Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11)

Interpreting and coding causal relationships for quality and safety using ICD-11

Many circumstances necessitate judgments regarding causation in health information systems, but these can be tricky in medicine and epidemiology. In this article, we reflect on what the ICD-11 Reference Guide provides on coding for causation and judging when relationships between clinical concepts are causal. Based on the use of different types of codes and the development of a new mechanism for coding potential causal relationships, the ICD-11 provides an in-depth transformation of coding expectations as compared to ICD-10. An essential part of the causal relationship interpretation relies on the presence of "connecting terms," key elements in assessing the level of certainty regarding a potential relationship and how to proceed in coding a causal relationship using the new ICD-11 coding convention of postcoordination (i.e., clustering of codes). In addition, determining causation involves using documentation from healthcare providers, which is the foundation for coding health information. The coding guidelines and examples (taken from the quality and patient safety domain) presented in this article underline how new ICD-11 features and coding rules will enhance future health information systems and healthcare.

ICD-11: A catalyst for advancing patient safety surveillance globally

The World Health Organization's (WHO) international classification of disease version 11 (ICD-11) contains several features which enable improved classification of patient safety events. We have identified three suggestions to facilitate adoption of ICD-11 from the patient safety perspective. One, health system leaders at national, regional, and local levels should incorporate ICD-11 into all approaches to monitor patient safety. This will allow them to take advantage of the innovative patient safety classification methods embedded in ICD-11 to overcome several limitations related to existing patient safety surveillance methods. Two, application developers should incorporate ICD-11 into software solutions. This will accelerate adoption and utility of software-enabled clinical and administrative workflows relevant to patient safety management. This is enabled as a result of the ICD-11 application programming interface (or API) developed by the WHO. Third, health system leaders should adopt the ICD-11 using a continuous improvement framework. This will help leaders at national, regional and local levels to take advantage of specific existing initiatives which will be strengthened by ICD-11, including peer review comparisons, clinician engagement, and alignment of front-line safety efforts with post marketing surveillance of medical technologies. While the investment to adopt ICD-11 will be considerable, these will be offset by reducing the ongoing costs related to a lack of accurate routine information.

Coding mechanisms for diagnosis timing in the International Classification of Diseases, Version 11

Background

Diagnoses that arise after admission are of interest because they can represent complications of health care, acute conditions arising de novo, or acute decompensation of a chronic comorbidity occurring during the hospital stay. Three countries in the world have adopted diagnosis timing codes for a number of years. Their experience demonstrates the feasibility and utility of associating an International Classification of Diseases, Version 9 or International Classification of Diseases, Version 10 diagnostic code with information on diagnosis timing, either as part of a diagnostic field or as a separate field. However, diagnosis timing is not an integrated feature of these two classifications as it will be for International Classification of Diseases, Version 11.

Methods

We examine the different types of diagnosis timing that can be used to describe complex patients and present examples of how the new International Classification of Diseases, Version 11 codes may be used.

Results

Extension codes are one of the important new features of International Classification of Diseases, Version 11 and allow more specificity in diagnosis timing.

Conclusion

Imbedded and standardized diagnosis timing information is possible within the International Classification of Diseases, Version 11 classification system.

The three-part model for coding causes and mechanisms of healthcare-related adverse events

ICD-11 provides a promising new way to capture healthcare-related harm or injury. In this paper, we elaborate on the framework for describing healthcare-related events where there is a presumed causal link between an event and underlying healthcare-related factors. The three-part model for describing healthcare-related harm or injury in ICD-11 consists of (1) a healthcare-related activity that is the cause of injury or other harm (selected from Chapter 23 of ICD-11); (2) a mode or mechanism of injury or harm, related to the underlying cause (also from Chapter 23 of ICD-11); and (3) the harmful consequences of the event to the patient, selected from any of Chapters 1 through 22 of ICD-11 (most importantly, the injury or harm experienced by the patient). Concepts from these three elements are linked/clustered through postcoordination to reflect the three-part model in a single coded expression. ICD-11 contains many novel features, and the three-part model described here for healthcare-related adverse events is a notable example.

ICD-11 extension codes support detailed clinical abstraction and comprehensive classification

Background

The new International Classification of Diseases—11th revision (ICD-11) succeeds ICD-10. In the three decades since ICD-10 was released, demands for detailed information on the clinical history of a morbid patient have increased.

Methods

ICD-11 has now implemented an addendum chapter X called “Extension Codes”. This chapter contains numerous codes containing information on concepts including disease stage, severity, histopathology, medicaments, and anatomical details. When linked to a stem code representing a clinical state, the extension codes add significant detail and allow for multidimensional coding.

Results

This paper discusses the purposes and uses of extension codes and presents three examples of how extension codes can be used in coding clinical detail.

