Florence Nightingale was the first person to make a proposal to develop a model for collection of hospital data the International Statistical Congress held in London in 1860 (1). Jacques Bertillon, a French physician first simulated a paper classifying the causes of death among the population in the International Statistical Institute in 1893, Chicago. Several countries popularized the Bertillon system where the diseases were segregated into general and localized forms to classify the deaths in Paris (2). This lead to revision of this technique by many countries like UK, Germany and Switzerland and each country implemented and modified according to their own needs. The classification grew from 44 categories to a whopping 161 categories. It was proposed by the American Public Health Association in 1898 to adopt similar techniques in Canada, Mexico as well as United States. Revision of the policy was also recommended by the APHA every ten years to keep the policy updated according to the current medical practices. This lead to the inauguration of the first International Classification Causes of Death conglomerate in the 1900. The revisions and updates occurring consequently after 10 years (3). The initial classification system consisted of a tabular list with alphabetical arrangement to help identify the diseases. Many revisions changed the setting of policy codes until only after revision of the sixth update the policy was segregated into two categories, the Statistical Classification of Diseases and Injuries and Causes of Death or ICD. Before the segregation the ICD acts was under the governance of a union of ISI and Health Organization of the League of Nations called Mixed Commission. It was in 1948 that the World Health Organization undertook the responsibility to handle the ICD matters of governance and revision every ten years (4). The subsequent revisions were conducted by WHO after every ten years but it was later decided that the time span was too short for updates. Currently ICD is the most widespread statistical classification many major countries like Australia, Canada as well as United states and implemented their own adaptations according to the country’s diseases prevalence. The codes now classify for diagnostic and operative techniques.
Legislative track of ICD
The joint efforts of the international health organizations lead the development of the ICD governing body since the beginning of sixth century. The accumulated efforts formed a constructive governing body to track disease epidemics across the globe. The Registration Act was passed in 1837 in England to study the causation of mortality rates in the country as a population study (5). 1909 was the beginning from where the use of ICD-1 was being implemented as a part of The United Nations. The responsibility of the governance of ICD was passed to WHO in 1946. The central office of the American Hospital association (AHA) published the Memorandum of Understanding twenty years later for the ICD-9 based issues. The beginning of late 1960s leads the development of ICD-8 codes. After which in 1975 the WHO published the specific changes in the policy of the ICD codes and became ICD-9. It was this time the segregation of the codes was done to include the diagnostic procedural in the coding system. The ICD-10 code set included 155,000 codes from the ICD-9 version, which were 17,000 codes (6). The draft for this development was implemented in the United States only five years later in 1995. Thereafter, UK legislations started implementing the codes for the purpose of reimbursements in that year. A year later after the publication of the new codes, thirteen new countries adopted the ICD0-10 for assessment of morbid statistic purposes. The evaluation of ICD-10 codes was conducted by the national Centre for Health Statistics in 1997, which included updated revision of terminologies, classification of diseases and updated medical advancements. The French, Norway and other countries also implemented the codes for reimbursement purposes. The US government started utilizing the code to evaluate mortality rates in the year 1999 and it became a part of the healthcare service during that time. During the same time the Health endurance Portability and Accountability (HIPPA) the Health and Human Services (HHS) which utilized the data from ICD-10 passed act. The International Classification of Functioning, Disability and Health (ICF) was approved by World Health assembly along with the publication of ICD-10 in 42 foreign languages along with 6 official WHO languages. ICD-9 was identified by the HIPPA as a medium for presenting diagnostic procedures associated with electronic administrative transaction in the year 2003. In 2008, HHS gave a legislative proposal to update the new codes for ICD-10 on 2011 (7). In the 2013, the HHS finalized the publication date to change the rule, which provided the legislative bodies and stakeholder additional couple of years to inaugurate the preparation for the transition. An estimation was published by the Centres for Medicare and Medicaid services (CMS), which showed that the increases of 0.03 % revenue would result for the implementation of ICD-10. The US Secretary was banned from adopting the ICD-10 by the Protecting Access to Medicare Act in 2014, that resulted in the delay of the compliance. During this time the WHO announced were appropriately reported. Their updated version of ICD-11 on 2017. The White House proceeded with the freeze of ICD-10 with support from the AMA to avoid the financial disaster along with CMS collaboration.
