MEDINFO 2017: Precision Healthcare through Informatics 965 A.V. Gundlapalli et al. (Eds.) © 2017 International Medical Informatics Association (IMIA) and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License 4.0 (CC BY-NC 4.0). doi:10.3233/978-1-61499-830-3-965

A Method for Constructing a New Extensible Nomenclature for Clinical Coding Practices in Sub-Saharan Africa

Sven Van Laere, Marc Nyssen, Frank Verbeke

Department of Public Health (GEWE), Research Group of Biostatistics and Medical Informatics (BISI), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium

Abstract The word nomenclature has to be used with care in the context Clinical coding is a requirement to provide valuable data for of sub-Saharan Africa. By the word “nomenclature”, usually billing, epidemiology and health care resource allocation. In they understand: “a coding system to provide codes that are sub-Saharan Africa, we observe a growing awareness of the used in invoices, to specify the health services that were pro- need for coding of clinical data, not only in health insurances, vided for particular patients”. We define nomenclature in a but also in governments and the hospitals. Presently, coding broader way, also taking into account the clinical definition of systems in sub-Saharan Africa are often used for billing pur- health services. poses. In this paper we consider the use of a nomenclature to In this paper we will present a way to build this new nomen- also have a clinical impact. Often coding systems are assumed clature for sub-Saharan Africa, based on existing nomencla- to be complex and too extensive to be used in daily practice. tures. Here, we present a method for constructing a new nomencla- ture based on existing coding systems by considering a mini- Methods mal subset in the sub-Saharan region. Evaluation of com- pleteness will be done nationally using the requirements of In nomenclature construction, it is key to have a clear goal. national registries. The nomenclature requires an extension For example, the existing Anatomical Therapeutic Chemical character for dealing with codes that have to be used for mul- (ATC) classification is used as a tool to register drug utiliza- tiple registries. Hospitals will benefit most by using this exten- tion in order to improve the quality of drug use [5]. Our pur- sion character. pose is to see what is necessary per sub-Saharan country and Keywords: to find a common subset between these countries (see Fig. 1). Clinical Coding; Names; Africa South of the Sahara We will start from the lists containing all health services that are necessary for billing purposes. This means we will at least Introduction include codes of existing procedure classifications. The Cur- rent Procedural Terminology (CPT), International Classifica- Medical coding systems have shown their relevance in health tion of Health Interventions (ICHI) and NOMESCO Classifi- information management (HIM) systems. Clinical coding is an cation for Surgical Procedures (NCSP) can help in providing integral part of HIM practice which provides valuable data for these specifications. health care quality evaluation, health care resource allocation, However, not only the billing aspect of procedures are of health services research, medical billing, public health pro- interest in an electronic medical record. To provide more gramming and Case-Mix/DRG funding.[1] granularity compared to what is often used, we will also in- In sub-Saharan Africa, several countries use their own coding clude codes for medication and lab results. Possible terminol- system by (1) setting up their own code system, (2) using an ogies to include are respectively ATC and the Logical Obser- in-house designed code system based on another reference vation Identifiers Names and Codes (LOINC). The idea is to terminology, or (3) by making use of an existing code system. design a new nomenclature of codes, at least including the However, to the best of our knowledge, there is little literature about clinical coding in sub-Saharan Africa. The may be due to limited available capacity and resources to carry out com- prehensive and significantly sound community assess- ments.[2] Moreover, sub-Saharan countries often lack the structure and technologies to provide data. For this purpose, open-source hospital information systems such as OpenClinic GA [3] may help. A study in 19 African health facilities [4] demonstrated that by applying this software, structured reporting improved dramatically. If we look towards interoperability between countries, still a lot can be done, since every health facility reports information in a different way. Moreover, the complex structures of exist- ing coding systems limit the use of them. The idea of a new Figure 1: Idea of constructing a minimal subset of concepts nomenclature for the sub-Saharan region that is extensible for (colored part) necessary to represent medical data a country or as more specialized hospital rise. 966 S. Van Laere et al. / A Method for Constructing a New Extensible Nomenclature for Clinical Coding Practices topics mentioned above, in which it is possible to refer to the original code used. To enable traceability, we will use follow- ing structure: PREFIX.CODE[.XXX], where PREFIX indicates a reference to the original terminolo- gy, CODE refers to the internal code of the code system that represents a clinical idea and an optional XXX part will refer to an index, necessary for capturing more granularity. This last XXX part will enable the handling of codes that are not provided by the minimal subset, but that are necessary on a national or even more local (hospital) basis. This extensibil- ity is one of the key aspects of this sub-Saharan nomenclature. How do we know when this extension feature will be needed? For this evaluation on a national basis, we will make use of Figure 2: Possible mapping scenarios between newly com- the information that is required to be provided by the hospitals posed nomenclature (left) and national register requirements for reporting purposes to the national registers. The data ele- (right); ments in the reporting requirements will be used as an evalua- Scenario A: mapping 1-1 (no problem) tion source. Scenario B: mapping N-1 (no problem) Three scenarios can occur in this evaluation part (see Fig. 2): Scenario C: mapping 1-N (extension required)  Scenario A: If there is a 1-1 mapping from the newly constructed nomenclature to the national requirement, no the American Medical Association through the CPT Editorial problem will arise. Each new concept that is used, can be Panel. Governments can use CPT for tracking the prevalence used to fill up the register regarding this concept. and value of procedures. Each CPT code is 5 characters long  Scenario B: If there is a N-1 mapping from our new no- and may be numeric or alphanumeric, depending on which menclature to the national registry, it means two (or category the CPT code is classified. CPT codes are divided more) concepts will be used to fill up the national register into 3 categories based on their usage. data. ICHI Alpha 2015  Scenario C: If there is a 1-N mapping from the new sub- The International Classification of Health Interventions (ICHI) Saharan nomenclature towards the requirements of a na- is a system of classifying procedure codes, maintained by tional register, it is necessary to provide an extension. WHO.[7] ICHI was originally designed to replace the Interna- This extension will then split up the newly generated code tional Classification of Procedures in Medicine (ICPM). The into multiple parts using the XXX part, until we obtain at classification is built around three axes: the target (the entity least one concept per national register requirement. on which the Action is carried out), the performed action (a First we will evaluate this regarding national requirements. deed performed by an actor to a target) and the means (the This extension of course can also be used on a more local processes and methods by which the ‘action’ is carried out). basis, for example in an African hospital specialized for a Extension codes are provided to allow users to describe more particular health care service. detail about the intervention in addition to the relevant ICHI code. Nomenclatures LOINC The Logical Observation Identifiers Names and Codes In this part we will briefly list up the code systems that can be (LOINC) provides universal identifiers for laboratory and of interested for the creation of this nomenclature. We need other clinical observations.[8] This classification is maintained concepts dealing with procedures in which CPT, ICHI and by the Regenstrief Institute. LOINC codes are composed by 5 NCSP. We also include the ATC and LOINC classifications or 6 parts that are separated by a colon: (1) compo- for registering respectively medication and laboratory infor- nent/analyte, (2) property observed, (3) timing of measure- mation. ment, (4) type of sample, (5) scale of measurement, and if relevant (6) the method of the measurement. ATC ATC stands for Anatomical Therapeutic Chemical and is a NCSP classification system used for medication.[5] It classifies sub- The NOMESCO Classification of Surgical Procedures stances based on the organ or system on which they operate (NCSP) is a classification for surgical procedures, maintained and their therapeutic, pharmacological and chemical proper- by Nordic Centre for Classifications in Health Care.[9] It is ties and is maintained by the World Health Organization based on the traditions of the surgical profession in the Nordic (WHO). Moreover, the ATC system also includes “defined countries. A NCSP code consists of three alphabetic charac- daily doses” (DDDs) for many drugs, indicating the usual dose ters (positions 1-3 of the code) and two numeric characters used per day. The classification uses the representation of the (positions 4-5 of the code). The alphanumeric part refers the concept identifier to classify medication at five different lev- classification (i.e. chapter) to which the code belongs and the els: (1) anatomic main group; (2) therapeutic subgroup; numeric part refers to the specific procedure within the proce- (3) pharmacological subgroup; (4) chemical subgroup and dure group, including surgical technique and precise anatomi- (5) chemical substance. cal location. CPT Discussion The Current Procedural Terminology (CPT) is a medical code set for uniform communication about services and procedures specifying which services health care providers have per- In sub-Saharan Africa many actors are willing to improve the formed on the patient.[6] This terminology is maintained by health care system, especially the documentation of it. Not S. Van Laere et al. / A Method for Constructing a New Extensible Nomenclature for Clinical Coding Practices 967 only health insurance companies, but also ministries, public ing terminologies. To cope with national and local differences and private hospitals are ready to improve documentation. in sub-Saharan regions, this new nomenclature is made exten- Nowadays most of the health care actions still are documented sible. For evaluating this nomenclature we will use the registry on paper patient charts or remain (partly) undocumented. information per country. When one code is necessary for When documentation is provided on these charts or in health providing the required information for multiple national regis- information systems (HIS), registration is often incomplete, tries, an extension will be the solution for providing the coun- inaccurate and/or performed in an untimely way.[10] try with the correct data. This nomenclature has the benefit of The reason for this, is that documentation schemes are just too being adaptable to both the needs of the hospitals and to the complex and too time-consuming (in the opinion of the man- needs of the countries. agement of a hospital and for the nursing staff). However, a mental change in sub-Saharan Africa is progressing: they tend References to see benefits of documenting. In HIS used in sub-Saharan countries, documentation is often [1] I. T. Adeleke, O. O. Ajayi, A. B. Jimoh, A. A. Adebisi, S. used for billing purposes where each intervention that requires A. Omokanye, and M. K. Jegede, Current clinical coding several sub-actions is summarized into one general concept. practices and implementation of ICD-10 in Africa: A sur- For example, the documentation of the concept “child-birth” vey of Nigerian hospitals, Am J Health Res 3 (2015), 38- does not only include the hospitalization, but also procedures 46. and health services by various caregivers to help the patient in [2] D. T. Jamison, R.G. Feachem, M.W. Makgoba, E.R. Bos, delivering a baby. However, in most cases hospitals will pro- F.K. Baingana, K.J. Hofman, and K.O. Rogo , Disease vide an invoice only based on giving child birth. and Mortality in Sub-Saharan Africa, 2nd edition, The It is important to stress that the documentation of these various World Bank, Washington, NW, 2006. actions will lead to possible new insights regarding the func- [3] F. Verbeke, OpenClinic GA [Internet]. Available from: tioning of the hospital and/or the country’s health system. https://sourceforge.net/projects/open-clinic/ [cited 2016 Moreover, by documenting every step of the care process, Nov 29]. possible improvements with beneficiary outcome for the coun- [4] F. Verbeke, G. Karara, and M. Nyssen, Evaluating the try and/or hospital are possible. National institutes will be able impact of ICT-tools on health care delivery in sub- to provide epidemiologic summaries enabling them to im- Saharan hospitals, Stud Health Technol Inf 192 (2013), prove the health status of their country. Hospitals will be able 520-523. to calculate cost-benefit ratios based on what is documented [5] WHO Collaborating Centre for Drug Statistics Methodol- and may adapt their price system on their findings. ogy. Structure and Prinicples (of ATC) [Internet]. Availa- The aim of this paper is introduce a method for creating a new ble from: extensible documentation system based on existing nomencla- http://www.whocc.no/atc/structure_and_principles/ [cited tures for the sub-Saharan part of Africa. The reason is an in- 2016 Nov 29]. creasing awareness for the need of proper coding principles. [6] American Medical Association, Current Procedural Ter- Contrary to introducing a completely new coding system, we minology (CPT®) Editorial Panel [Internet]. Available will use existing coding systems. The benefit of reusing exist- from: https://www.ama-assn.org/about-us/current- ing terminologies is that this terminology will require less procedural-terminology-cpt-editorial-panel [cited 2016 maintenance compared to a completely new terminology. Nov 29]. We will construct this nomenclature by calculating a common [7] World Health Organization, International Classification subset of concepts over the sub-Saharan countries. After this, of Health Interventions (ICHI) [Internet]. Available from: an evaluation study is required to see if the new nomenclature http://www.who.int/classifications/ichi/en/ [cited 2016 covers every aspect necessary. The idea of extensibility is Nov 29]. essential to solve the problems cause by the different national registry requirements in every country. To meet these re- [8] Regenstrief Institute, Inc. and the Logical Observation quirements it is possibly necessary to extend the new nomen- Identifiers Names and Codes (LOINC) Committee, Logi- clature so that codes that map onto multiple register require- cal Observation Identifiers Names and Codes (LOINC®) ments can be split up, in order to be more fine-grained. - Users’ Guide [Internet]. Available from: http://loinc.org/downloads/files/LOINCManual.pdf [cited Not only nation-wide this extensibility will give improve- 2016 Nov 29]. ments, but also hospitals can benefit from this characteristic of this new nomenclature. Sometimes procedures are only exe- [9] Nordic Medico-Statistical Committee (NOMESCO), cuted in particular hospitals. These procedure codes will then NOMESCO Classification of Surgical Procedures Ver- not be part of the general nomenclature, but will be put in a sion 1.16 [Internet]. Available from: http://www. local extension. nordclass.se/NCSP_1_16.pdf. [cited 2016 Nov 29]. Finally, we will enable interoperability between countries [10]W. Mutale, N. Chintu, C. Amoroso, K. Awoonor- using this nomenclature. The power of this terminology lies in Williams, J. Phillips, et. al., Improving health information the origin of the common subset including only codes that are systems for decision making across five sub-Saharan Af- necessary. rican countries: Implementation strategies from the Afri- can Health Initiative, BMC Health Serv Res 13 (Suppl 2) Conclusion (2013), S9. Address for correspondence Sub-Saharan Africa is willing to improve the health care sys- Sven Van Laere, tems by investing in good documentation practices. This in- creasing awareness grows both in nationwide institutions, as Vrije Universiteit Brussel, Department of Public Health, well as inside the hospitals. Current terminology systems Research group of Medical Informatics and Biostatistics appear to be complex and too extensive in use. We propose a Laarbeeklaan 103, B-1090 Brussels, Belgium method for constructing a new nomenclature based upon exist- [email protected]