A Transformative Innovation to Clinical Coding for Better Data and Less Burden.

Area of Science:

• Health Informatics
• Medical Coding Systems
• Clinical Data Representation

Background:

• The International Classification of Diseases (ICD) is crucial for documenting healthcare concepts, evolving from statistical needs to diverse clinical applications.
• The World Health Organization's (WHO) eleventh revision, ICD-11, is being evaluated for its suitability in clinical quality, decision-making, and secondary data use.

Purpose of the Study:

• To evaluate the capabilities of ICD-10-CM, standard ICD-11 for Mortality and Morbidity Statistics (ICD-11-MMS), and an enhanced ICD-11-MMS prototype (ICD-11-CCL).
• To assess their effectiveness in representing clinical patient profiles for natural clinical language scenarios.
• To compare systems based on granularity, comprehensiveness, accuracy, precision, relevancy, and user-friendly coding support.

Main Methods:

• Comparison of coding systems: ICD-10-CM, standard ICD-11-MMS, and ICD-11-CCL.
• Evaluation using two natural clinical language scenarios.
• Assessment criteria included granularity, comprehensiveness, accuracy, precision, relevancy, and coding support usability.

Main Results:

• Both standard and enhanced ICD-11-MMS provided greater clinical detail than ICD-10-CM.
• ICD-11-CCL demonstrated superior comprehensiveness and allowed direct clinician input, unlike ICD-10-CM and standard ICD-11-MMS.
• ICD-11-CCL generated unique code clusters per scenario, avoiding the synonymous clusters seen in ICD-11-MMS.

Conclusions:

• An enhanced ICD-11-MMS, like ICD-11-CCL, can provide nuanced clinical data for secondary applications more effectively than standard ICD-11-MMS.
• It retains the capability for international comparative statistics while potentially reducing manual coding effort with automated tools.
• ICD-11-CCL represents a significant advancement over ICD-10 modifications and warrants further development for future adoption.