The document discusses plans for a collaboration between the American Medical Association (AMA) and the World Health Organization (WHO) to develop an integrated international classification of health interventions (ICHI). The goals are to improve interoperability of clinical data globally and enable cross-border data analysis. Key points discussed include establishing an expert group jointly appointed by AMA and WHO, developing ICHI using existing AMA and WHO source materials, and providing financial support for the project over 5 years.

1. International Classification of Health Interventions
COLLABORATION ARRANGEMENT

2. Outline
• WHO perspective Ustun
• AMA perspective Musacchio
• ICHI work to date Madden
• Computable Classifications Musen
• Content Model Tu & Nyulas
• Conclusions All
• Question & Answers

3. Why do we need an
Interventions Classification?
• Clinical Documentation
• Monitoring and Evaluation
• Quality Indicators
• Safety Indicators
• Efficiency and Effectiveness research
• Reimbursement
• Resource Allocation Decisions

4. Global Landscape
WHO SURVEY 2006
 Countries without an Intervention Classification: around 130
 Countries with an Intervention Classification: 60
 Countries using ICD-9-CM Vol 3: 12
 Countries using Casemix: 20
 OECD: sentinel interventions – Health Accounts 28

5. WHO Family of Classifications
REFERENCE
Classifications
I nternational
C lassification of
D iseases
I nternational
C lassification of
F unctioning,
Disability &
Health
I nternational
C lassification of
H ealth
I nterventions
(under development)
RELATED
Classifications
International Classification
of External Causes of
Injury (ICECI)
The Anatomical,
Therapeutic, Chemical
(ATC) classification system
with Defined Daily Doses
(DDD)
ISO 9999 Technical aids
for persons with disabilities
– Classification and
Terminology
International Classification
of Primary Care (ICPC)
DERIVED
Classifications
International Classification
of Diseases for Oncology,
Third Edition (ICD-O-3)
The ICD-10 Classification of
Mental and Behavioural
Disorders
Application of the
International Classification
of Diseases to Dentistry and
Stomatology
(ICD-DA)
Application of the
International Classification
of Diseases to Neurology
(ICD-10-NA)
5

6. Current Status - WHO
© Copyright WHO
alpha

7. Current Status - AMA
© Copyright AMA

8. FUTURE: AMA + WHO
+
2018
alpha


9. ICHI Development Goals
1. Evolve a multi-purpose and coherent classification
– primary care, clinical care, research, public health…
– Consistency & interoperability across different uses
2. Serve as an international and multilingual reference
standard for scientific comparability and communication
purposes
3. Ensure that ICHI will function in an electronic health
records environment.
• Link ICHI logically to underpinning terminologies and
ontologies

10. Unpacking the Future Classification
1. Ontology
Structure
2018
2. Ontology
Content
a) CPT…
b) ICHI α, β, 2018…

11. What is
NOntology?
• Ontology (philosophy)
NOT meant as the Organization of Reality  !!!
• Ontology (computer science)
– the explicit – operational description of the
conceptualization of a domain:
• Concepts: Entity
Properties
Value
• An ontology defines:
– a common vocabulary
 a shared understanding/exchange:
• among software agents ( & people ?)
– to reuse data - information
– to introduce standards to allow interoperability

12. Knowledge Representation
the triad of things, thoughts and words
(Ogden & Richards, 1923 )
APPLE
TERM

13. What is CPT®?
• CPT codes are an organized compilation of standardized descriptions and five
character alphanumeric codes that physicians, medical coders and billers use
to report healthcare services and procedures to payers for reimbursement
• CPT codes provide a uniform language accurately describing medical,
surgical and diagnostic services
• CPT codes serve as an effective means for reliable communications within the
U.S. healthcare industry

14. CPT Brief History
• First published as a 4 digit system in 1966
• Moved to its current 5 digit system in 1977
• Adopted for programs administered by the Centers for Medicare and Medicaid
Services in 1983
• Named as a Federal U.S. standard procedure code set for electronic
transactions for physician services and other healthcare services in August 2000
• Over 8000, surgical, diagnostic and cognitive procedures

15. The CPT Editorial Panel Process
• Panel Composition: Broad based and comprised of numerous sectors
o 11 physicians representing various medical specialties
o 3 physician payer representatives
o 1 hospital association physician representative
o 2 non-physician healthcare provider representatives
• Non-voting advisory participants from the health information management and
professional coding communities also participate

16. Collaboration Goal and Objectives
AMA and WHO are planning to collaborate in order to show global leadership in healthcare
information innovation through the development and distribution of integrated, ontology-based
terminologies to expand interoperability and analytical applications of clinical data.
Objectives:
 Working together in the development of a next-generation ICHI code set that can be
linked to other classification systems, such as ICD and ICF, providing a fully integrated
international healthcare classification system
 Enable cross-border data aggregation and analysis by deploying the next generation
ICHI as an augmenting code set for national health systems
 Establish AMA as a credible international partner in the WHO-Family of International
Classifications

17. Why The Collaboration Between AMA and WHO
Makes Sense Today!
WHO and AMA have organizational missions that are closely aligned and focus on the overall
betterment of healthcare
WHO Mission
To provide leadership on global health
matters, shaping the health research
agenda, setting norms and standards,
articulating evidence-based policy options,
providing technical support to countries
and monitoring and assessing health
trends.
AMA Mission
To promote the art and science of
medicine and the betterment of public
health through the strategic focus areas of
improving health outcomes, accelerating
change in medical education, and
increasing professional satisfaction and
practice sustainability

18. Collaboration Group
– Expert Group ~ 12 members
– appointed by AMA and WHO in equal numbers and with joint agreement.
• Richard Madden and Mark Musen will be the co-chairs of the group
• 4 management members of current ICHI will be included on the board
– AMA and WHO will appoint one Staff Member each to represent them in
the Advisory Group as ex-officio members.
• Bob Musacchio and Bedirhan Ustun
– The group will be advisory to AMA and WHO and will oversee the
project work according to the Project Plan appended to this agreement.

19. Project Plan
• Objectives
• Streams of work
• Deliverables
• Timelines
• Budget

20. Financial Aspects
• AMA will provide the financial resources to WHO in support of
the development of the ICHI to cover Project costs:
• For five years
– Central project management: WHO Project Staff
– Meetings: Expert Group, other work groups
– Consultants
– Contracts – Development, Field Trials, Reports
– Other

21. ICHI Development Background
 1978: WHO International Classification of Procedures in Medicine (ICPM)
 1988: ICPM not maintained
 Many national classifications developed:
 US, UK, Australia, Germany, ...
 Focus on medical/surgical interventions, hospital in-patients
 Duplication, not comparable
 Many countries with no classification
 Use of U.S. and Australian classification in other countries

22. Broad scope for ICHI
ICHI planned to include
 Medicine, surgery, diagnostics
 Primary care
 Allied health and provision of support
 Mental health
 Nursing interventions
 Public health
alpha

23. Structure of ICHI
 Finalised in 2010
 Multi-dimensional, based on European standard for
classification of surgical interventions: France and Canada had
followed this approach
 Definition
– A health intervention is an activity performed for, with or on behalf
of a person or a population whose purpose is to improve, assess or
modify health, functioning or health conditions.

24. ICHI Alpha-2 content - interventions
• 5648 interventions across medical and surgical, functioning and
other environmental and behaviour areas
– 4346 - Interventions on body systems and functions (incl ~ 1790
functioning interventions)
– 707 - Interventions on activities and participation domains
– 595 - Interventions to improve the environment and health
behaviour
• ncch/sydney.edu.au/health-sciences/ncch/resources.shtml

25. ICHI content - axes
• TARGET n = 633
• ACTION n = 131
• MEANS n = 59
• New hierarchical grouping of TARGET axis – with subchapters
for body parts and for types of activity.

26. New Target groups
provides the
tabular list with an
additional level of
hierarchy.

27. Extract from the Tabular list
illustrating the additional level of hierarchy.

28. ICD 9 CM Volume 3 and ICHI
• ICD-9-CM was included in the foundation (original base) for
ICHI
• Maps to ICD-9-CM were maintained
• An ICHI subset has been identified that can replace ICD-9-CM

29. Current ICHI Content Model
An Intervention in ICHI is represented by:
Title of Entity: Name of intervention
1. Textual definition
2. Hierarchy – Type – Use
3. Synonyms - Inclusion – Exclusion - Index terms- Notes
Descriptive characteristics
1 Target
A Body Part / Anatomical site D Environment
B Body Function E Behaviour
C Activities and Participation

30. Current ICHI Content Model (II)
2 Action
A Diagnostic C Managing
B Therapeutic D Preventing
3 Means
A Approach C Method
B Technique D Sample
Other relevant information
A Extension codes
B Device: Assistive Devices: ISO9999 (proprietary)
Implanted devices: GMDN (proprietary)
C Chemical substance: ATC
D Objective: ICD, ICF

31. WHO - 2018
alpha
2018

32. International Classification of Diseases and Disorders
2017
ICD-11
JLMMS.

33. Example of Content Model: ICD
http://www.who.int/classifications/icd/revision/contentmodel/en/

35. International Classification of Interventions
36
2018
2018
ICHI
ICPT
…

36. Content Model development process:
• Analyze of ICHI Alpha and CPT sources
• Propose prototype Content Model
• Review by ICHI/CPT community
• Test with “exemplars”
• Implement in Protégé
• Demonstrate prototype iCAT-ICHI Plus
• Refine model
• …

37. ICHI Alpha Source Materials

38. Conversion of ICHI Alpha to OWL

39. CPT Source Materials
CPT Developer Tool Kit (DTK)

40. DTK* formulation of CPT
• 14 axes used to describe
procedures
• Formulated in OWL

41. Intervention Content Model (Partial list)

42. Create Prototype Content Model
• Align CPT axes and ICHI axes, possibly creating new ones
• Determine sources of the value sets of axes
• Align CPT and ICHI intervention types
• For each intervention type, determine properties used to
describe the intervention
• Work out exemplars on paper
• Model Content Model in ontology authoring tool
10/15/14

43. Types of Content Model parameters
• WHO-FIC core parameters
– Shared among WHO-FIC classifications
• Descriptive/informational parameters
– Classification-specific information “about” a category
– Not inherited by derivative categories
• Structural parameters
– Axes along which a category can be abstracted or specialized

44. Content models for WHO-FIC classifications should
share core parameters
• Definitional parameters
– title, definitions, code (if any)
• Terms
– Synonyms
– Index terms
– Inclusions
– Exclusions
10/15/14

45. WHO-FIC core parameters: Linearization parameters
Fine Needle Aspiration Surgical Procedures

46. Descriptive/Informational parameters:
Taken from CPT and ICHI Alpha
• From CPT
– CPT code
– Reportable
– Short/medium/consumer-friendly/clinical... Descriptor
– …
• ICHI Alpha
– Inclusion notes?
– Exclusion notes?
– …

47. Structural parameter: hasAction

48. Structural parameter: hasTarget
ICHI Target + CPT Anatomic Site ICD Extension Codes

49. Structural parameter: hasAssociatedProcedure
• CPT DTK definition: “Specifies
the procedure for which a CPT
procedure is designated”
• Value Set
– ICHI Plus Intervention

50. Exemplars for Validation
Stanford resident modeled ~80 exemplars

51. ICHI Meeting, Chicago June 2014
• Attended by ICHI Alpha developers and CPT experts
• Plenary as well as smaller groups using provisional CM to model
exemplars
– Dissected 3 exemplars together
– Two groups
• Dissected 2 common procedures
• Group 1: One additional procedure
• Group 2: Three additional procedures
– Remarkable consistency

52. Current Status
• 16 parameters derived or reformulated from ICHI Alpha or DTK
axes/parameters
• Value sets need to be defined
• Top-level interventions/procedures need to be finalized
• Prototype Content Model has been encoded in computable
representation language

53. 54

54. Implication of our modeling approach to WHO-FIC
• We have created an shared core WHO-FIC content model
• We cross reference WHO-FIC classification terms
• We are using the same post-coordination paradigm across
WHO-FIC classifications (ICD-11 and ICHI)
• We will be experimenting with value sets shared across WHO-FIC
classifications (ICD-11 and ICHI)
• We use the same iCAT software infrastructure to support the
development of WHO-FIC classifications
Revised 55

55. Conclusions

56. Collaboration Timing
Drivers for Change: Interoperability to Manage Health Outcomes Globally
• The lack of interoperability in the healthcare system is holding back needed
innovations in quality of care and cost efficiencies
• Most countries have adopted their own standards for classifying procedural data,
making it difficult for cross-border integration and analysis
• In light of the growing global disease burden, especially concentrated in
developing nations, WHO has forged partnerships across the globe to combat
these challenges, enabling greater data exchange across countries would
support greater success of these initiatives

57. Collaboration Strengths
• In direct support of WHO’s and AMA’s missions
• Combines the power of the healthcare and terminology leaders
• Benefit from ICHI Alpha development and AMA’s CPT content
• Leverages WHO’s international prowess and structured classification experience
• Leverages AMA’s editorial and implementation prowess
• Delivers significant benefits to global healthcare

58. What does WHO want ?
• Meaningful exchange of health information
– Enable aggregation of health information from different sources
• One stop-shop for different users / developers
– In multiple languages
• Crystallization spiral for knowledge representation
– formalization  conceptualization  formalization
• Linkages between different domains of health information
• Translational research tool + semantic consistency

59. ICHI - 2018
• A reference classification-ontology set
– provision of semantics to enable users to use data in a consistent manner
– provision of possible services for:
• classification
• terminology
• linkages
• For use cases such as:
– Universal Health Coverage
– Billing & Reimbursement
– Casemix and Resource Allocation
– Quality and Safety monitoring
– Comparative Effectiveness Studies