1. WHO ICHI 와 의료행위분류 2012.11.07 가톨릭의대 김석일

2. Acknowledgement Jean Marie Rodrigues, Emeritus president of PCS international, University of Saint Etienne Richard Madden, University of Sydney co- chair of WHO FIC FDC

3. WHO Family of Classifications International Classification of Diseases – ICD-10 International Classification of Functioning, Disability and Health – ICF International Classification of Interventions – ICHI (under development)

4. ICHI history WHO International Classification of Procedures in Medicine: 1978 (ICPM) Out of date within 10 years Decision not to update in late 1980s Renewed interest from 2000, work begins 2006 Structure, Content Model and Coding Scheme now in place Alpha version is published

5. The situation now Proliferation of national classifications (US, Australia, France, Germany...) Limited scope of national classifications Many countries without a classification Drawback for international comparisons Drawback for an international casemix system and now End of ICD-9-CM Volume 3 (2013)

6. International Classification of Health Interventions National systems –ICD-9-CM –ACHI –CCI –CCAM –NCSP –OPS –OPCS4 –ICPM extensions (The Netherlands, Hungary et.) –ICD10 PCS International systems –UMLS metathesaurus –SNOMED CT –LOINC

7. Main existing coding systems of surgical procedures(1) ICHI: International Classification of Health Intervention: ICHI project plan version 2.2.R Madden.In Proc WHO-FIC Annual meeting Toronto 16-22 Octobre 2010 CCAM, Classification Commune des Actes Medicaux : http://www.ameli.fr/fileadmin/user_upload/documents/ CCAMV23.pdf http://www.ameli.fr/fileadmin/user_upload/documents/ CCAMV23.pdf ICD-9-CM International classification of Disease 9 Clinical Modification: http://icd9cm.chrisendres.com/http://icd9cm.chrisendres.com/ ACHI Australian Classification of Health Intervention: http://www3.fhs.usyd.edu.au http://www3.fhs.usyd.edu.au CCHI Canadian Classification of Health Intervention : http://secure.cihi.ca/cihiweb/dispPage.jsp http://secure.cihi.ca/cihiweb/dispPage.jsp

8. Main existing coding systems of surgical procedures (2) NCSP NOMESCO Classification of Surgical Procedures: http://www.helsedirektoratet.no/vp/multimedia/archive/ 00269/Ncsp_1_14_269099a.pdf http://www.helsedirektoratet.no/vp/multimedia/archive/ 00269/Ncsp_1_14_269099a.pdf OPS Operationen und ProedurenSchlüssel: http://www.dimdi.de/static/en/klassi/index.htm http://www.dimdi.de/static/en/klassi/index.htm OPCS4 Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures: http://www.connectingforhealth.nhs.uk/systemsandser vices/data/clinicalcoding/codingstandards/opcs4 http://www.connectingforhealth.nhs.uk/systemsandser vices/data/clinicalcoding/codingstandards/opcs4 ICD 10 PCS Procedure Coding System: www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_I CD10.asp www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_I CD10.asp

9. Why develop a new ICHI To describe and compare with a common framework the provision and effectiveness of health interventions at the local, national or international level and across different populations or subpopulations To provide a classification of appropriate scope detail to which countries may align their more finely grained national classifications To make available a classification that can be used without adaptation in countries which do not wish to develop their own classification or use another country's coding system To support efficiency based health policies (eg, activity based funding) To avoid duplication of efforts at national level

10. ICHI definition An activity performed for, with or on behalf of a client(s) –This definition includes interventions that apply to more than one client or to a population group Whose purpose is –to improve individual or population health, –to alter or diagnose the course of a health condition, or –to improve functioning.

