things – and does the indication make sense
Interoperability
Technical: Can information systems exchange information and use it?
Semantic Can information systems interpret the data with the same meaning?
Sustainability
Secured maintenance: commitment to stability with earlier versions
Openness to address emerging technical issues
SNOMED & WHO Classifications
are synergistic and not antagonistic

20. ICD & WHO FIC International Public Good Available in multiple formats:
Openly Accessible
Free for WHO Member States
Available in multiple formats:
Printed Book editions
Internet-edition
Various computerized tools

21. ICD & WHO FIC Simultaneous development in Multiple Languages
التصنيف الدولي للأمراض
國際疾病與相關健康問題統計分類
International Classification of Diseases
Classification internationale des maladies
Международная классификация болезней
Clasificación internacional de enfermedades

22. ICD & WHOFIC Multiple Settings: Specialty Adaptations: Primary Care
Clinical Services
Research
Specialty Adaptations:
Children and Youth
Oncology
Mental Health
Neurology
Musculoskeletal
Dermatology
Dentistry
e.g. ICD-10 Diagnostic Guidelines for Mental Health in Primary Care

23. Desiderata for a global terminology (1)
Comprehensiveness:
Coverage for all aspects of health care
Adequacy:
Is it fit or purpose – multiple purposes?
Does it have a good information model and ontological basis?
Multilingual applicability
language independent formal concept representation
Representation in multiple languages – more than translation
Utility:
Is it beneficial for:
Care providers : decision making, outcome evaluation
Consumers : participation – ownership – evaluation – risk reduction
Policy/Decision Makers : informed decision making on costs, benefits, efficiency
Reliability:
does it give the same results in different users

24. Desiderata for a global terminology (2)
Validity:
Does it indicate the right things – and does the indication make sense
Comparability
Does the data in different context have same properties to be compared?
Interoperability
Technical: Can information systems exchange information and use it?
Semantic: Can information systems interpret the data with the same meaning?
Quality Assurance
Product: Annotation and Content
Process: Use and Usability
Sustainability
Secured maintenance: commitment to stability with earlier versions
Openness to address emerging technical issues