1. Introduction of the PANEL by Co-Chairs

2. COLLABORATION ARRANGEMENT International Classification of Health Interventions

3. Outline WHO perspectiveUstun AMA perspectiveMusacchio ICHI work to dateMadden Computable ClassificationsMusen Content Model Tu & Nyulas ConclusionsAll Question & Answers

4. USTUN WHO perspectives

5. Why do we need an Interventions Classification? Clinical Documentation Monitoring and Evaluation Quality Indicators Safety Indicators Efficiency and Effectiveness research Reimbursement Resource Allocation Decisions

6. Global Landscape WHO SURVEY 2006  Countries without an Intervention Classification: around 130  Countries with an Intervention Classification: 60  Countries using ICD-9-CM Vol 3: 12  Countries using Casemix: 20  OECD: sentinel interventions – Health Accounts 28

7. WHO Family of Classifications REFERENCE Classifications I nternational C lassification of D iseases I nternational C lassification of F unctioning, Disability & Disability & Health Health I nternational C lassification of H ealth I nterventions (under development) (under development) RELATED Classifications 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 International Classification of Primary Care (ICPC) 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 (ICD-DA) Application of the International Classification of Diseases to Neurology (ICD-10-NA) 7

8. Current Status - WHO © Copyright WHO alpha

9. Current Status - AMA © Copyright AMA

10. FUTURE: AMA + WHO + 2018 alpha 

11. ICHI Development Goals 1.Evolve a multi-purpose and coherent classification public health… –primary care, clinical care, research, public health… –Consistency & interoperability across different uses 2.Serve as an international and multilingual reference standard for scientific comparability and communication purposes 3.Ensure that ICHI will function in an electronic health records environment. Link ICHI logically to underpinning terminologies and ontologies

12. Unpacking the Future Classification Structure 1.Ontology Structure 2018 2.Ontology Content Content a)CPT… b)ICHI α, β, 2018…

13. Ontology (philosophy) NOT meant as the Organization of Reality !!! Ontology (computer science) – the explicit – operational description of the conceptualization of a domain: Concepts: Entity Properties Value An ontology defines: – a common vocabulary  a shared understanding/exchange: among software agents ( & people ?) – to reuse data - information – to introduce standards to allow interoperability N What is NOntology?

14. Knowledge Representation thingsthoughts Knowledge Representation the triad of things, thoughts and words (Ogden & Richards, 1923 ) APPLE TERM

15. MUSACCHIO AMA perspectives

16. What is CPT ®? CPT codes are an organized compilation of standardized descriptions and five character alphanumeric codes that physicians, medical coders and billers use to report healthcare services and procedures to payers for reimbursement CPT codes provide a uniform language accurately describing medical, surgical and diagnostic services CPT codes serve as an effective means for reliable communications within the U.S. healthcare industry

17. CPT Brief History First published as a 4 digit system in 1966 Moved to its current 5 digit system in 1977 Adopted for programs administered by the Centers for Medicare and Medicaid Services in 1983 Named as a Federal U.S. standard procedure code set for electronic transactions for physician services and other healthcare services in August 2000 Over 8000, surgical, diagnostic and cognitive procedures

18. The CPT Editorial Panel Process Panel Composition: Broad based and comprised of numerous sectors o 11 physicians representing various medical specialties o 3 physician payer representatives o 1 hospital association physician representative o 2 non-physician healthcare provider representatives Non-voting advisory participants from the health information management and professional coding communities also participate

19. Collaboration Goal and Objectives Objectives:  Working together in the development of a next-generation ICHI code set that can be linked to other classification systems, such as ICD and ICF, providing a fully integrated international healthcare classification system  Enable cross-border data aggregation and analysis by deploying the next generation ICHI as an augmenting code set for national health systems  Establish AMA as a credible international partner in the WHO-Family of International Classifications AMA and WHO are planning to collaborate in order to show global leadership in healthcare information innovation through the development and distribution of integrated, ontology-based terminologies to expand interoperability and analytical applications of clinical data.

