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Banner Epidemiological Bulletin

Article No.3 - Vol.28, No.3 - September 2009

Regional Action Plan for Human Resources Training International Classification of Diseases – ICD

   Health statistics are a very important element for analyzing health situation, the definition of policies and programs, decision making and evaluation of results. In particular, information on morbidity and mortality are directly reflected by the suffering of the population, indicating the necessary actions for prevention, treatment or rehabilitation.

   In order to have such information, the quality and coverage of data collected are of vital importance, where medical records are the most important primary source, as is the information on causes of death in the death certificates, disease and health problems treated in hospitalizations, and on diagnoses made at outpatient visits.

   The organization of this information requires a tool capable to systematizing it in a standardized way that can be comparable in time and space. This instrument is the International Classification of Diseases and Health Related Problems, now in its Tenth Revision, ICD-10.

   For the correct use of ICD, adequately trained coders are required, and the basic structure of training should be consistent with the definitions of the Education Committee (Education Committee - EC) of the WHO Family of International Classifications Network (WHO-FIC Network).

Training needs

1) Diagnostic information - medical records

   As the main source of data on health problems of the population, the quality of medical records is the first foundation necessary to sustain a good information system, so it deserves special attention.

   First of all it is necessary to make clear that the definition of diagnosis of conditions and diseases is of medical nature and attribution of physicians (except for external causes of injury and poisoning). While it is true that in many cases a doctor may not be available, lay information, when available, should be regarded with reserve and should not be mixed with those provided by professional practitioners.

   The first aspect to be considered is the most opportune time to address this issue with the physicians. There are at least three occasions to consider:

      • During the course of medical graduation: In many cases the subject of medical records, including certification of deaths, is addressed by the middle of the course, often in conjunction with the legal aspects of medicine. Experience has shown that this may not be the most appropriate approach, first because at that stage the students are more motivated to learn to cure and save lives, and not in certifying causes of death, and they use to see the "paperwork" as a burocracy tool and not as an important source of health information. Second, many times the legal issues is dealt almost exclusively with the precautions when making medical records, not to engage with the medical situations that might require legal interpretation or intervention.
  • Complementation of graduation (residences, post graduation or internships): Generally this is a good opportunity to train doctors, mainly because, very often, those just graduated are who have to fill the records, in special death certificates. This training can be done through workshops, conferences and brief courses for doctors. In the same way, this is a good practice to discuss with the physicians at any time, the importance of health statistics and the proper filling of death certificates.
      • At EC meetings, the basic content for the training of doctors, especially for the certification of causes of death, have been discussed and defined:

• Role of the physician as a generator of legal, statistics, health and demographic information;

• Ethical and legal issues in the country where the certification is done;

• The importance of mortality statistics and cause of death;

• International form for medical certificate of cause of death. How to certify;

• Basic definitions in vital statistics;

• Examples and exercises.

   Due to legal and operational differences between the various countries of the Region, the training of doctors for the filling of medical records requires the development of a specific plan.

2) Morbidity

The first point to consider is the definition of the type of intended use for the data. Unlike the mortality data, where the basic use is related to the prevention of early and avoidable deaths, which derived the concept of underlying cause of death, there are much more diversified uses of morbidity data :

• Orient medical research;

• Identify long-stay cases;

• Determine needs for beds, staff, clinical and specialist services;

• Identify public health problems, and orient programs;

• Assess national health status and health problems;

• Public health planning, research, teaching;

• Integrate with mortality for enhanced view of proportionate importance of various diseases.

   From this diversity, different possibilities for defining a primary diagnosis of a hospital discharge are derived, which can be summarized in three basic concepts:

• the condition established after study to be chiefly responsible for occasioning the admission of the patient into the hospital ("reason for hospitalization"),

• the condition treated during the hospitalization considered to be the most important in terms of clinical significance and resources consumed ("main condition"),

• the underlying cause of the condition that occasioned the patient’s admission ("underlying cause") .

   While the reason for hospitalization is related to the need for immediate care to the patient, availability of human resources and technologies in the particular hospital and, in addition, with the nature of acute problems, the main condition is strongly related to costs, procedures, and financing of the system. On the other hand, the underlying cause is much more related to health situation analysis, main health problems, health programs and policies, and prevention measures.

   Another important aspect to be considered refers to the differences between data related to hospital and those from the outpatient. From the first, it is almost always possible to obtain precise information of the health problems treated, according to the types of diagnoses mentioned above. From outpatient visits, it’s frequently only possible to get signs and symptoms, less useful for assessing the health situation. It is also questionable if for such data ICD is the best instrument or another, such as ICPC (International Classification for Primary Care), used in many countries, either in its original version or adapted nationally.

   Finally, given the lack of full international standards, the different needs and national interests, the different roles of public, philanthropic and private institutions, training coders for morbidity, as well as physicians, requires a specific plan.

3) Mortality

   Recent studies conducted by the Education Committee (EC) of the WHO-FIC Network, together with PAHO, have identified, in the Region of the Americas, an important need to train coders for mortality, increasing the amount available and improving coding quality.

   Furthermore, the processes of decentralization, under way in most countries, and also the increased coverage that is being achieved, have expanded the need for mortality coders throughout the Region.

   Another aspect to be considered is the turnover of the coders, in part because in general the coding function has not a recognized importance and value, leaving them almost always looking for better career opportunities. In that sense, the EC has been working not only with the definition of content (see below), but also in establishing a credentialing process, both nationally and internationally, with the aim of assessing the function of the coder. It is necessary, however, that governments recognize the importance of this work, so that the coders are not designed to other functions, not coding anymore.

