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

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MEDINFO 2017: Precision Healthcare through Informatics A.V. Gundlapalli et al. (Eds.)

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© 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 of sub-Saharan Africa. By the word “nomenclature”, usually they understand: “a coding system to provide codes that are used in invoices, to specify the health services that were provided for particular patients”. We define nomenclature in a broader way, also taking into account the clinical definition of health services. In this paper we will present a way to build this new nomenclature for sub-Saharan Africa, based on existing nomenclatures.

Clinical coding is a requirement to provide valuable data for billing, epidemiology and health care resource allocation. In sub-Saharan Africa, we observe a growing awareness of the need for coding of clinical data, not only in health insurances, but also in governments and the hospitals. Presently, coding systems in sub-Saharan Africa are often used for billing pur- poses. In this paper we consider the use of a nomenclature to also have a clinical impact. Often coding systems are assumed to be complex and too extensive to be used in daily practice. Here, we present a method for constructing a new nomencla- ture based on existing coding systems by considering a mini- mal subset in the sub-Saharan region. Evaluation of com- pleteness will be done nationally using the requirements of national registries. The nomenclature requires an extension character for dealing with codes that have to be used for mul- tiple registries. Hospitals will benefit most by using this exten- sion character.

Methods

In nomenclature construction, it is key to have a clear goal. For example, the existing Anatomical Therapeutic Chemical (ATC) classification is used as a tool to register drug utilization in order to improve the quality of drug use [5]. Our purpose is to see what is necessary per sub-Saharan country and to find a common subset between these countries (see Fig. 1).

Keywords:

  • 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 include codes of existing procedure classifications. The Current Procedural Terminology (CPT), International Classification of Health Interventions (ICHI) and NOMESCO Classification for Surgical Procedures (NCSP) can help in providing these specifications. However, not only the billing aspect of procedures are of interest in an electronic medical record. To provide more granularity compared to what is often used, we will also include codes for medication and lab results. Possible terminologies to include are respectively ATC and the Logical Observation Identifiers Names and Codes (LOINC). The idea is to design a new nomenclature of codes, at least including the

Introduction

Medical coding systems have shown their relevance in health information management (HIM) systems. Clinical coding is an integral part of HIM practice which provides valuable data for health care quality evaluation, health care resource allocation, health services research, medical billing, public health programming and Case-Mix/DRG funding.[1] In sub-Saharan Africa, several countries use their own coding system by (1) setting up their own code system, (2) using an in-house designed code system based on another reference terminology, or (3) by making use of an existing code system. 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 comprehensive and significantly sound community assessments.[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 existing coding systems limit the use of them. The idea of a new nomenclature for the sub-Saharan region that is extensible for a country or as more specialized hospital rise.

Figure 1: Idea of constructing a minimal subset of concepts
(colored part) necessary to represent medical data

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S. V a n 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 following structure:

PREFIX.CODE[.XXX],

where PREFIX indicates a reference to the original terminology, 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 extensibility 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 the information that is required to be provided by the hospitals for reporting purposes to the national registers. The data elements in the reporting requirements will be used as an evaluation source.
Figure 2: Possible mapping scenarios between newly com- posed nomenclature (left) and national register requirements
(right);
Scenario A: mapping 1-1 (no problem) Scenario B: mapping N-1 (no problem)
Scenario C: mapping 1-N (extension required)
Three scenarios can occur in this evaluation part (see Fig. 2):

ꢀꢀꢀ

Scenario A: If there is a 1-1 mapping from the newly constructed nomenclature to the national requirement, no problem will arise. Each new concept that is used, can be used to fill up the register regarding this concept. Scenario B: If there is a N-1 mapping from our new nomenclature to the national registry, it means two (or more) concepts will be used to fill up the national register data. Scenario C: If there is a 1-N mapping from the new subSaharan nomenclature towards the requirements of a national register, it is necessary to provide an extension. This extension will then split up the newly generated code into multiple parts using the XXX part, until we obtain at least one concept per national register requirement. the American Medical Association through the CPT Editorial Panel. Governments can use CPT for tracking the prevalence and value of procedures. Each CPT code is 5 characters long and may be numeric or alphanumeric, depending on which category the CPT code is classified. CPT codes are divided into 3 categories based on their usage.

