HEALTH DATA CLASSIFICATION 1

BY G. WANJA. T

TOPIC ONE

INTRODUCTION TO ICD, ICPM AND ICHI

COURSE OBJECTIVES
 Definition of ICD 11 and ICPM/ICHI
 Terms used in both ICD10 and ICD11
 Types of classification
 Principles of classification
 Historical development of ICD, ICPM and ICHI
 Structure of the classification
 General arrangement of ICD 10, ICD 11 and ICPM
 Differences between ICD 10 and ICD 11 and their application
 WHO concept of family of international classification
 Advantages of ICD 10 and the ICD 11 package and the components

Definitions

ICD- International Classification of Diseases and other related health problems formerly
referred to as International Statistical Classification of Diseases.
• It is a tool for recording, reporting and grouping conditions and factors that influence health.
It contains categories for diseases and disorders, health related conditions, external causes of
illness or death, anatomy, sites, activities medicines, vaccines and more.
• The ICD is:
• Internationally: Produced by the WHO (World Health Organization) as the result of
international agreements.
• Statistical classification of diseases: Used by the member countries so that comparative
figures produced in statistical tables of disease and injuries arranged in a meaningful way •
ICPM- It means international classification of procedures in medicine. ICPM outline the
classification of therapeutic, diagnostic and prophylactic procedures in medicine. It covers
surgery, radiology, laboratory and other
• ICHI- The International Classification of Health Interventions. Replaces the former ICPM
Procedures.

DEFINATION OF OTHER COMMONLY USED TERMS

• Health- A complete state of physical, mental and social wellbeing of an individual and
not merely the absence of disease or infirmly
• Disease classification- Disease classification according to WHO can be defined as a
system of categories to which morbid entities are assigned according to established criteria •
Code- Refers to a specific system or number agreed upon in a given set up to offer a
classification or an arrangement order for that particular set up.
• Coding- It is the process of establishing a specified number for a given disease or
condition for a patient statement of cause of admission into the hospital.
• Indexing- it is the process of writing down the patients’ particulars on to an identified
material or equipment once coding has been done • Morbidity- A state of being diseased or
having disease.
• Mortality- refers t-o the number of deaths that have occurred due to a specific illness
or condition.
• Diagnosis- this refers to the patients’ disease or conditions or statements of cause of
admission • Discharge summary- this is the patients’ document written by clinician at the time
of discharge.
Types of classification

1. Reference classifications
• These are the classifications that cover the main parameters of the health system, such as
death, and disease (ICD), disability, functioning and health (ICF) and health interventions
(ICHI). WHO reference classifications are a product of international agreements. They have
achieved broad acceptance and official agreement for use and are approved and
recommended as guidelines for international reporting on health.
• Examples include:
• 1. International Classification of Diseases and Health Related Problems (ICD) - Used to
capture morbidity and morbidity
• 2. International Classification of Functioning, Disability & Health (ICF) - Used to capture
information on various domains of human functioning and disability and health
• 3. International Classification Health Interventions (ICHI) - Replaces the former ICPM used to
classify procedures in medicine. ICHI is much broader than the ICPM as it includes
interventions across all functional sectors of the health system, covering acute care, primary
care, rehabilitation, assistance with functioning, prevention, public health, and ancillary
services delivered by all types of providers.

2. Derived classifications

 Derived classifications are often tailored for use at the national or international level or
for use in particular specialty.
 They are based on reference classifications (i.e. ICD, ICF, ICHI)
  Derived classifications are prepared by: adopting the reference classification structure
and classes, providing additional detail beyond that provided by the reference
classification and the rearrangement or by aggregation of items from one or more
reference classifications.
 The classifications include:
• The International classification of diseases for oncology, 3rd edition (ICD-O-3) -
published by WHO in2000, is intended for use in cancer registries, and in pathology and other
departments specializing in cancer
The international classification of diseases to dentistry and stomatology, 3rd edition (ICD-DA).
It brings together ICD categories for diseases or conditions that occur in, have manifestations
in, or have associations with the oral cavity and adjacent structures.
• The ICD-10 classification of mental and behavioral disorders (included in Chapter V of
the ICD10). The ICD-10 classification of mental and behavioral disorders: clinical descriptions
and diagnostic guidelines, published by WHO in 1992, provides a general description and
guidelines concerning the diagnosis, as well as comments about differential diagnosis and a
listing of synonyms and exclusion terms.
• The international classification of diseases to neurology, 2nd edition (ICD-10-NA)-which
retains the classification and coding systems of ICD-10 but is further, subdivided at the
fifthcharacter level and beyond, to allow neurological diseases to be classified with greater
precision.
3. Related classifications
Related classifications describe important aspects of health or the health system not covered
by reference or derived classifications.
They include:
• International Classification of Primary Care (ICPC)
• International Classification of External Causes of Injury (ICECI)
• Technical aids for persons with disabilities (ISO9999)
• The Anatomical Therapeutic Chemical Classification with Defined Daily Doses (ATC/DDD)
The International Classification for Nursing Practice (ICNP)

Principles of classification of ICD/diseases

• The structure of ICD was proposed by William Farr who recommended that for all practical,
epidemiological purposes, statistical data on diseases and conditions and their causes should
be grouped in the following way:
• Epidemic diseases
• Constitutional or General Diseases that affect the whole body
• Local diseases arranged by site
• Developmental diseases
• injuries
This pattern can be identified in the chapters of both ICD 10 and ICD [Link] has stood the test of
time and, though in some ways arbitrary, is still regarded as a more useful structure for general
epidemiological purposes than any of the alternatives tested.
The first two and the last two as listed above comprise of special groups which bring together
conditions that would be conveniently arranged for epidemiological study were they to be
scattered.
In a classification arrange by primary anatomical site, the remaining group, local diseases
arranged by site includes the ICD chapters for each of the main body systems
The distinction between the special groups and the body systems chapters has practical
implications for understanding the structure of the classification, for coding to it, and for
interpreting statistics based on it
It has to be remembered that in general, conditions are primarily classified to one of the
special group’s chapters. Where there is any doubt as to where a condition should be
positioned; the special group chapters should take priority.

EXAMPLES OF SPECIAL GROUP CHAPTERS

Historical development of ICD and ICPM
• The classification of diseases dates back to 1600s, when a captain, John Graunt directed the
attention of the world to morbidity and mortality statistics.
• He is credited with a statistical study of diseases.
• His publication was based on London Bills of Mortality in 1662.

• The kind of classification is exemplified by his attempt to estimate the proportion of live

born children who died before reaching the age of six years, no records of age at death
being available.
• He took all deaths and classified as thrush, convulsions, rickets, teeth and worms, abortive,

infants, live-grown and overlaid and added to them deaths classed as smallpox, swinepox,
measles and worms without convulsions.
• Between 1706-1777, Francois Bossier de Lacroix, better known as Sauvages, made his first

attempt to classify diseases systematically. Sauvages ‘comprehensive treatise was published

under the title Nosologia methodica. In 1707-1778, a contemporary of sauvages called
Linnaeus also published a classification entitled General Morborum, a catalogue of diseases.
•
At the beginning of 19th century, the classification of disease in most general use was one by
William Cullen (1710-1790), of Edinburgh, which was published in 1785 under the title
synopsis nosologiae methodicae.
• Fortunately for the progress of preventive medicine, the General Register Office of England

and Wales, at its inception in 1837, found in William Farr (1807–1883) – its first medical
statistician –a man who not only made the best possible use of the imperfect classifications
of disease available at the time, but labored to secure better classifications and
international uniformity in their use.
• Farr found Cullen’s classification in use in the public services. It had not been revised to

embody the advances in medical science, nor was it deemed by him to be satisfactory for
statistical purposes
• Farr realized that small numbers that would result from a detailed classification would not

permit statistical inferences to be made.

• In the first Annual Report of the Registrar General, therefore, Farr discussed the principles

that should govern a statistical classification of disease and urged the adoption of a uniform
statistical
Classification.
• Both nomenclature and statistical classification received constant study and consideration by

Farr in his annual ‘Letters’ to the Registrar General published in the Annual Reports of the
Registrar General. Farr did much to promote his classification but could not find general
acceptance.
• However, the utility of a uniform classification of causes of death was so strongly recognized

at the first International Statistical Congress, held in Brussels in 1853, that the Congress
requested William Farr and Genevan Marc d’Espine to prepare an internationally applicable,
uniform classification of causes of death.
• At the next Congress, in Paris in 1855, Farr and d’Espine submitted two separate lists which
were based on very different principles.
• Farr’s classification was arranged under five groups: epidemic diseases, constitutional

(general) diseases, local diseases arranged according to anatomical site, developmental

diseases, and diseases that are the direct result of violence.
• D’Espine classified diseases according to their nature (gouty, herpetic, hematic, etc.).The

Congress adopted a compromise list of 139 rubrics.

• Importantly, the 1855 Congress also recommended that each country should ask for

information on causes of death from the doctor who had been attending the deceased, and
that each country should take measures to ensure that all deaths were verified by doctors •
At the Fourth International Statistical Congress, held in London in 1860, Florence Nightingale
urged the adoption of Farr’s classification of diseases for the tabulation of hospital morbidity
in the paper, ‘Proposals for a uniform plan of hospital statistics.’
• In 1864, this classification was revised in Paris on the basis of Farr’s model and was

subsequently further revised in 1874, 1880, and 1886.

• Although this classification was never universally accepted, the general arrangement

proposed by Farr, including the principle of classifying diseases by etiology followed by

anatomical site, survived as the basis of the International List of Causes of Death. • At its
1891 meeting in Vienna, the International Statistical Institute, the successor to the
International Statistical Congress, charged a committee chaired by Jacques Bertillon
(18511922), Chief of Statistical Services of the City of Paris, with the preparation of a
classification of causes of death.
• The committee’s report was presented and adopted at the meeting of the International

Statistical Institute in Chicago in 1893.

• For main headings, Bertillon adopted the anatomical site rather than the nature of disease,

according to Farr’s plan.

• Bertillon’s list included defined diseases most worthy of study by reason of their

transmissible nature or their frequency of occurrence.

• In accordance with the instructions of the Vienna Congress, Bertillon included three

classifications: an abridged classification of 44 titles; a classification of 99 titles; and a

classification of 161 titles.
• Bertillon also prepared some rules or guidelines on the resolution of problems; for example,

how statistical clerks should classify what is written without imputing what the doctor might
have meant.
• The ‘Bertillon Classification of Causes of Death’, as it was first called, received general
approval and was adopted by several countries, as well as by many cities.
• The classification was first used in North America by Jesus E. Monjaras for the statistics of
San Luis de Potosi, Mexico.

• In 1898, the American Public Health Association, at its meeting in Ottawa, Canada,
recommended the adoption of the Bertillon Classification by registrars of Canada, Mexico,
and the United States of America.
• The Association further suggested that the classification should be revised every ten years. •
At the meeting of the International Statistical Institute at Christiania in 1899, Bertillon
presented a report on the progress of the classification, including the recommendations of
the American Public Health Association for decennial revisions.
• The French Government therefore assembled in Paris, in August 1900, the first International
Conference for the Revision of the Bertillon or International List of Causes of Death.
Delegates from 26 countries attended this Conference.
• A detailed classification of causes of death consisting of 179 groups and an abridged
classification of 35 groups was adopted on 21 August 1900.
• The desire for decennial revisions was recognized, and the French Government was
requested to call the next meeting in 1910.
• In fact, the next conference was held in 1909, and the Government of France called
succeeding conferences in 1920, 1929, and 1938.
• Bertillon continued to be the guiding force in the promotion of the International List of
Causes of Death, and the revisions of 1900, 1910, and 1920 were carried out under his
leadership.
• As Secretary- General of the International Conference, he sent out the provisional revision
for1920 to more than 500 people, asking for comments.
• His death in 1922 left the International Conference without a guiding hand.
• At the 1923 session of the International Statistical Institute, Michel Huber, Bertillon’s
successor in France, recognized this lack of leadership and introduced a resolution for the
International Statistical Institute to renew its stand of 1893 in regard to the International
Classification of Causes of Death and to cooperate with other international organizations in
preparation for subsequent revisions.
• The health organization of the League of Nations had also taken an active interest in vital
statistics and appointed a Commission of Statistical Experts to study the classification of
diseases and causes of death, as well as other problems in the field of medical statistics.
• E. Roesle, Chief of the Medical Statistical Service of the German Health Bureau and a
member of the Commission of Statistical Experts, prepared a monograph that listed the
expansion in the rubrics of the 1920International List of Causes of Death that would be
required if the classification were to be used in the tabulation of statistics of morbidity. This
careful study was published by the health organization of the League of Nations in 1928.
• In order to coordinate the work of both agencies, an international ‘Mixed Commission’ was
created with an equal number of representatives from the International Statistical Institute
and the Health organization of the League of Nations.
• This Commission drafted the proposals for the Fourth (1929) and the Fifth (1938) revisions of
the International List of Causes of Death.

THE FIFTH DECENNIAL REVISION CONFERENCE

• The Fifth International Conference for the Revision of the International List of Causes of
Death was convened by the Government of France and was held in Paris in October 1938.
 •The Conference approved three lists: a detailed list of 200 titles, an intermediate list of 87
titles and an abridged list of 44 titles.
• Apart from bringing the lists up to date in accordance with the progress of science,
particularly in the chapter on infectious and parasitic diseases, and changes in the chapters
on puerperal conditions and on accidents, the Conference made as few changes as possible
in the contents, number, and even in the numbering of the items.
• A list of causes of stillbirth was also drawn up and approved by the Conference.
• As regards classification of diseases for morbidity statistics, the Conference recognized the
growing need for a corresponding list of diseases to meet the statistical requirements of
widely differing organizations, such as health insurance organizations, hospitals, military
medical services, health administrations, and similar bodies.
• The following resolutions were adopted:
• International list of diseases
• Previous classifications of diseases for morbidity statistics United States Committee on
Joint
Causes of Death- the American Secretary of State in 1945 appointed the United States
Committee on Joint Causes of Death under the chairmanship of Lowell J. Reed, Professor of
Biostatistics at Johns Hopkins University.

SIXTH REVISION OF THE INTERNATIONAL LIST

• The International Health Conference held in New York City in June and July 1946 entrusted
the Interim Commission of the World Health Organization with the responsibility of
‘reviewing the existing machinery and of undertaking such preparatory work as may be
necessary in connection with :
• (i) the next decennial revision of ‘The International Lists of Causes of Death’ (including the
lists adopted under the International Agreement of 1934, relating to Statistics of Causes of
Death); and
• (ii) the establishment of International Lists of Causes of Morbidity.’
• To meet this responsibility, the Interim Commission appointed the Expert Committee for the
Preparation of the Sixth Decennial Revision of the International Lists of Diseases and Causes
of death.
• This Committee, taking full account of prevailing opinion concerning morbidity and mortality
classification, reviewed and revised the above-mentioned proposed classification which had
been prepared by the United States Committee on Joint Causes of Death.
• The resulting classification was circulated to national governments preparing morbidity and
mortality statistics for comments and suggestions under the title, International
Classification of Diseases, Injuries, and Causes of Death.
• The International Conference for the Sixth Revision of the International Lists of Diseases and
Causes of Death was convened in Paris from 26 to 30 April 1948 by the Government of
France under the terms of the agreement signed at the close of the Fifth Revision Conference
in 1938.
• Its secretariat was entrusted jointly to the competent French authorities and to the World
Health Organization, which had carried out the preparatory work under the terms of the
arrangement concluded by the governments represented at the International Health
Conference in 1946.
• The Conference adopted the classification prepared by the Expert Committee as the Sixth
Revision of the International Lists.
• The Conference approved the International Form of Medical Certificate of Cause of Death,
accepted the underlying cause of death as the main cause to be tabulated, and endorsed the
rules for selecting the underlying cause of death as well as the special lists for tabulation of
morbidity and mortality data.
• The International Classification, including the Tabular List of Inclusions defining the content
of the categories, was incorporated, together with the form of the medical certificate of
cause of death, the rules for classification and the special lists for tabulation, into the Manual
of the International Statistical Classification of Diseases, Injuries, and Causes of Death.
• The Manual consisted of two volumes, Volume 2 being an alphabetical index of diagnostic
terms coded to the appropriate categories. In the Sixth Revision, morbid conditions resulting
from injuries, poisoning sand other external causes were classified according to both the
external circumstances giving rise to the injury and to the kind of injury.
• The Sixth Decennial Revision Conference marked the beginning of a new era in international
vital and health statistics.

THE SEVENTH AND EIGHTH REVISION

• The International Conference for the Seventh Revision of the International

Classification of Diseases was held in Paris under the auspices of the WHO in February 1955.
• In accordance with a recommendation of the WHO Expert Committee on Health
Statistics, this revision was limited to essential changes and amendments of errors and
inconsistencies.
• The Eighth Revision Conference was convened by the WHO met in Geneva, from 6 to
12 July1965. This revision was more radical than the Seventh but left unchanged the basic
structure of the Classification and the general philosophy of classifying diseases, whenever
possible, according to their etiology rather than a particular manifestation.
• During the years that the Seventh and Eighth Revisions of the ICD were in force, the use
of the ICD for indexing hospital medical records increased rapidly and some countries
prepared national adaptations which provided the additional detail needed for this application
of the ICD.

THE NINTH REVISION

• The International Conference for the Ninth Revision of the International Classification of
Diseases, convened by the WHO, met in Geneva from 30 September to 6 October 1975.
• In the discussions leading up to the conference, it had originally been intended that there
should be little change other than updating of the classification.
• This was mainly because of the expense of adapting data processing systems each time the
classification was revised.
• There had been an enormous growth of interest in the ICD and ways had to be found of
responding to this, partly by modifying the classification itself and partly by introducing
special coding provisions.
• A number of representations were made by specialist bodies which had become interested in
using the ICD for their own statistics.
• Some subject areas in the classification were regarded as inappropriately arranged and there
was considerable pressure for more detail and for adaptation of the classification to make it
more relevant for the evaluation of medical care, by classifying conditions to the chapters
concerned with the part of the body affected rather than to those dealing with the
underlying generalized disease.
• At the other end of the scale, there were representations from countries and areas where a
detailed and sophisticated classification was irrelevant, but which nevertheless needed a
classification based on the ICD in order to assess their progress in health care and in the
control of disease.
• The final proposals presented to and accepted by the Conference retained the basic
structure of the ICD, although with much additional detail at the level of the four-digit
subcategories, and some optional five digit subdivisions.
• For the benefit of users not requiring such detail, care was taken to ensure that the
categories at the three-digit level were appropriate.
• For the benefit of users wishing to produce statistics and indexes oriented towards medical
care, the Ninth Revision included an optional alternative method of classifying diagnostic
statements, including information about both an underlying general disease and a
manifestation in a particular organ or site.
• This system became known as the dagger and asterisk system.
• The Twenty Ninth World Health Assembly, noting the recommendations of the International
Conference for the Ninth Revision of the International Classification of Diseases, approved
the publication, for trial purposes, of supplementary classifications of Impairments and
Handicaps and of Procedures in Medicine as supplements to, but not as integral parts of, the
International Classification of Diseases.
THE TENTH REVISION

• Even before the Conference for the Ninth Revision, the WHO had been preparing for
the Tenth Revision.
• It recognized that the great expansion in the use of the ICD necessitated a thorough
rethinking of its structure and an effort to devise a stable and flexible classification, which
should not require fundamental revision for many years to come.
• The WHO Collaborating Centers for Classification of Diseases were consequently called
upon to experiment with models of alternative structures for ICD–10.
• It had also become clear that the established ten-year interval between revisions was
too short. • Work on the revision process had to start before the current version of the ICD
had been in use long enough to be thoroughly evaluated, mainly because the necessity to
consult so many countries and organizations made the process a very lengthy one.
• The Director General of the WHO therefore wrote to the Member States and obtained
their agreement to postpone a1985 Tenth Revision Conference until 1989, and to delay the
introduction of the Tenth Revision which would have been due in 1989.
• In addition to permitting experimentation with alternative models for the structure of
the ICD, this allowed time for the evaluation of ICD-9, for example through meetings organized
by some of the WHO Regional Offices and through a survey organized at headquarters. • The
International Conference for the Tenth Revision of the International Classification of Diseases,
attended by delegates from 43 Member States, was convened by the World Health
organization in Geneva from 26 September to2 October 1989.
• The United Nations, the International Labor Organization, and the WHO Regional
Offices sent representatives to participate in the Conference, as did the Council for
International organizations of Medical Sciences.
• Twelve other non-governmental organisations concerned with cancer registration, the
deaf, epidemiology, family medicine, gynecology and obstetrics, hypertension, health records,
preventive and social medicine, neurology, psychiatry, rehabilitation and sexually transmitted
diseases were also invited.
• The main innovation in the Tenth Revision was the use of an alphanumeric coding
scheme of one letter followed by three numbers at the four-character level.
• This had the effect of more than doubling the size of the coding frame in comparison
with the Ninth Revision and enabled the vast majority of chapters to be assigned a unique
letter or group of letters, each capable of providing 100three-character categories.
• Of the 26 available letters, 25 had been used, the letter U being left vacant for future
additions and changes, and for possible interim classifications to solve difficulties arising at the
national and international level between revisions.
• Another important innovation was the creation towards the end of certain chapters of
categories for post procedural disorders.
• These identified important conditions that constituted a medical care problem in their
own right. Post procedural conditions that were not specific to a particular body system
continued to be classified in the chapter on ‘Injury, poisoning and certain other consequences
of external causes’.
• The Revision included definitions, standards, and reporting requirements related to
maternal mortality and to fetal, perinatal, neonatal and infant mortality.
• It was published in three volumes: one containing the Tabular List, a second containing
all related definitions, standards, rules and instructions, and a third containing the Alphabetical
Index.
• The tenth revision was adopted in 1990, published in 1992 and was first used by the
member states in 1994.

Eleventh revision of ICD

• The ICD-11 is the eleventh revision of the International Classification of Diseases, and will
replace theICD-10asthe global standard for coding health information and causes of death.
• The ICD is developed and annually updated by the World Health Organization (WHO).
• Development of the ICD-11 started in 2007 and spanned over a decade of work, involving
over 300 specialists from55 countries divided into 30 work groups, with an additional 10,000
proposals from people all over the world.
• A stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all
WHO members during the 72nd World Health Assembly on 25 May 2019. The ICD-11
officially came into effect on 1 January 2022.

ICPM BRIEF HISTORY

• When ICD-9 was published by WHO, the ICPM was also developed in 1975 and published in
1978 but it was not maintained.
• ICPM was published separately from the ICD disease classification.
• ICHI was developed to replace the former ICPM because it is much broader which includes a
full range of interventions.
• ICHI development together with ICD-11 began in 2007 as a joint effort of the WHO family of
international classifications network.
• Content development commenced in 2011, and a first version was available in late 2012,
with subsequent yearly updates. ICHI development was undertaken by a broad-based
international team of experts and was followed by a range of tests and field at country and
international level. • Initial planning was not to attempt to match the level of granularity in
existing national classifications. To allow users to add more detail if they chose, extension
codes were added to ICHI as the content development and refinement continued. Extension
codes werebeing included at the same time in the development of ICD-11, and care was
taken to avoid duplication and inconsistencies.
• The initial electronic platform for ICHI was developed in 2016 by the University of Udine,
Italy, which made the ICHI development process transparent and served as a development
platform.
• In 2020, the Beta-3 version of ICHI was released. ICHI was incorporated on to the WHO’s
classifications platform, which includes all three WHO reference classifications. The platform
provides an updating mechanism which allows improvements in user guidance and scientific
updates without compromising the statistical use of the classification.