   It is also important to mention that, despite automated coding processes are being implemented for selection of the underlying cause of death (ACME System of the United States and other derived from the same, such as the SCB of Brazil), the need for well trained coders will not be reduced, for two main reasons:

• The automated systems require the assignment of codes to each diagnostic information from death certificates, and

• Both the external and natural causes of death have always a residue that can vary from 10 to 20 percent of the deaths, which requires manual coding.

   In the latter case, since the death certificates have often a more complex coding, coders need to have deeper understanding of the coding process.

   As part of a strategy to enable a better quality of mortality data in countries of the Region, it would be of great importance to create and/or strengthening of centers or reference groups in disease classification and coding. Several countries already have centers or national reference groups (such as Cuba, Argentina, Canada and Colombia) and even internationally, with PAHO/WHO collaborating centers, such as Brazil, United States, Mexico and Venezuela. However, in most countries there is a lack of facilities or reference groups.

   On one hand, to accelerate the process of improving mortality statistics in the short and medium terms, it is necessary to train a large number of coders, which will be discussed later. On the other, the training of trainers in countries, as well as enabling the continued training of new coders and updating those that already exist, may be the initial core of those mentioned reference groups, for what the support of PAHO, CRAES and the collaborating centers will be of great importance.

   The training of trainers in international courses, although already done by some of the collaborating centers, is still, somewhat, an incipient activity, which requires incentives and support from PAHO, including finding funds to supplement financing costs, as learning materials (including sets of ICD-10), and the necessary travel of the trainers and participants and their stay in the places where the training is done.

   The training of coders and trainers is the key objective of the EC, which has been working, among other things, in the definition of the content for the training of coders at different levels. There are four defined levels, with regard to skills and training needs:

Basic level: Must have the equivalent of a high school education and good reading skills. Must be able to consult books and reference manuals on using the ICD. Must be able to examine the books and medical journals to gain familiarity with the terminology, etiology, symptoms, signs and pathology of the diseases. Training needs and career development: Concepts of anatomy, physiology and medical terminology, the use of ICD and the rules and conventions for coding the underlying cause of death.

Intermediate level: Must have at least two years of experience in coding death certificates. Must have successfully completed a basic training in anatomy, physiology and medical terminology. Needs for training and professional development: Bases of medical science, including etiology, signs, symptoms and pathology of the diseases.

Advanced level: Must be accredited as an intermediate coder level with at least five years experience in coding death certificates. Must demonstrate an ability to train others in the coding of cause of death with the ICD. Needs for training and professional development: techniques for ensuring the quality and skills to make presentations.

Nosologist: Has a detailed understanding of the history of the ICD, its uses and its development. Has the capacity to contribute to define policies and strategies for classifying and coding in national and international levels. A nosologist demonstrates expertise in the application, interpretation and intent of the classification. Needs for training and professional development: Statistical analysis, epidemiology, reporting and skills to train coders and make presentations.

The basic training of the coders of all levels includes the following educational needs:

• Availability of essential materials and references for coding (sets of ICD-10, medical dictionaries, training materials, references about drugs and medicines, and definition of contacts for clarifications);

• Basic knowledge of medical science (medical terminology, anatomy, physiology and basic pathology, etiology, signs and symptoms);

• Privacy and confidentiality principles;

• Uses of coded data:

o Analysis of the health situation and trends (leading causes of death, defining policies and priorities, program planning and health services, health indicators);

o Critical elements to identify public health problems (risk groups, medical and health research needs);

o Epidemiological surveillance (first or main source of information about certain diseases at local level, case investigation and control measures of diseases, specific population groups / problems [maternal and infant mortality, adolescents, older adults]);

o Health Assessment (quality of care, achievement of specific programs, different technologies).

• Major users of coded data and type of need for each (epidemiologists, statisticians, program coordinators, clerks, policy makers, researchers, demographers, funeral agencies, and national and international organizations);

• The International Classification of Diseases - ICD (international context, standardization and comparability, history and structure of the Classification, revision and update mechanisms);

• Data source documents (death certificate or equivalent, police reports, forensic and other reports, documents as data source);

• How to code (using the different volumes of the ICD, concepts and definitions, rules and conventions for coding underlying cause of death, international form of medical certificate of cause of death);

• Appropriate exercises on the selection of the underlying cause and coding;

• Quality assurance (consultation processes - for example, sequence in the certificate, who and how to consult, review and validation of data, responsibility for the quality of data, processes for access to expert advice).

   At recent years it has been developed, in different countries, several self-learning tools for coding with the ICD, and the selection of principal diagnosis for mortality and for morbidity (underlying cause and main condition). PAHO, with the support of CEMECE (Mexico), CBCD (Brazil), CEVECE (Venezuela) and CNCE (Argentina), has developed the INTERCOD, offered on a CD-ROM in the four official languages of the Organization, Spanish, Portuguese, English and French. This instrument has been widely used in many countries, even in other regions of the world. WHO is currently finalizing a new training tool for use via the Internet.

   Such instruments are very important tools in the training of coders. However, experience shows that, especially for newbie’s with no experience, such training is often not sufficient so that the person can perform satisfactorily as a coder. At least for those who have no previous experience, in addition to those tools, a previous face to face training in a formal course is necessary, where an experienced coach can better guide the learning process, and to address questions and identify additional training needs each individual participant may require.

   As a preliminary number, it is estimated that in the next three to four years about three thousand coders and one hundred of multipliers should be trained.

For further information: Dr. Roberto Becker, Regional Advisor in FIC ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

Note: This paper was presented and aproved at the meeting of the Regional Advisory Committee on Health Statistics (CRAES) held in Washington, DC, from 11 to 13 of August, 2009.

Source: Health Surveillance and Disease Prevention and Control (HSD); Health Information and Analysis (HSD/HA). PAHO.

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