ICHI Alpha 2015

The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes, maintained by WHO.[7] ICHI was originally designed to replace the International Classification of Procedures in Medicine (ICPM). The classification is built around three axes: the target (the entity on which the Action is carried out), the performed action (a deed performed by an actor to a target) and the means (the processes and methods by which the ‘action’ is carried out). Extension codes are provided to allow users to describe more detail about the intervention in addition to the relevant ICHI code.
First we will evaluate this regarding national requirements. This extension of course can also be used on a more local basis, for example in an African hospital specialized for a particular health care service.

LOINC

Nomenclatures

The Logical Observation Identifiers Names and Codes (LOINC) provides universal identifiers for laboratory and other clinical observations.[8] This classification is maintained by the Regenstrief Institute. LOINC codes are composed by 5
In this part we will briefly list up the code systems that can be of interested for the creation of this nomenclature. We need concepts dealing with procedures in which CPT, ICHI and NCSP. We also include the ATC and LOINC classifications for registering respectively medication and laboratory information.

  • or
  • 6
  • parts that are separated by
  • a
  • colon: (1) compo-

nent/analyte, (2) property observed, (3) timing of measurement, (4) type of sample, (5) scale of measurement, and if relevant (6) the method of the measurement.

ATC
NCSP

ATC stands for Anatomical Therapeutic Chemical and is a classification system used for medication.[5] It classifies substances based on the organ or system on which they operate and their therapeutic, pharmacological and chemical properties and is maintained by the World Health Organization (WHO). Moreover, the ATC system also includes “defined daily doses” (DDDs) for many drugs, indicating the usual dose used per day. The classification uses the representation of the concept identifier to classify medication at five different levels: (1) anatomic main group; (2) therapeutic subgroup; (3) pharmacological subgroup; (4) chemical subgroup and (5) chemical substance.
The NOMESCO Classification of Surgical Procedures (NCSP) is a classification for surgical procedures, maintained by Nordic Centre for Classifications in Health Care.[9] It is based on the traditions of the surgical profession in the Nordic countries. A NCSP code consists of three alphabetic characters (positions 1-3 of the code) and two numeric characters (positions 4-5 of the code). The alphanumeric part refers the classification (i.e. chapter) to which the code belongs and the numeric part refers to the specific procedure within the procedure group, including surgical technique and precise anatomical 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 performed on the patient.[6] This terminology is maintained by
In sub-Saharan Africa many actors are willing to improve the health care system, especially the documentation of it. Not

S. V a n Laere et al. / A Method for Constructing a New Extensible Nomenclature for Clinical Coding Practices

967

only health insurance companies, but also ministries, public and private hospitals are ready to improve documentation. Nowadays most of the health care actions still are documented on paper patient charts or remain (partly) undocumented. When documentation is provided on these charts or in health information systems (HIS), registration is often incomplete, inaccurate and/or performed in an untimely way.[10] The reason for this, is that documentation schemes are just too complex and too time-consuming (in the opinion of the management of a hospital and for the nursing staff). However, a mental change in sub-Saharan Africa is progressing: they tend to see benefits of documenting. ing terminologies. To cope with national and local differences in sub-Saharan regions, this new nomenclature is made extensible. For evaluating this nomenclature we will use the registry information per country. When one code is necessary for providing the required information for multiple national registries, an extension will be the solution for providing the country with the correct data. This nomenclature has the benefit of being adaptable to both the needs of the hospitals and to the needs of the countries.