Conclusion

ICD-11 with its extension codes implemented has the potential to improve precision and evidence based health care worldwide.

ICD-11: an international classification of diseases for the twenty-first century

BACKGROUND

The International Classification of Diseases (ICD) has long been the main basis for comparability of statistics on causes of mortality and morbidity between places and over time. This paper provides an overview of the recently completed 11th revision of the ICD, focusing on the main innovations and their implications.

MAIN TEXT

Changes in content reflect knowledge and perspectives on diseases and their causes that have emerged since ICD-10 was developed about 30 years ago. Changes in design and structure reflect the arrival of the networked digital era, for which ICD-11 has been prepared. ICD-11's information framework comprises a semantic knowledge base (the Foundation), a biomedical ontology linked to the Foundation and classifications derived from the Foundation. ICD-11 for Mortality and Morbidity Statistics (ICD-11-MMS) is the primary derived classification and the main successor to ICD-10. Innovations enabled by the new architecture include an online coding tool (replacing the index and providing additional functions), an application program interface to enable remote access to ICD-11 content and services, enhanced capability to capture and combine clinically relevant characteristics of cases and integrated support for multiple languages.

CONCLUSIONS

ICD-11 was adopted by the World Health Assembly in May 2019. Transition to implementation is in progress. ICD-11 can be accessed at icd.who.int.

[Evidence of Improved Patient Safety in Germany]

Since 2015, the requirement for data transparency has been met in Germany by publishing structured quality reports in licensed hospitals, but one of the main concerns of patients, namely treatment safety, has not been a prominent feature of these reports. Therefore, this study was undertaken to find out what examples of improved patient safety have been published in Germany in the last 10 years. A systematic literature search identified 10 studies which highlight the quantitatively measured success of 13 interventions.

[Quality of care analyses using ICD 11 : Detailed capture of treatment events]

The identification of treatment errors, the so-called "undesirable" or "critical incidents", is crucial for improving and developing the quality of care. The new International Statistical Classification of Diseases and Related Health Problems-ICD-11-supports a structured data collection in the context of the quality of care and patient safety. Documentation conceptually relies on the multiple coding of the three dimensions of a critical incident: harm, cause, and mode. In this way, it is possible to capture the event in great detail, including the reasons for it and the effects it has. An evaluation of this concept in a field trial using 45 clinical case studies showed good concordance in coding across the documented participants.As the ICD-11 permits the detailed capture of near misses and their context, it could be used for structured documentation in incident reporting systems (databanks for the anonymous reporting of treatment errors). In this way, the error reports can be gathered in a more systematic way, so that they can be used for better quality improvement.In quality assessment, it is important to consider the time of diagnosis. Thus, the feature present on admission (POA) is a diagnosis qualifier that is of substantial importance for quality assessment and is widely used internationally. Up to now, it has not been permanently available in Germany. ICD-11 includes the relevant code.

A comparison of two structured taxonomic strategies in capturing adverse events in U.S. hospitals

OBJECTIVE

To compare the Agency for Healthcare Research and Quality's Quality and Safety Review System (QSRS) and the proposed triadic structure for the 11th version of the International Classification of Disease (ICD-11) in their ability to capture adverse events in U.S. hospitals.

DATA SOURCES/STUDY SETTING

One thousand patient admissions between 2014 and 2016 from three general, acute care hospitals located in Maryland and Washington D.C.

STUDY DESIGN

The admissions chosen for the study were a random sample from all three hospitals.

DATA COLLECTION/EXTRACTION METHODS

All 1000 admissions were abstracted through QSRS by one set of Certified Coding Specialists and a different set of coders assigned the draft ICD-11 codes. Previously assigned ICD-10-CM codes for 230 of the admissions were also used.

PRINCIPAL FINDINGS

We found less than 20 percent agreement between QSRS and ICD-11 in identifying the same adverse event. The likelihood of a mismatch between QSRS and ICD-11 was almost twice that of a match. The findings were similar to the agreement found between QSRS and ICD-10-CM in identifying the same adverse event. When coders were provided with a list of potential adverse events, the sensitivity and negative predictive value of ICD-11 improved.

CONCLUSIONS

While ICD-11 may offer an efficient way of identifying adverse events, our analysis found that in its draft form, it has a limited ability to capture the same types of events as QSRS. Coders may require additional training on identifying adverse events in the chart if ICD-11 is going to prove its maximum benefit.

Clinical and Health System Determinants of Venous Thromboembolism Event Rates After Hip Arthroplasty: An International Comparison

BACKGROUND

Routinely collected hospital data provide increasing opportunities to assess the performance of health care systems. Several factors may, however, influence performance measures and their interpretation between countries.

