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 Table of Contents  
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 186-192

Implementation of International Classification of Diseases 10: Preparedness for E-medical records and health reporting

1 Department of Health Information Management, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
2 Department Medical Records, Kasturba Hospital, Manipal, Karnataka, India

Date of Web Publication16-Mar-2015

Correspondence Address:
N R Jathanna Pamila
Department of Health Information Management, School of Allied Health Sciences, Manipal University, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2348-3334.153276

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Context: International Statistical Classification of Diseases and Related Health Problems (ICD 10) define the universe of diseases that exist, and classify them according to specified criteria. World Health Organization (WHO) has mandated ICD 10 for health reporting by its member states. In India, few of the hospitals in the state are following the standard coding and reporting system. Ministry of Health and Family Welfare (MOHFW), India, have notified the electronic medical records standards to be followed by health care providers in August, 2013 and recommended ICD 10 as reporting standard for both mortality and morbidity. The current study was carried out to promote standard reporting practices and implementation of ICD 10 coding system as per WHO/MOHFW reporting norms in a 150 bedded mission hospital in Udupi District of Karnataka State and successfully implemented with VI phase project. The phases included awareness and knowledge interviews, orientation, training, implementation, and testing. Although the standards and notification have been put up in government MOHFW web pages, it is suggested that the authorized bodies to mandate standard reporting of disease by all types of healthcare providers and upgrading/training programs to be extended to private healthcare sectors as well.

Keywords: International statistical classification of diseases and related health problems 10, implementation, mission hospital, training

How to cite this article:
Jathanna Pamila N R, Prajwal S, Shreepathi U, Prabhakara B. Implementation of International Classification of Diseases 10: Preparedness for E-medical records and health reporting. CHRISMED J Health Res 2015;2:186-92

How to cite this URL:
Jathanna Pamila N R, Prajwal S, Shreepathi U, Prabhakara B. Implementation of International Classification of Diseases 10: Preparedness for E-medical records and health reporting. CHRISMED J Health Res [serial online] 2015 [cited 2022 May 23];2:186-92. Available from: https://www.cjhr.org/text.asp?2015/2/2/186/153276

  Introduction Top

Classifications of diseases are essential. They define the universe of diseases that exist, and classify them according to specified criteria. Internationally endorsed classifications facilitate easy storage, retrieval, analysis, and interpretation of health data. It also helps in epidemiology, prevention, managing health care, allocation of resources, outcomes monitoring, research, clinical context and primary care. Hospital records coded uniformly using International Statistical Classification of Diseases and Related Health Problems (ICD 10) form a vast database as conclusions drawn on the analyzed information is extremely important for understanding the public health situation of the country. World Health Organization (WHO) brought out the 10 th version of ICD 10 in 1993 for systematic coding of morbidity and mortality causes in the medical records of medical/health institutions to be used for reporting by the member states.

International Classification of Diseases -10 contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [1] The code set allows more than 14,400 different codes and permits the tracking of many new diagnoses. The codes can be expanded to over 16,000 codes by using optional sub-classifications. [2] ICD 10 coding was introduced by WHO in 1993 and India adopted it in 2000. In 2001, the Indian Registrar General Surveyor introduced an enhanced form of verbal autopsy for assessing the cause of death. [3] These reports were independently coded to ICD-10 categories by at least two of a total of 130 physicians trained in ICD-10 coding. A total of 136,000 deaths were enumerated between January 2001 and December 2003. Verbal autopsies could not be conducted for 12% of the deaths for reasons such as family migration or change of residence. An additional 9% of the reports could not be coded because of data quality problems, resulting in a final dataset of 122,848 coded records.

Global, regional, and country statistics on population and health indicators are important for assessing development and health progress and for guiding resource allocation. [4] Much of the current focus is on monitoring progress toward the targets of the (health-related) millennium development goals, including time series and country-level estimates that are regularly updated. However increasingly, the demand is for comprehensive estimates across the full spectrum, including noncommunicable diseases and injuries. [4] In global health estimates technical paper, 2014, WHO reported that the countries that have adapted accuracy and completeness in reporting using coding method were included in their 2010-2012 report. The inclusion criteria included level of completeness of recorded mortality data. The proportions of deaths with underlying cause coded to "garbage" codes were calculated using the formula: Percentage usable = completeness (%) × (1 − proportion garbage).

The "Garbage Codes" listed by WHO are as follows: [4]

  • Symptoms, signs and ill-defined conditions (ICD 10 codes R00-R99)
  • Injuries undetermined whether intentional or unintentional (ICD 10 Y10-Y34, Y87.2)
  • Ill-defined cancers (C76, C80, and C97), and
  • Ill-defined cardiovascular diseases (I47.2, I49.0, I46, I50, I51.4, I51.5, I51.6, I51.9 and I70.9).

A summary usability score was calculated using the formula: Percent Usable = Completeness (%) × (1 − Proportion Garbage).

Out of 131 member states with a mean percent usable below 70% during the period 2000 to latest available year were excluded, and India is excluded from the list because of inefficient reporting methods. [4]

The pace of implementation and adoption of ICD 10 in many of the states of India could not meet up to the reported standards put forth by WHO as many of the providers of healthcare need to understand and accept ICD as reporting tool. Only a fraction of the hospitals in the state is following this global coding system. [5]

Department of Health Information Management, of Manipal University, is one of the few private training centers that aim to create awareness of the importance of health documentation and ICD 10 in the state. The current project was taken up to promote standard documentation practices and implement ICD 10 coding system in a 150 bedded Mission Hospital in Udupi District, and to assist them with the implementation of ICD coding system and guide them in the production of high quality coded morbidity and mortality data to be compatible with electronic medical records (EMR).

Background of study setting

The early years of 1900s there were one or two male doctors in Udupi town. However, pregnant women had no access to medical aid provided by male doctors. A young lady from Switzerland at 14 got a divine-inspired desire to study medicine. She was not aware of the need of Udupi or in India, nor was she aware that she was to come and be an instrument in God's hands to relieve the sufferings of the pregnant women in such a faraway land, her spirit caught the vision and answered those poignant calls. Some 8 years later, Dr. Eva Lombard added impetus to her decision made years back and gave a new shape to it.

This was only a start-very small indeed, and there was no turning back and in l925, a new maternity ward was opened. Later, buildings were added, to suit the various needs of the patients.

Thus, the Mission Hospital at Udupi developed from its infancy to the present stage. In the beginning, it was having only a small dispensary, one small operation theater and a few staff. Currently, Lombard Memorial Hospital has grown up to 150-bedded hospital and teaching center with more than 200 staffs working in harmony round the clock serving the health needs of the community.

Currently, the hospital is catering to needs of the community with the following services:

  • In-patient and out-patient services
  • Obstetrics and Gynecology, including infertility clinics for both sexes. General Medicine, including Diabetic care and cardiac care
  • Pediatrics including neonatal care
  • General Surgery, including laparoscopic surgeries
  • Ophthalmology including contact and intraocular lens implants
  • Urology, ENT, dental unit
  • Orthopedics including accident and emergency round the clock
  • Psychiatry including alcoholics de-addiction center
  • Family planning advice and service.

Diagnostic facilities available:

  • All types of ultra-sound scanning tests, color Doppler
  • Radiology: Plain, barium studies, intravenous urograms etc
  • Echocardiography, treadmill test
  • Fill-fledged laboratory; X-ray and electrocardiography (ECG)
  • Endoscope, Gastroscopy, sigmoidoscopy, fetal monitor.

Need of the hour

Since the functioning of the hospital in year 1920 hospital progressed eventually. It is moving on with the latest technologies and services. Side by side with the healthcare services, standard documentation of care and health reporting is becoming norm of healthcare providers. This was our effort to promote standard documentation practices and implementation of ICD 10 as per WHO/Ministry of Health and Family Welfare (MOHFW) reporting norms.

The implementation phases

With the permission of the Managing Director, it was planned to the current project was carried out in V phases.

Phase I: Interviews and awareness

During this period, investigators conducted random interviews with employees to have an insight into their knowledge regarding standard documentation and reporting system. Some of the questions asked were "is there any policies regarding documentation and coding?" "Do you know about WHO definition for diagnosis, comorbidity?" "Do you know about abstraction?". In these informal interviews, it was observed that most were not aware of these standards and wanted to know about it. Based on the observation result, a formal study on awareness of hospital staffs and students regarding ICD and it's useful was conducted. Questionnaire with five parameters [Table 1] were distributed to administrative staffs, front office, Medical Records Department (MRD) staffs, nursing tutors and staffs, nursing students, laboratory and pharmacy staffs with their written consent. The sample size was 81.
Table 1: Response to the awareness questionnaire

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The result showed [Table 1] that 71% of respondents were not aware of ICD and more than 64% were not aware of its uses. Nearly 89% wanted orientation regarding ICD and its uses.

Phase II: Orientation

As maximum participants wanted to know about coding system, orientation/workshop program was held on February 26, 2013 in which 33 participants took part. As few of the participants were from administration, role of policy makers in policies regarding reporting and coding were discussed. Single coding and multiple coding systems with the definitions for the main condition, comorbidity, complication, and external causes were explained with illustrations. Role of authorized documenters and coders were explained with characteristics of a good documentation. The good diagnosis documentation should be based on three prime questions that are, what is the name of the diagnosis? Where is the location of the disease? Which type of disease? this will make the abstraction easy for coder. For example in diagnosis "Lobar pneumonia right upper lobe", the "lobar" represents which type; pneumonia represents what; right upper lobe represents where. These three components are a must for a good diagnosis to locate accurate code J18.1. Bad diagnosis may lead to J18.9 (unspecified). Participants were introduced to classification of disease, features of code numbers (e.g. ICD 10 code for scalp laceration is S01.0 - one alphabet followed by two numeric digits then a point and a digit), volumes of ICD 10, its contents: Volume 1: [6] Chapters of tabular list [Table 2], categories of chapters were explained [Table 2] blocks, three-character categories, four-character subcategories, and conventions used in Volume 1 was also explained.
Table 2: Chapters of international classifi cation of diseases 10, volume 1 categorized

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List of conventions used in Volume 1 of ICD 10:

  • Inclusion terms
  • Exclusion terms
  • Chapter V glossary descriptions
  • Dagger and asterisk
  • Parentheses ()
  • Square brackets [ ]
  • Colon:
  • Brace }
  • Not otherwise specified NOS
  • Not elsewhere classified NEC
  • AND in code titles
  • Point dash -.

Uses of each convention were briefly explained. How to refer the modification rules and Instructions and coding guidelines in contained in volume 2 [7] was explained referencing volume 2. Volume 3 [8] is an alphabetical index and is comprehensive listing of all conditions in the tabular list. Volume 3 is divided into three sections as follows:

  • Lists all the terms classifiable to Chapters I-XIX and Chapter XXI, XXII except drugs and other chemicals.
  • Is the index of external causes of morbidity and mortality and contains all the terms classifiable to Chapter XX, except drugs and other chemicals.
  • Gives the table of drugs and chemicals, lists for each substance the codes for poisonings and adverse effects of drugs classifiable to Chapter XIX, and the Chapter XX codes that indicate whether the poisoning was accidental, deliberate (self-harm), undetermined, or an adverse effect of a correct substance properly administered.

Features of index including lead terms, essential modifiers, nonessential modifiers, conventions, reference notes were explained with relevant examples. Practical training was given in identifying lead terms, steps involved in accurate coding and its benefits.

Example: Steps involved in assigning a code from index for diagnosis "Bilateral inguinal hernia."

Step 1: Identifying the lead term in a given condition. Lead term is usually written in the extreme right hand side of the condition. Here, hernia is the lead term is present on the extreme left hand side in the alphabetic index (Vol. 3) and is always written in bold and the first letter of lead term starts with upper case

Step 2: Search in the first indentation below the lead term "Hernia" for the next term "inguinal." Terms written inside the parenthesis are the nonessential modifiers, which do not make any changes in the code numbers

Step 3: Search is not finished yet. There is another term "bilateral." Now move to the next indentation where you find the term "with" an essential modifier that changes the code number

Step 3: Identify the term "bilateral" in the second indentation

Step 4: Here the code for a given diagnosis is to the right of the term "bilateral". The search is over in the index.