Changes made by the Committees
Over the years the ICD have been updated and revised to include the current medical trends with the change in the world. The ICD-6 published in 1949 was the first updated version of the modern coding system, which included the morbidities. The code included the combination for the injuries and recorded the external factors. The need for inclusion of mental health was for the first time considered that were added in the next update (8). The ICD-7 included the mentioned inclusion of mental health records and was published in 1955. The eighth revision of ICD codes ICD-8a was published in Geneva, 1965 where the updated revision was done in a more thorough approach. The initial structures of the Codes were not changed but the indexing of hospital records was included in the new revised version. The independent group in USA devised an analytical evaluation of the codes, which included the hospital morbidity data. The American Hospital Association’s “Advisory Committee to the Central Office on ICDA” introduced the adaptation procedures (9). Finally, in 1968 the ICDA released the updated data of codes, which included the diagnostic data along with both morbidity and mortality statistics of the hospitals. In 1975 the WHO published the ninth revision of the codes of ICD contained the codes which were about 3-4 digits long with approximately 3000 codes. The technology described the ninth codes were not updated to the current times. The laterality of the codes was outdated. The terminologies used were general instead of clinical. The methodology and technology did not describe the details. The data was insufficient. The updated version of the tenth version ICD code was published in 1999 (10). The code set included seven digit long letter and numbers for inclusion of more data, which contributed to make 87.000 codes. The new code set included newer and updated terminology where the terms, body parts and techniques were described properly as per clinical standards. The segregation of the body parts were according to the diseases morbidities. The newest version of the ICD code was published as a draft in 2015. The new draft is supposedly inclusive of the diseases with important definitions in normal readable format. The newer version contains a “content model” describes the coded definition of key terms (11). The version includes a title of identity with the classification properties as well as textual; definitions, terms, description of structure, temporal properties, description of severity of the diseases, manifestation of diseases, casual properties, functional properties, specific conditions, treatment as well as diagnostic criteria. These will be separate chapter of the codes published version. The newer version includes the historical information along with current information. Additionally the digitization of the ICD codes is being developed. According to the WHO website the new updated version will include online editing, granted access to users. Quality will be assured by peer reviewed journal and article citations. Multiple languages will be incorporated (12). The ICD-11 will include electronic health application additions and will be freely downloadable for personal use.
Identification of Stakeholders
The identified stakeholders of the ICD are doctors, nurses, researchers, healthcare providers, coders, Information technology workers, policy makers and healthcare organizations that utilize the codes for their benefit. The importance of the support of the stakeholders is implementation of changes, which benefit the system. The CMS allows the stakeholders to identify the problems with the codes and make respective changes by accessing the technical supportive system (13). Various government organizations that utilize the codes for maintain the surveillance of health risks respective of every country is also part of the stakeholders of the ICD.
Beneficiaries of the ICD codes
The purpose the ICD codes is to help readers, government health officials, policy makers, practitioners, nurses and other medical professionals stay updated on the current medical trends and develop better clinical practice initiates and identify the risks for providing better care to the general public (13). The public is the main benefactor of the codes as the health outcomes derived from the codes are dependent on the development of newer improved health policies.
Adversaries of the ICD codes
The misguidance from the ICD will have direct effect on the healthcare professionals and researchers. The development of improved medicines is depending on the accuracy of the information provided by the ICD (14). The ultimate effect will be focused on the public who will be deprived form the advancements if the policies are not up to date.
Cost of the ICD program
The WHO does not disclose the cost of production for the ICD codes along with the necessary updates, but considering the large impact and effectiveness of the codes, it can be contemplated that the cost of making is in millions.
Personally, I will be using the codes to keep myself updated about the current medical affairs and diseases, since my duty, as a nursing student is to keep myself updated about the current clinical practices.
Currently the changes that need to be incorporated in the ICD, is the inclusion of social determinants of health that affect the minority community for the identification of the health gaps and developments of separate criteria.
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