OBJECTIVE

We compared the occurrence of in-hospital venous thromboembolism (VTE) in patients undergoing hip replacement across 5 countries and explored factors that could explain differences across these countries.

METHODS

We performed cross-sectional studies independently in 5 countries: Canada; France; New Zealand; the state of California; and Switzerland. We first calculated the proportion of hospital inpatients with at least one deep vein thrombosis (DVT) or pulmonary embolism by using numerator codes from the corresponding Patient Safety Indicator. We then compared estimates from each country against a reference value (benchmark) that displayed the baseline risk of VTE in such patients. Finally, we explored length of stay, number of secondary diagnoses coded, and systematic use of ultrasound to detect DVT as potential factors that could explain between-country differences.

RESULTS

The rates of VTE were 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in California, and 0.37% in Switzerland, while the benchmark was 0.58% (95% confidence interval, 0.35-0.81). Factors that could partially explain differences in VTE rates between countries were hospital length of stay, number of secondary diagnoses coded, and proportion of patients who received lower limb ultrasound to screen for DVT systematically before hospital discharge. An exploration of the French data showed that the systematic use of ultrasound may be associated with over detection of DVT but not pulmonary embolism.

CONCLUSIONS

In-hospital VTE rates after arthroplasty vary widely across countries, and a combination of clinical, data-related, and health system factors explain some of the variations in VTE rates across countries.

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events

Objective

To assess the utility of the proposed World Health Organization (WHO)'s International Classification of Disease (ICD) framework for classifying patient safety events.

Setting

Independent classification of 45 clinical vignettes using a web-based platform.

Study participants

The WHO's multi-disciplinary Quality and Safety Topic Advisory Group.

Main outcome measure(s)

The framework consists of three concepts: harm, cause and mode. We defined a concept as 'classifiable' if more than half of the raters could assign an ICD-11 code for the case. We evaluated reasons why cases were nonclassifiable using a qualitative approach.

Results

Harm was classifiable in 31 of 45 cases (69%). Of these, only 20 could be classified according to cause and mode. Classifiable cases were those in which a clear cause and effect relationship existed (e.g. medication administration error). Nonclassifiable cases were those without clear causal attribution (e.g. pressure ulcer). Of the 14 cases in which harm was not evident (31%), only 5 could be classified according to cause and mode and represented potential adverse events. Overall, nine cases (20%) were nonclassifiable using the three-part patient safety framework and contained significant ambiguity in the relationship between healthcare outcome and putative cause.

Conclusions

The proposed framework enabled classification of the majority of patient safety events. Cases in which potentially harmful events did not cause harm were not classifiable; additional code categories within the ICD-11 are one proposal to address this concern. Cases with ambiguity in cause and effect relationship between healthcare processes and outcomes remain difficult to classify.

[Field tests for the beta version of the ICD-11-MMS in Germany: background and methods]

BACKGROUND

The World Health Organization (WHO) has been developing the 11th revision of the International Classification of Diseases (ICD) since 2007. ICD-11 is different from the ICD-10 in volume and structure. Therefore, the WHO planned field tests with a coding of diagnoses and cases.

OBJECTIVES

To describe the background of the field tests and their implementation in Germany.

MATERIALS AND METHODS

Interested parties were invited to submit proposals through a call to the Association of the Scientific Medical Societies (AWMF). The Technology, Methods, and Infrastructure for Networked Medical Research (TMF) was responsible for the coordination, supported by the German Institute for Medical Documentation and Information (DIMDI). The target was a beta version of the ICD-11 for Mortality and Morbidity Statistics (ICD-11-MMS), denoted as "draft for quality assurance".

RESULTS

Eleven field tests were maintained between March and September 2017. With the exception of one field test analyzing diagnoses terms from the thesaurus of the ICD-10-GM, all field tests focused on a specific medical field. Eight different quality criteria were investigated over the 11 field tests, and 22 of the 27 chapters of the ICD-11-MMS were at least partially covered.

CONCLUSIONS

Despite the strict time frame, the field tests were successfully implemented and concluded in Germany. Mostly, the ICD-11 tools from the WHO were used. A high percentage of the ICD chapters were partially covered. In summary, it has been demonstrated for the first time that field tests are a valuable approach to evaluate the ICD in parallel to its development. However, a methodological framework integrating the field tests should be developed, taking into account all relevant requirements.

A national evaluation of community-based mental health strategies in Finland

Objective

High-quality mental health care requires written strategies to set a vision for the future, yet, there is limited systematic information available on the monitoring and evaluation of such strategies. The aim of this nationwide study is to evaluate local mental health strategies in community-based mental health services provided by municipalities.