20. Why The Collaboration Between AMA and WHO Makes Sense Today! WHO and AMA have organizational missions that are closely aligned and focus on the overall betterment of healthcare WHO Mission To provide leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends. AMA Mission To promote the art and science of medicine and the betterment of public health through the strategic focus areas of improving health outcomes, accelerating change in medical education, and increasing professional satisfaction and practice sustainability

21. The Collaboration Between AMA and WHO WHO and AMA’s information products support similar objects and combined will form a foundation for innovation Internationally-endorsed ICD classifications enable data comparison within and between populations and the compilation of nationally consistent data WHO CPT code set facilitates analysis of interventional activity, comparative research, reimbursement, performance measurement and reporting of services AMA Expanded integration and analysis of intervention, disease-state, and functional data across patient populations and national health systems

22. Collaboration Group Collaboration Group –Expert Group ~ 12 members –appointed by AMA and WHO in equal numbers and with joint agreement. Richard Madden and Mark Musen will be the co-chairs of the group 4 management members of current ICHI will be included on the board –AMA and WHO will appoint one Staff Member each to represent them in the Advisory Group as ex-officio members. Bob Musacchio and Bedirhan Ustun –The group will be advisory to AMA and WHO and will oversee the project work according to the Project Plan appended to this agreement.

23. Project Plan Objectives Streams of work Deliverables Timelines Budget

24. Financial Aspects AMA will provide the financial resources to WHO in support of the development of the ICHI to cover Project costs: For five years –Central project management: WHO Project Staff –Meetings: Expert Group, other work groups –Consultants –Contracts – Development, Field Trials, Reports –Other

25. MADDEN ICHI Development

26. ICHI Development Background  1978: WHO International Classification of Procedures in Medicine (ICPM)  1988: ICPM not maintained  Many national classifications developed:  US, UK, Australia, Germany,...  Focus on medical/surgical interventions, hospital in-patients  Duplication, not comparable  Many countries with no classification  Use of U.S. and Australian classification in other countries

27. Broad scope for ICHI ICHI planned to include  Medicine, surgery, diagnostics  Primary care  Allied health and provision of support  Mental health  Nursing interventions  Public health alpha

28. Structure of ICHI  Finalised in 2010  Multi-dimensional, based on European standard for classification of surgical interventions: France and Canada had followed this approach  Definition –A health intervention is an activity performed for, with or on behalf of a person or a population whose purpose is to improve, assess or modify health, functioning or health conditions.

29. 5648 interventions across medical and surgical, functioning and other environmental and behaviour areas –4346 - Interventions on body systems and functions (incl ~ 1790 functioning interventions) –707 - Interventions on activities and participation domains –595 - Interventions to improve the environment and health behaviour ncch/sydney.edu.au/health-sciences/ncch/resources.shtml ICHI Alpha-2 content - interventions

30. TARGET n = 633 ACTION n = 131 MEANS n = 59 New hierarchical grouping of TARGET axis – with subchapters for body parts and for types of activity. ICHI content - axes

31. New Target groups provides the tabular list with an additional level of hierarchy.

32. Extract from the Tabular list illustrating the additional level of hierarchy.

33. ICD-9-CM was included in the foundation (original base) for ICHI Maps to ICD-9-CM were maintained An ICHI subset has been identified that can replace ICD-9-CM ICD 9 CM Volume 3 and ICHI

34. Current ICHI Content Model An Intervention in ICHI is represented by: Title of Entity: Name of intervention 1. Textual definition 2. Hierarchy – Type – Use 3. Synonyms - Inclusion – Exclusion - Index terms- Notes Descriptive characteristics 1 Target A Body Part / Anatomical site DEnvironment B Body Function EBehaviour C Activities and Participation

35. Current ICHI Content Model (II) 2 Action A DiagnosticCManaging B TherapeuticDPreventing 3 Means A Approach CMethod B Technique DSample Other relevant information A Extension codes B Device: Assistive Devices: ISO9999 (proprietary) Implanted devices: GMDN (proprietary) C Chemical substance: ATC D Objective: ICD, ICF

36. WHO - 2018 alpha 2018

37. MUSEN computer requirements for the new ICHI and CPT

38. International Classification of Diseases and Disorders 2017 ICD-11 JLMMS.

39. Example of Content Model: ICD http://www.who.int/classifications/icd/revision/contentmodel/en/

41. International Classification of Interventions 41 2018 ICHI ICPT …

42. Content Model development process: Analyze of ICHI Alpha and CPT sources Propose prototype Content Model Review by ICHI/CPT community Test with “exemplars” Implement in Protégé Demonstrate prototype iCAT-ICHI Plus Refine model …