References

[1] I. T. Adeleke, O. O. Ajayi, A. B. Jimoh, A. A. Adebisi, S.
A. Omokanye, and M. K. Jegede, Current clinical coding practices and implementation of ICD-10 in Africa: A survey of Nigerian hospitals, Am J Health Res 3 (2015), 38- 46.
In HIS used in sub-Saharan countries, documentation is often used for billing purposes where each intervention that requires several sub-actions is summarized into one general concept. For example, the documentation of the concept “child-birth” does not only include the hospitalization, but also procedures and health services by various caregivers to help the patient in delivering a baby. However, in most cases hospitals will provide an invoice only based on giving child birth. It is important to stress that the documentation of these various actions will lead to possible new insights regarding the functioning of the hospital and/or the country’s health system. Moreover, by documenting every step of the care process, possible improvements with beneficiary outcome for the country and/or hospital are possible. National institutes will be able to provide epidemiologic summaries enabling them to improve the health status of their country. Hospitals will be able to calculate cost-benefit ratios based on what is documented and may adapt their price system on their findings. The aim of this paper is introduce a method for creating a new extensible documentation system based on existing nomenclatures for the sub-Saharan part of Africa. The reason is an increasing awareness for the need of proper coding principles. Contrary to introducing a completely new coding system, we will use existing coding systems. The benefit of reusing existing terminologies is that this terminology will require less maintenance compared to a completely new terminology.
[2] D. T. Jamison, R.G. Feachem, M.W. Makgoba, E.R. Bos,
F.K. Baingana, K.J. Hofman, and K.O. Rogo , Disease

and Mortality in Sub-Saharan Africa, 2nd

World Bank, Washington, NW, 2006.

edition, The

[3] F. Verbeke, OpenClinic GA [Internet]. Available from: https://sourceforge.net/projects/open-clinic/ [cited 2016 Nov 29].
[4] F. Verbeke, G. Karara, and M. Nyssen, Evaluating the impact of ICT-tools on health care delivery in sub-

Saharan hospitals, Stud Health Technol Inf 192 (2013),

520-523.
[5] WHO Collaborating Centre for Drug Statistics Methodology. Structure and Prinicples (of ATC) [Internet]. Availa-

  • ble
  • from:

http://www.whocc.no/atc/structure_and_principles/ [cited 2016 Nov 29].
[6] American Medical Association, Current Procedural Terminology (CPT®) Editorial Panel [Internet]. Available

procedural-terminology-cpt-editorial-panel [cited 2016 Nov 29].
We will construct this nomenclature by calculating a common subset of concepts over the sub-Saharan countries. After this, an evaluation study is required to see if the new nomenclature covers every aspect necessary. The idea of extensibility is essential to solve the problems cause by the different national registry requirements in every country. To meet these requirements it is possibly necessary to extend the new nomenclature so that codes that map onto multiple register requirements can be split up, in order to be more fine-grained. Not only nation-wide this extensibility will give improvements, but also hospitals can benefit from this characteristic of this new nomenclature. Sometimes procedures are only executed in particular hospitals. These procedure codes will then not be part of the general nomenclature, but will be put in a local extension.
[7] World Health Organization, International Classification of Health Interventions (ICHI) [Internet]. Available from: http://www.who.int/classifications/ichi/en/ [cited 2016 Nov 29].
[8] Regenstrief Institute, Inc. and the Logical Observation
Identifiers Names and Codes (LOINC) Committee, Logical Observation Identifiers Names and Codes (LOINC®)

  • -
  • Users’
  • Guide
  • [Internet].
  • Available
  • from:

http://loinc.org/downloads/files/LOINCManual.pdf [cited 2016 Nov 29].
[9] Nordic Medico-Statistical Committee (NOMESCO),
NOMESCO Classification of Surgical Procedures Version 1.16 [Internet]. Available from: http://www. nordclass.se/NCSP_1_16.pdf. [cited 2016 Nov 29].
[10]W. Mutale, N. Chintu, C. Amoroso, K. Awoonor-
Williams, J. Phillips, et. al., Improving health information systems for decision making across five sub-Saharan African countries: Implementation strategies from the African Health Initiative, BMC Health Serv Res 13 (Suppl 2) (2013), S9.
Finally, we will enable interoperability between countries using this nomenclature. The power of this terminology lies in the origin of the common subset including only codes that are necessary.

Conclusion

Address for correspondence

Sub-Saharan Africa is willing to improve the health care systems by investing in good documentation practices. This increasing awareness grows both in nationwide institutions, as well as inside the hospitals. Current terminology systems appear to be complex and too extensive in use. We propose a method for constructing a new nomenclature based upon exist-

Sven Van Laere, Vrije Universiteit Brussel, Department of Public Health, Research group of Medical Informatics and Biostatistics Laarbeeklaan 103, B-1090 Brussels, Belgium [email protected]

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