Design and setting

Mental health strategy documents were gathered through an online search and an e-mail survey of the local authorities of all Finnish mainland municipalities (n = 320).

Participants

Out of 320 municipalities, documents for 129 municipalities (63 documents) were included in the study.

Intervention

The documents obtained (n = 63) were evaluated against the World Health Organization checklist for mental health strategies and policies.

Main outcome measures

Evaluation of the process, operations and content of the documents, against 31 indicators in the checklist.

Results

Out of 320 Finnish municipalities, 40% (n = 129) had a mental health strategy document available and 33% (n = 104) had a document that was either in preparation or being updated. In these documents, priorities, targets and activities were clearly described. Nearly all (99%) of the documents suggested a commitment to preventative work, and 89% mentioned a dedication to developing community-based care. The key shortfalls identified were the lack of consideration of human rights (0%), the limited consideration of research (5%) and the lack of financial planning (28%) to successfully execute the plans. Of the documents obtained, 60% covered both mental health and substance abuse issues.

Conclusions

This study contributes to the limited evidence base on health care strategy evaluations. Further research is needed to understand the potential impact of policy analysis.

Factors precipitating the risk of aspiration in hospitalized patients: findings from a multicentre critical incident technique study

Objective

To elucidate factors, other than those clinical, precipitating the risk of aspiration in hospitalized patients.

Design

The Critical Incident Technique was adopted for this study in 2015.

Setting

Three departments located in two academic hospitals in the northeast of Italy, equipped with 800 and 1500 beds, respectively.

Participants

A purposeful sample of 12 registered nurses (RN), all of whom (i) had reported one or more episodes of aspiration during the longitudinal survey, (ii) had worked ≥3 years in the department, and (iii) were willing to participate, were included.

Main Outcome Measure(s)

Antecedent factors involved in episodes of aspiration as experienced by RNs were collected through an open-ended interview, and qualitatively analysed.

Results

In addition to clinical factors, other factors interacting with each other may precipitate the risk of aspiration episodes during hospitalization: at the nursing care level (misclassifying patients, transferring tasks to other healthcare professionals and standardizing processes to remove potential threats); at the family level (misclassifying patients, dealing with the cultural relevance of eating) and at the environmental level (positioning the patient, managing time pressures, distracting patient while eating, dealing with food consistency and irritating oral medication).

Conclusions

At the hospital level, an adequate nursing workforce and models of care delivery, as well as time for initial and continuing patient and family assessment are required. At the unit level, patient-centred models of care aimed at reducing care standardization are also recommended; in addition, nursing, family and environmental factors should be recorded in the incident reports documenting episodes of aspiration.

Adverse drug events in German hospital routine data: A validation of International Classification of Diseases, 10th revision (ICD-10) diagnostic codes

OBJECTIVE

Adverse drug events (ADEs) during hospital stays are a significant problem of healthcare systems. Established monitoring systems lack completeness or are cost intensive. Routinely assigned International Statistical Classification of Diseases and Related Health Problems (ICD) codes could complement existing systems for ADE identification. To analyze the potential of using routine data for ADE detection, the validity of a set of ICD codes was determined focusing on hospital-acquired events.

MATERIAL AND METHODS

The study utilized routine data from four German hospitals covering the years 2014 and 2015. A set of ICD, 10th Revision, German Modification (ICD-10-GM) diagnoses coded most frequently in the routine data and identified as codes indicating ADEs was analyzed. Data from psychiatric and psychotherapeutic departments were excluded. Retrospective chart review was performed to calculate positive predictive values (PPV) and sensitivity.

RESULTS

Of 807 reviewed ADE codes, 91.2% (95%-confidence interval: 89.0, 93.1) were identified as disease in the medical records and 65.1% (61.7, 68.3) were confirmed as ADE. For code groups being predominantly hospital-acquired, 78.5% (73.7, 82.9) were confirmed as ADE, ranging from 68.5% to 94.4% dependent on the ICD code. However, sensitivity of inpatient ADEs was relatively low. 49.7% (45.2, 54.2) of 495 identified hospital-acquired ADEs were coded as disease in the routine data, from which a subgroup of 12.1% (9.4, 15.3) was coded as drug-associated disease.

CONCLUSIONS

ICD codes from routine data can provide an important contribution to the development and improvement of ADE monitoring systems. Documentation quality is crucial to further increase the PPV, and actions against under-reporting of ADEs in routine data need to be taken.

Exploring similarities and differences in hospital adverse event rates between Norway and Sweden using Global Trigger Tool

OBJECTIVES

In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT).

DESIGN

All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology.

SETTING

Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care.

PARTICIPANTS

10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden.

RESULTS

No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% (95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and 'other' AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs.

CONCLUSIONS

The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues.