Reports

ICD-11 review: toward implementation planning in Australia

Mardi Ellis

Background

The International Classification of Diseases 11 th Revision (ICD-11), was launched by the World Health Organization (WHO) in June 2018. In May 2019, the World Health Assembly adopted ICD-11 for implementation by Member States from 1 January 2022. The WHO will provide transitional arrangements for at least five years from that date, and as long as it is necessary, to support implementation.

The Australian Institute of Health and Welfare (AIHW) undertakes a program of work relating to health classifications, including the management of the WHO Family of International Classifications Australian Collaborating Centre (WHO-FIC ACC), with funding support from the Australian Government Department of Health (the Department). The AIHW’s work program under the WHO-FIC ACC for 2018–20 included a review of ICD-11 and its potential implementation in Australian health information systems (the Review project).

In Australia, ICD-10 and ICD-10-AM (the Australian Modification) are currently in use in vital statistics, hospital and some other health service patient statistical reporting systems, and in Activity Based Funding arrangements. A decision has not yet been made in Australia as to whether, when or how ICD-11 may be implemented in Australian health information systems to replace some or all of these statistical and reporting arrangements.

The AIHW’s ICD-11 Review project aimed to provide evidence to support that decision making and implementation planning. The first phase of the Review project was a stakeholder consultation process, overseen by the AIHW’s Australian Health Classifications Advisory Committee (AHCAC) and led by Jennie Shepheard, from Shepheard Health Management Consultants.

This article presents an overview of the stakeholder consultation process (stakeholders and resources), summarises the key findings (common themes, strengths, weaknesses, opportunities and threats) and describes the next steps for the Review project. The complete ICD-11 Review Stakeholder Consultation Report will be published by the AIHW in early 2020.

Stakeholder consultation process Stakeholders The Review commenced in 2018 with a stakeholder workshop to inform the consultation process. Twenty individual and group consultations were conducted between January and April 2019, with representatives from: Australian governments, the New Zealand Ministry of Health, the private health sector, the medical software industry and individuals with expertise in classification development and statistical reporting.

The Review was overseen by the AHCAC, with members from the Commonwealth Department of Health, Australian Bureau of Statistics, Independent Hospital Pricing Authority, The Australian Digital Health Agency and two representatives nominated by the Australian Health Ministers’ Advisory Council (AHMAC) from New South Wales and Queensland.

The AIHW’s National Health Information and Data Standards Committee (NHDISC) and Strategic Committee for National Health Information (SCNHI) were also consulted in the development of the ICD-11 Review and proposed work program.

Resources

AIHW advertised the consultation process, and ICD11, through the review flyer, published on the AIHW website and available at the 2018 Health Information Management Association Australia and National Centre for Classification in Health (HIMAA NCCH) conference.

Stakeholders received a pre-consultation paper ahead of their consultation to provide background, context and the 22 questions framing the consultation process. These questions gathered insight on: • Current use of ICD-10 and ICD-10-AM, as well as other classifications and terminologies • Knowledge and understanding of ICD-11

• Current gaps and limitations that may be filled by ICD-11 • Impact of implementing ICD-11, including on current projects, workforce, systems and processes • Consequences of not implementing ICD-11

• The process, timeframes and resourcing required for implementation.

The flyer and pre-consultation paper are available on the AIHW website, at https://www.aihw.gov.au/ourservices/international-collaboration

Key findings Common themes

Six common themes emerged from the consultation process, from across the breadth of the stakeholder group: governance arrangements, workforce capacity and capability, infrastructure, resourcing, communication and education, and intervention classifications.

In discussing governance arrangements for the ICD11, stakeholders expressed a need to understand arrangements at both national and international levels. There was a need for greater clarity on where the responsibilities lay for ongoing development, maintenance and local management of the classification.

In relation to workforce capacity and capability, stakeholders with previous exposure to ICD-11 through WHO development processes understood the future

workforce requirements. These stakeholders discussed the need for more data scientists, data brokers and documentation specialists to realise fully the benefits of ICD-11. The expectation that clinical coding will be largely automated within the next few years, and that this would lead the clinical coding workforce to transition to new roles in the electronic environment, was raised often.

Infrastructure planning issues related to the fact that the full benefit of ICD-11 is realised when it is integrated into electronic health records. Stakeholders expressed concern that the roll out of electronic records is not consistent across Australia, that vendors have tenyear roadmaps with little or no provision for ICD-11 implementation and that these issues may prove to be a barrier to implementation in some settings.

Another common theme was that resourcing requirements are currently unknown. There was insufficient knowledge among stakeholders about the technical developments in ICD-11 and the likely timeframes for implementation made it difficult for stakeholders to have any confidence in providing information on resource requirements. Stakeholders agreed that implementation of ICD-11 is not simply a matter of replacing one classification with another, as was largely the case when ICD-10 (and ICD-10- AM) replaced ICD-9 (and ICD-9-CM) in the late 1990s. Stakeholders also noted that the different settings in which ICD-11 can be implemented may create different pathways to implementation with different resource requirements.

Stakeholders were clear that communication and education are key to stakeholder engagement and acceptance of ICD-11 and that comprehensive communication and education should be provided as soon as possible. Education should initially focus on those who will contribute to decision-making about implementation.

Stakeholders also commonly raised questions about the accompanying procedure/intervention classification to ICD-11, noting that the WHO’s International Classification of Health Interventions (ICHI) should be a complementary consideration. It was thought that significant investigation will be needed to ascertain whether there is a need to update Australia’s existing intervention classification, or whether ICHI will be a suitable replacement. Strengths, weaknesses, opportunities and threats Stakeholder consultation for AIHW’s ICD-11 Review project showed a number of strengths and opportunities for implementing ICD-11 in Australia, along with weaknesses and threats that need to be considered in implementation decision-making and planning.