43. ICHI Alpha Source Materials

44. Conversion of ICHI Alpha to OWL

45. CPT Source Materials CPT Developer Tool Kit (DTK)

46. DTK* formulation of CPT 14 axes used to describe procedures Formulated in OWL

47. Intervention Content Model (Partial list)

48. 48

49. TU & NYULAS

50. Create Prototype Content Model Align CPT axes and ICHI axes, possibly creating new ones Determine sources of the value sets of axes Align CPT and ICHI intervention types For each intervention type, determine properties used to describe the intervention Work out exemplars on paper Model Content Model in ontology authoring tool 10/15/14

51. Types of Content Model parameters WHO-FIC core parameters –Shared among WHO-FIC classifications Descriptive/informational parameters –Classification-specific information “about” a category –Not inherited by derivative categories Structural parameters –Axes along which a category can be abstracted or specialized

52. Content models for WHO-FIC classifications should share core parameters Definitional parameters –title, definitions, code (if any) Terms –Synonyms –Index terms –Inclusions –Exclusions 10/15/14

53. WHO-FIC core parameters: Linearization parameters Fine Needle Aspiration Surgical Procedures

54. Descriptive/Informational parameters: Taken from CPT and ICHI Alpha From CPT –CPT code –Reportable –Short/medium/consumer-friendly/clinical... Descriptor –… ICHI Alpha –Inclusion notes? –Exclusion notes? –…

55. Structural parameter: hasAction

56. Structural parameter: hasTarget ICHI Target + CPT Anatomic Site ICD Extension Codes

57. Structural parameter: hasAssociatedProcedure CPT DTK definition: “Specifies the procedure for which a CPT procedure is designated” Value Set –ICHI Plus Intervention

58. Exemplars for Validation Stanford resident modeled ~80 exemplars

59. ICHI Meeting, Chicago June 2014 Attended by ICHI Alpha developers and CPT experts Plenary as well as smaller groups using provisional CM to model exemplars –Dissected 3 exemplars together –Two groups Dissected 2 common procedures Group 1: One additional procedure Group 2: Three additional procedures –Remarkable consistency

60. Current Status 16 parameters derived or reformulated from ICHI Alpha or DTK axes/parameters Value sets need to be defined Top-level interventions/procedures need to be finalized Prototype Content Model has been encoded in computable representation language

61. 61

62. Implication of our modeling approach to WHO-FIC We have created an shared core WHO-FIC content model We cross reference WHO-FIC classification terms We are using the same post-coordination paradigm across WHO-FIC classifications (ICD-11 and ICHI) We will be experimenting with value sets shared across WHO- FIC classifications (ICD-11 and ICHI) We use the same iCAT software infrastructure to support the development of WHO-FIC classifications Revised62

63. Conclusions

64. Collaboration Timing Drivers for Change: Interoperability to Manage Health Outcomes Globally The lack of interoperability in the healthcare system is holding back needed innovations in quality of care and cost efficiencies Most countries have adopted their own standards for classifying procedural data, making it difficult for cross-border integration and analysis In light of the growing global disease burden, especially concentrated in developing nations, WHO has forged partnerships across the globe to combat these challenges, enabling greater data exchange across countries would support greater success of these initiatives

65. Collaboration Strengths In direct support of WHO’s and AMA’s missions Combines the power of the healthcare and terminology leaders Benefit from ICHI Alpha development and AMA’s CPT content Leverages WHO’s international prowess and structured classification experience Leverages AMA’s editorial and implementation prowess Delivers significant benefits to global healthcare

66. What does WHO want ? Meaningful exchange of health information –Enable aggregation of health information from different sources One stop-shop for different users / developers –In multiple languages Crystallization spiral for knowledge representation –formalization  conceptualization  formalization Linkages between different domains of health information Translational research tool + semantic consistency

67. ICHI - 2018 A reference classification-ontology set –provision of semantics to enable users to use data in a consistent manner –provision of possible services for: classification terminology linkages For use cases such as: –Universal Health Coverage –Billing & Reimbursement –Casemix and Resource Allocation –Quality and Safety monitoring –Comparative Effectiveness Studies

68. QUESTIONS & ANSWERS