The 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) was developed by the World Health Organisation (WHO), released in 2018 and adopted by the Seventy-second World Health Assembly in May 2019. In addition to updated scientific content, ICD-11 has been developed for use in electronic environments and is linked to relevant other classifications and terminologies (WHO 2019). In these respects, ICD-11 represents a significant advance on the 10th revision of ICD, currently in use in Australia and internationally.
The Australian Institute of Health and Welfare (AIHW), as the Australian Collaborating Centre (ACC) for the WHO Family of International Classifications (WHO-FIC), was commissioned by the Commonwealth Department of Health to undertake a review of ICD-11 (the Review) and to explore the case for implementation in Australia.
The Review commenced in 2018 with a stakeholder workshop to inform the consultation process. Twenty individual and group consultations were then 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. Six common themes emerged from these consultations: governance (national and international); workforce; health information infrastructure; resources, settings and timeframes; communication and education; and the procedure/intervention classification.
Governance arrangements for clarity around maintenance and management
With respect to governance, stakeholders expressed a need to understand arrangements at both national and international levels and wanted clarity around where the responsibilities lay for ongoing development, maintenance and local management of the classification.
Workforce capacity and capability to fully realise the benefits of a new classification
Workforce issues raised by stakeholders related to the capacity and capability of the existing workforce. Those with previous exposure to ICD-11, through WHO developmental processes, understand the future workforce requirements. These people discussed the need for more data scientists, data brokers and documentation specialists to fully realise the benefits of ICD-11. It is expected that clinical coding will be largely automated (about 80%) within the next few years, leaving the clinical coding workforce to transition to new roles in the electronic environment.
Infrastructure planning required for electronic health information systems
The full benefit of ICD-11 is realised when it is integrated into an electronic health record. Concern was expressed that the roll out of electronic records is not consistent across Australia, being different between jurisdictions and between public and private health networks. Vendors have ten-year roadmaps and at this stage have made no provision for ICD-11 implementation, almost certainly due to lack of information about this new classification. These issues may prove to be a barrier to implementation in some settings.
Resourcing requirements are currently unknown
Stakeholders had insufficient knowledge about the technical developments in ICD-11 and the likely timeframes for implementation to be confident about providing information on resources that will be needed. They agreed that the integrated nature of existing health data systems means that the 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-CM in the late 1990s. It was also noted that the different settings in which ICD-11 can be implemented may create different pathways to implementation with different resource requirements.
Communication and education is key to stakeholder engagement and acceptance
It became apparent that comprehensive communication and education should be provided as soon as possible. Suggestions were made for case studies to be developed that illustrate the new concepts in ICD-11, for pilot programs to be undertaken to inform larger and more complex implementation programs and for the establishment of implementation committees to manage communication and education in advance of implementation. Education material provided by the WHO may be useful as the basis of Australian specific education.
Complementary intervention classification is a consideration
Some stakeholders raised questions about an accompanying procedure/intervention classification to ICD-11. The WHO is developing an International Classification of Health Interventions (ICHI) which could be considered as a replacement to the Australian Classification of Health Interventions (ACHI). Significant investigation will be needed to ascertain the need to update Australia’s existing intervention classification, the suitability of ICHI and the timing of a replacement.
Strength and opportunity in the digital nature of ICD-11
A SWOT analysis of the information collated through the stakeholder consultation process revealed:
- Significant strengths and opportunities related to the digital solution that ICD-11 provides for improved output reporting, linkage of information from multiple sources, co-ordination of the flow of data from eHealth systems to statistical outputs, the capacity to collect data not previously able to be collected, improved international comparability of health data and the opportunity to reassess many existing processes and systems.
- Weaknesses related to outstanding work to complete some aspects of the classification, the lack of detailed documentation about the differences between ICD-10 and ICD-11 and the lack of mapping tables between ICD-11 and commonly used terminologies such as SNOMED, which underpin electronic health records.
- Threats related mainly to perceived underdeveloped governance arrangements and relationships between terminologies and classifications, workforce issues, lack of education material, and different levels of electronic health record maturity, especially between public and private sectors.
Recommendations to advance readiness for ICD-11 implementation
Key recommendations, drawn from the stakeholder consultation, the key themes and the SWOT analysis related to:
- international and national collaborative efforts to take advantage of work being done in other countries to prepare for ICD-11 implementation and to ensure that Australia’s various information agencies are working together to achieve the benefits promised by ICD-11.
- the committee structure that may be needed to manage implementation and other projects that could be undertaken, possibly in the short to medium term, to advance Australia’s readiness for ICD-11 implementation.