-inguinal (direct) (external) (funicular) etc., K40.9

- -with

- --gangrene (and obstruction) K40.4

---obstruction K40.3

--bilateral K40.2.

Step 5:

Once a code is identified in index that is, K40.2, cross check in the tabular list and confirm the code.

K40.2 Bilateral inguinal hernia, without obstruction or gangrene

Bilateral inguinal hernia NOS.

The uses and importance of accurate coding in reporting, reimbursement, education and research were explained. Many more examples were worked out and discussed. The role of WHO in preventive care and use of ICD and reporting diseases were explained referring ICD 10 volumes and also with WHO online information.

A feedback form regarding orientation program was taken from participants. The response showed [Table 3] that the maximum participants (55%) felt that the program as very good. And 18% felt it was excellent.
Table 3: Result of feedback on orientation program

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Phase III: Training program

Once the orientation was conducted and feedback was taken, training on ICD-10 was initiated. As per the direction from the administrator, it was decided to train MRD staff and also the interested administrative members. In total eight staffs were recruited into training program. Well planned modules that contained the importance of documentation, accurate coding, contents of ICD 10 its advantages over the previous revisions ICD 9, abstraction and coding on live files was prepared. The training started with teaching of basic parts of terminologies (prefix, suffix, root etc.), its construction was explained with examples. Next module was to search for medical terminology using a medical dictionary and online information. What to code from the patient records? How to abstract the conditions to be coded? Which is the principal diagnosis and other diagnosis? were explained.

  • World Health Organization definition [7] of main diagnosis or main condition: …The diagnosis established at the end of the episode of care to be the condition primarily responsible for the patient receiving treatment or being investigated…that condition that is determined to have been mainly responsible for the episode of health care
  • Secondary diagnosis/other condition: [7] A diagnosis that either co-exists with the main diagnosis at the time of admission or which appears during the episode of care-co morbidities and complications.

Example of abstraction

A 60-year-old male with hypertension was admitted with severe chest pain radiating down his left arm. Subendocardial myocardial infarction was diagnosed on ECG.

According to WHO definition, the main condition in the given case is "acute subendocardial myocardial infarction" ICD 10 code is I21.4; other condition is "essential (primary) hypertension with heart involvement" and the ICD 10 code is I11.9.

Training program was carried out from 9 th March to 10 th of April, 2013. Two separate sessions on each topic were taken to MRD and Administrative staffs in morning and afternoon as per their convenience. Sample cases were given for abstraction and coding practice in the beginning. Efforts were taken for maximum accuracy. At the end of the training program, staffs were made to code on the live files [Figure 1].
Figure 1: Medical Records Department staff entering the International Statistical Classifi cation of Diseases and Related Health Problems 10 codes to the system. Source: Inserted with consent from hospital authorities

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Phase: IV and V: Implementation and testing

After 1 month training, as per the suggestions given by the administrator, codes were entered on a Microsoft excel spreadsheet following the format of manual register of the hospital. Electronic Stedman's medical dictionary and abbreviation and acronyms software were installed to the system to check the spelling, meanings and full form of medical terms in which it was helpful for coding. Currently, the hospital is updating their E-reporting system and ICD 10 software to be installed. Government of India (GOI) intends to introduce an uniform system for maintenance of EMR/electronic health records (EMR/EHR) by the Hospitals and healthcare providers in the country. [9] As per the EHR standards released in August 2013 by the MOHFW, GOI [10] ICD and Systematized Nomenclature of Medicine-Clinical Terms is recommended for diagnosis coding and metadata reporting to MOHFW, GOI by all healthcare providers for mortality and morbidity by ICD coding system. [10]

During the testing phase regular visits to the hospital in intervals by the project team, to see any gaps or errors in the coding process was done and was corrected. Finally, the rating was done from the staffs to see their interest and sustainability of the process.