11. ICHI Framework/Structure Starting point: –Pr EN ISO 1828: Categorial Structure for terminological systems of surgical procedures –Pr EN ISO 18104: Categorial Structure for terminological systems of nursing –Used in several national classifications: France (CCAM), Canada (CCI)

12. ICHI Framework: Categorial Structure Categorial structure for healthcare terminological systems: –Minimal set of domain constraints to represent a healthcare terminology in a precise domain with a precise goal a.list of semantic categories b.goal of the categorial structure c.list of semantic links authorised with their associated semantic categories, d.set of minimal constraints necessary to comply with the standard (DL/like)

13. CEN EN 1828 Categorial structure for terminological systems of surgical procedures A list of semantic categories –surgical deed, human anatomy, lesion, device The goal of the terminological system represented by the categorial structure The list of semantic links between semantic categories authorised with their associated semantic categories –(ex hasObject,hasSite,hasMeans, hasSubsurgicaldeedj The minimal constraints

14. UML diagram for EN/ISO1828 for Terminological systems of surgical procedures

15. Minimal constraints Each surgical procedure terminological phrase shall, as a minimum, consist of a surgical deed and have the semantic link ‘hasObject’. Each surgical procedure terminological phrase shall contain the category human anatomy in relation with the semantic link ‘hasObject’ or ‘hasSite’. It can also have both. The surgical procedure terminological phrase shall include the category lesion when the surgical deed is applied to a modified human anatomy structure without mention of the disease cause of the lesion

16. Each surgical procedure terminological phrase may need more than one surgical deed. One surgical deed shall be chosen as a main deed and the others as subprocess deeds related to the main deed by the semantic link hasSubsurgicaldeed'. Each surgical procedure sub-process terminological phrase shall as a minimum, consists of a surgical deed,the semantic link 'hasObject' (4.4.1) and of the category human anatomy in relation with the semantic links 'hasObject' (4.4.1) or 'hasSite' (4.4.2)

17. Categrorial structure and classification of health interventions

18. ICHI Structure Target3 characters –Anatomy –Function –Activities & Participation –... Actions2 characters –Investigation –Treating –Managing –Assisting –Preventing –... Means2 characters –Approach –Technique –Method –...

19. PREVIOUS EXPERIENCE IN KCHI

20. Method: Hierarchy IS-A Hierarchy New Classification ICD-9-CM Covered item by insurance Uncovered item by insurance TARGET MEANS ACTION 3 AXES

21. No Code for axes terms Strong probability of code change Possible introduction of notations for rich content expression Flat hierarchy – needs to be extended to multilevel hierarchy Human readable understanding of each axes by human being –Items can be substituted to code easily by computing

22. Discrepancy among the coders Limited number of terms with definition –Different level of understanding about the terms in axes Inborn error of the axes structure

23. Hierarchical rearrangement

24. Exact Match SourceTerm3 axes ICD-9-CMCode66.01TargetMeansAction English Salpingootomy Fallopian tubeOpenIncision Korean 자궁관 절개자궁관개방절개

25. Broad Match : Lower level terms after “:” SourceTerm3 axes ICD-9-CMCode73.6TargetMeansAction English episiotomy Vulva:PerineumOpenIncision Korean 외음절개외음부개방절개

26. Broad Match : & for two or more terms in a axis SourceTerm3 axes ICD-9-CMCode65.62TargetMeansAction English Other removal of remaining ovary and tube Fallopian tube & Ovary OpenRemoval Korean 기타 잔존 난소 및 자궁관 제거 자궁관 및 난소개방제거

27. Broad Match : “or” | SourceTerm3 axes ICD-9-CMCode66.93TargetMeansAction English Implantation or replacement of prosthesis of fallopian tube Device:Prosthes is>Fallopian tube Open Implantation of device|Change Korean 자궁관 인공삽입물 삽입 또는 교체 인공삽입물 > 자 궁관 개방삽입 또는 교체

28. Broad Match : “with” &+ SourceTerm3 axes ICD-9-CMCode66.62TargetMeansAction English Salpingectomy with removal of tubal pregnancy Fallopian tube&+ Fetal or embryonic structure OpenExcision&+Removal Korean 자궁관 임신 제거가 동반된 자궁관 절제 자궁관 및 난소개방제거