The Review project showed that the strengths of ICD-11 lie in: • Its digital design, enabling a common framework for integrated classifications and implementations to be developed to suit health information needs in different settings • The improved specificity and clinical currency of codes, applicable to multiple care settings and providing more detailed information for researchers and evidence to underpin policy analysis • The capacity to realise benefits of data not currently able to be collected, such as in primary care, community health or ambulatory care and aged care settings • Better mechanisms for research and for reporting healthcare safety and quality events, with a clustering mechanism that explicitly links characteristics of a patient’s condition, or cause of death.

The opportunities of ICD-11 were seen to include the: • Impetus to change some of things about the way we operate currently, including streamlining existing update processes • Adoption of automated clinical coding tools, such as the WHO coding tool, to ensure the ongoing collection of clinically coded data and freeing up existing clinical coding skills to be used in evaluation and interpretation of data • Potential to introduce a new procedure/intervention classification, using the same change management committees and processes as for an ICD-11 implementation.

The threats to implementation of ICD-11 were perceived by stakeholders to lie in: • The evolving governance frameworks and associated support mechanisms, at the national and international levels for the classification and its implementation, as well as a need for more clarity about the use of clinical terminologies in Australia, their governance, and relationships between digital health information and statistical health information

• Workforce issues, with shortages of appropriately skilled workforce to support eHealth applications and a lack of currently available education material to support workforce readiness • Different levels of electronic health record maturity in Australia, with particular concerns about differential timeframes for rolling out electronic health care systems, the associated costs with new ICD-11-ready systems, and the potential development of multiple clinical coding tools without proper regulation that could affect data integrity

The weaknesses were revealed as: • Concerns about readiness for adoption, which largely related to a lack of clear information about the development of the classification and associated processes, and concerns about it being incomplete at the time of the Review. • The lack of accessible and detailed documentation about the differences between ICD-10 and ICD-11. • That mapping from the Sytematized Nomenclature of Medicine (SNOMED) is not yet available, and this is likely to be necessary to harness the benefits of ICD11 in an e-Health environment.

Next steps The Review showed that Australian stakeholders had limited knowledge of ICD-11, and that concerns related to threats and weaknesses of ICD-11 as raised by stakeholders would need to be addressed ahead of implementation. In this way, the Review revealed a suite of work that could be undertaken to address acknowledged concerns regarding the classification, leverage and realise the strengths of the classification as a digital enabling tool, advance understanding to inform decision making, and to facilitate transition to implementation following a decision to do so.

“... the Review revealed a suite of work that could be undertaken to address acknowledged concerns regarding the classification, leverage and realise the strengths of the classification as a digital enabling tool, advance understanding to inform decision making, and to facilitate transition to implementation following a decision to do so.

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The AIHW developed a proposed work program based on the findings of the Review and with input and advice from AHCAC, NHDISC and SCNHI, in mid-2019.

This program of work was endorsed for further prioritisation and work planning at AHMAC in October 2019.

Proposed work program for prioritisation

The AIHW proposed four broad areas of work to progress investigation of ICD-11 implementation in Australia, as described below. 1. A comprehensive review of how ICD-10-AM is, and ICD-11 could be, used in health information systems, including digital settings. This review would investigate the issues associated with ICD-10-AM and consider the way in which ICD-11 addresses these, to ensure that decision making about implementation covers all possible impacts. 2. Development of a national roadmap for classifications and terminologies and how they will be used together within health information arrangements. This would ensure that classifications and terminologies are used appropriately with consideration of their varied use cases.

3. Strategic communications activities to ensure that decision makers and their advisors can contribute to further work and decision-making over the next year about whether, when and how to implement ICD-11. 4. Continued planning for implementation in mortality data systems and to maintain and advance Australia’s current involvement in this international process.

Figure 2: Broad areas of work and supporting activities

Broad areas of work

Comprehensive review of how ICD is and could be used in health information systems National roadmap for classification and terminologies Strategic communication activities to support decision-makers

Supporting activities

Implementation planning for mortality data systems

Governance arrangements for decision-making International engagement for Australian input, collaboration and cooperation Scoping pilot projects to inform implementation arrangements

AIHW proposed that these four broad themes of work be supported by three other activities: 1. Development of governance arrangements for decision making about ICD-11 implementation and for governance of any future implementation and maintenance activities.

2. International engagement to maintain current Australian input and advice on WHO ICD-11- related processes and to support digital health interoperability. 3. Scoping of pilot projects to demonstrate value and inform implementation planning.

Further planning and prioritisation of this proposed program of work will be undertaken in early 2020, with regular reporting to stakeholders and through the oversight committee structure.

Further information

The report of the AIHW’s ICD-11 stakeholder consultation review will be published and freely available on the AIHW website in early 2020. Information on the Review and ICD-11 is currently available at www. aihw.gov.au/our-services/international-collaboration.

For further information, email the Australian Collaborating Centre at who-fic-acc@aihw.gov.au.

Mardi Ellis Senior Project Officer, Cardiovascular Diabetes and Kidney Unit (formerly Acting Head, Metadata and METeOR Unit) Australian Institute of Health and Welfare GPO Box 570 Canberra ACT 2601 Tel: +61 2 6244 1128 Email: mardi.ellis@aihw.gov.au