The analysis of their rating showed [Table 4] 75% of the staffs who have developed coding skills rated the training program as excellent.
Table 4: Result showing feedback on training and implementation of ICD

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Today, the hospital is sustaining the coding system, and they code principal diagnosis, secondary diagnosis, co-morbidities and complications on in-patient records. This coded data are used for reporting to government agencies, statistical report for administrative purpose and maintaining disease index.

  Discussion Top

In India, health reporting system is much diversified. There is a wide gap between the corporate hospitals where they have EMR with ICD 10 and on the other hand majority of hospitals in suburban and rural localities use paper medical records. Moreover in these, few hospitals have adapted ICD coding, and other hospitals are unaware of the existence of disease coding system. In public sector, the reporting of communicable diseases is done in a standard format with disease codes of communicable diseases printed on the format, but health reporters lack knowledge in ICD.

To create an awareness, Central Bureau of Health Intelligence (CBHI) undertook a case study of 20 hospitals in Delhi and Rohtak under the aegis of WHO/GOI Biennium 2004 and 2005. Participants were from: Central Government, State Government, Local Bodies and Private Sector. One of main recommendations of the workshop was that all medical and health institutions, including hospitals of any size, in the country should equip themselves with WHO publication on ICD 10 (three volumes) as a reference; ICD 10 codes relevant to each medical specialty be prominently made available in concerned wards in the hospitals; no medical record should remain without ICD 10 code for the diagnosed disease. Each year CBHI have scheduled short-term training programs for ICD 10 in most of the states for candidates working in government health care settings making an effort to meet the present needs in health reporting. [7]

One decade is gone by but there is not much changes happening in the documentation and reporting process of many of the Indian hospitals in spite of efforts by government bodies. There needs to be a revolution in the health reporting process in India and the importance and benefits of classification if disease system to be made known to every health cares both public and private. Although the standards and notification have been put up in MOHFW web pages, it is suggested that the authorized bodies to mandate standard reporting of disease by all types of healthcare providers and upgrading/training programs to be extended to private healthcare sectors as well.

  Acknowledgment Top

We acknowledge the Medical Superintendents Dr. Rathish Johnson of Lombard Memorial Hospital, Udupi for hisr kind permission to carry out our project.

  References Top

Central Bureau of Health Investigation, Government of India. Improving and Strengthening the Use of ICD 10 and Medical Record System in India: A Case Study National Health Profile; 2007.  Back to cited text no. 1
World Health Organization. International Classification of Diseases (ICD). Available from: http://www.who.int/classification/icd/en/. [Last accessed on 2013 May 02].  Back to cited text no. 2
Preen DB, Holman CD, Spilsbury K, Semmens JB, Brameld KJ. Length of comorbidity lookback period affected regression model performance of administrative health data. J Clin Epidemiol 2006;59:940-6.  Back to cited text no. 3
WHO. WHO Methods and Data Sources for Country-Level Causes of Death 2000-2012 Department of Health Statistics and Information Systems. Global Health Estimates Technical Paper WHO/HIS/HSI/GHE/2014.7. Geneva: WHO; 2014. Available from: http://www.who/int. [Last accessed on 2014 Oct 07].  Back to cited text no. 4
Central Bureau of Health Investigation, Government of India. Module and Workbook - Orientation Training on ICD 10. 2 nd ed. New Delhi, India: Central Bureau of Health Investigation, Government of India; 2008.  Back to cited text no. 5
World Health Organization. International Statistical Classification of Diseases and Related Health problems. 10 th Revision, 2 nd ed., Vol. 1., Switzerland: World Health Organization; 2004.  Back to cited text no. 6
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10 th Revision, 2 nd ed., Vol. 2. Switzerland: World Health Organization; 2004.  Back to cited text no. 7
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10 th Revision, 2 nd ed., Vol. 3. Switzerland: World Health Organization; 2004.  Back to cited text no. 8
Central Bureau of Health Investigation, Government of India. www.cghidghs.nic.in link. Available from: http://www.cbhidghs.nic.in/writereaddata/linkimages.pdf. [Last accessed on 2013 Dec 08].  Back to cited text no. 9
EMR/EHR Standards for India as Notified by MOHFW - August, 2013. Available from: http://www.mohfw.nic.in. [Last accessed on 2013 Dec 08].  Back to cited text no. 10


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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