29. Broad Match : “without” &- SourceTerm3 axes ICD-9-CMCode73.21TargetMeansAction English Internal and combined version without extraction Fetal or embryonic structure Per Orifice/Transorifice Reposition:Internal version and combined version &- Extraction: Delivery Korean 만출술이 동반되 지 않은 내태아회 전 및 복합태아회 전 태아구멍을 통해만출술이 동반되지 않은 내 태아 회전 및 복합태아 회전

30. Broad Match : condition ] SourceTerm3 axes ICD-9-CMCode75.92TargetMeansAction English Evacuation of other hematoma of vulva or vagina Vulva|Vagina]HematomaOpenDrainage:Evacuation Korean 외음 또는 질의 기 타 혈종의 배출 외음 또는 질 ] 혈종개방배출

31. Broad Match : ”D.O>I.O” SourceTerm3 axes ICD-9-CMCode66.93TargetMeansAction English Implantation or replacement of prosthesis of fallopian tube Device:Prosthesis >Fallopian tube Open Implantationof device|Change Korean 자궁관 인공삽입물 삽입 또는 교체 인공삽입물 (D.O) > 자궁관 (I.O) 개방삽입 또는 교체

32. 2 개 이상의 행위 실제 행위가 특정 목적을 위한 것이고, 목적이 행위로 정의되는 경우 – 보험급여에서는 하나의 행위 –Ligation (of fallopian tube) = occlusion –insertion of pessary (in prolaps uteri)= restoration 연속적인 행위 – 보험급여의 경우 () 안의 것은 급여 대상이 아님 –(Craniotomy + )clipping of aneurysm = clipping of aneurysm –(Skin incision+)appendectomy = appendectomy 최종 행위를 위해 동시에 일어나는 행위 –sonoguided endoscopic biopsy 본래 endoscopy 가 main. Endoscopy 를 하는 과정에서 biopsy 가 필요한 경우 의도적으로 biopsy 를 하기 위해 sonoguided, endoscopy 를 하는 경우 독립된 두 개의 행위 – 보험급여에서 부가적인 행위를 50% 인정 –Ceaserian section + appendectomy

33. Ambiguity in actions Action as the purpose of intervention vs action by itself –Ligation (of fallopian tube) = occlusion –insertion of pessary (in prolaps uteri)= restoration ( of prolaps uteri) Series of actions vs final action –(Craniotomy + )clipping of aneurysm = clipping of aneurysm –(Skin incision+)appendectomy = appendectomy Selection of final action in a series of actions –sonoguided endoscopic biopsy Endoscopy is the main action and sonoguided biopsy is done when needed Sonoguided endoscopy is done to do biopsy Two separate actions in one time –Ceaserian section + appendectomy

34. 실 행위 기술 vs 행위의 목적 기술 전립선내 주사 –Injection of drug into prostate gland Action = injection, IO = prostate, DO = drug –Destruction or reduction of size of prostate using injection of drug Action = destruction|reduction of size, target = prostate, means = injection of drug –Pharmacotherapy 확인 경피적내신우절개술 [ 경피적신 ( 우 ) 루설치술, 방사선료포함 ] –Dilatation of renal pelvis by incision Action = dilatation, target = renal pelvis, means = endoscopic&transparietal &incision Action = incision, target = renal pelvis, means = endoscopic&transparietal

35. Different models for the same concept Urology –Injection of silicon to ureteral submucosa Action = injection, IO = ureteral submucosa, DO = silicon –Reduction of size of ureteral caliber with silicon Action = reduction of size(temporary), target = ureteral caliber, means = silicon

36. Additional intervention on the main procedure Endoscopic biopsy –Action = biopsy, means = endoscopy – 요관경검사 [ 요관점막하주입포함 ]- 경성요관경 Action = injection, IO = ureter, DO = silicon 등, means = endoscope:ureteroscope

37. Future plan Application of extended model with 3 axes values to the real classification for KCHI Consensus on the building guideline Hard work!!! ICHI meeting: 17 – 21 June 2013 in Uddevalle, Sweden