Trouble with timelines (1) DSM-5, ICD-10-CM, ICD-11 and ICD-11-CM

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ICD-11: ETA: Currently projected for dissemination in 2016

WHO is invested in the DSM-5 development process.

The revision of DSM-IV and development of DSM-5 began in 1999, with an initial research planning conference under joint sponsorship of the American Psychiatric Association and the National Institute of Mental Health. 13 global research planning conferences, under the auspices of the American Psychiatric Institute for Research and Education (APIRE) and the World Health Organization, were held between 2004 and 2008.

WHO participates with the American Psychiatric Association in an International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and a DSM-ICD Harmonization Coordination Group.

The International Advisory Group is co-ordinated by Senior Project Officer, Dr Geoffrey Reed, Ph.D., seconded to the Department of Mental Health and Substance Abuse through IUPsyS (International Union for Psychological Science).

Meetings are chaired by Steven Hyman, MD, Harvard University, Cambridge, MA, a former Director of the National Institute of Mental Health (NIMH) and a DSM-5 Task Force Member.

DSM-5 Task Force Chair, David Kupfer, MD, and Vice-chair, Darrel Regier, MD, have attended Advisory Group meetings as observers and presenters. Some members of ICD Revision consultation and working groups for the ICD mental health chapter are also members of DSM-5 work groups.

[Summary reports of International Advisory Group Meetings 1-4 here. No summary reports have been published for the 5th meeting or any subsequent meetings that may have taken place since the 4th meeting in December 2008.]

ICD-11 timeline also slipping

ICD-11, 2012-05-29, København, Robert Jakob, Bedirhan Ustun

     Workshop Presentation: ICD-11 Beta overview

May 2012 PowerPoint Slide 14 states: “Completion of chapters by mid June 2012″

Work on the ICD-11 Beta drafting is running behind schedule.

The original dissemination date for ICD-11 had been 2011/2012, with the timelines for revision of DSM-IV and ICD-10 running more or less in parallel. The dissemination date for ICD-11 was later extended to 2015+.

See comments in red text, in this Agenda Appendix (Page 8), on the impact that limited funding, lack of resources, the workload burden for Topic Advisory Group editing managers and members, and the lack of an overall project manager is having on targets: ICD-11 April 11 Meeting Agenda.

ICD-11 Revision does not have the $25M to throw at this project that has so far been spent on DSM-5.

In this (subscription required) article, published in March 2012, by Christopher Chute, MD, (Chair, ICD-11 Revision Steering Group) et al, dissemination of ICD-11 is now expected “around 2016″ (three years later than DSM-5).

Given the ambitious scale of the project, its technical complexity and with ICD-11 still at the Beta drafting stage, I shall not be surprised if at some point before the end of this year, Revision Steering Group announces an extension to the projected dissemination date or a scaling back of the project, if completion of ICD-11, ICD-11-PHC and several planned speciality versions including Mental health disorders, Paediatrics and Neurology, is to be reached by 2016.

Joint commitment to “harmonization”

For the next editions, WHO has stated that APA and WHO have committed as far as possible:

To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria.”

with the objective that:

The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.

The WHO acknowledges there may be areas where concordance between the two classifications might not be achievable.

With the timelines for DSM-5 and ICD-11 running out of synch (DSM-5 slated for publication in May 2013; ICD-11 still at the Beta drafting stage, with a two year period scheduled for completion of  ICD-11 and Primary Care version field trials, and continuous stakeholder input), this may pose difficulties for harmonization.

But the concept of, and extent to which the two systems might be harmonized for category descriptions and criteria raises issues around influence, copyright, intellectual property and publication revenues:

Extract from 4th Meeting of the Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders, 1 – 2 December 2008 Geneva: 

[...]

9. ICD/DSM Harmonization Group

Presenters: Dr. Darrel Regier and Dr. David Kupfer (APA); Dr. Benedetto Saraceno and Dr. Shekhar Saxena (WHO).

Dr. Hyman began this discussion by raising the issue of how the international community might best be involved in the DSM process. To the extent that ICD and DSM diverge, this may create unintentional divergence in treatment, research, and epidemiology. It is often clear that the two systems agree about the nature of the phenomenon that categories represent, but approach them in slightly different ways. This challenge is elevated – when groups begin to revise individual criteria sets, as research has demonstrated that relatively minor differences in criteria can have a large impact on prevalence estimates.

Speaking for the APA side of the harmonization agenda, Dr. Regier placed the current situation in a historical context. While there had been early collaboration between ICD and DSM for DSM-I and DSM-II, DSM-III made a major break and as a result was substantially different from ICD-9.

In retrospect, this represented a failure to communicate and collaborate. At the same time, it is possible that DSM-III was so different from ICD that it would have been very difficult for WHO to obtain the necessary agreement to make so dramatic a change in any case. Dr. Regier indicated that APA had made a major effort to make the DSM process as collaborative as possible beginning in 1999, and characterized the DSM process as cross-cultural and interdisciplinary. He described the DSM process as a very transparent one; the proceedings from all of the working conferences have been published or are in process. He emphasized the importance of an advisory review process that can help to make sure that DSM-V will fit the needs of the world, crossculturally, and to make sure that it can be integrated with other components of the ICD…

…Dr. Saraceno, speaking from the WHO side of the harmonization issue, raised a number of concerns related to harmonization. As Director of the WHO Department of Mental Health and Substance Abuse, he routinely receives communications from global leaders in the field. In recent months, the topic of the ICD revision has been prominent, and the issue of harmonization with the DSM has been raised frequently. The importance of harmonization is widely endorsed, but many have emphasized that the two processes should be parallel and independent and that WHO’s development of ICD should not be substantially influenced by the DSM process. Some have specifically criticized APA’s and WHO’s attendance at one another’s revision meetings, pointing out that other classification groups—Chinese, Cuban, etc.—are not treated equivalently.

There has also been criticism of cross-membership on DSM and ICD working groups. These issues regarding the interaction of the ICD and DSM processes will need to take into account, both in terms of their substance and in terms of perception, even in the overall context of harmonization as a general goal.

Dr. Saxena, also speaking on behalf of WHO, acknowledged a history of successful collaboration between WHO and APA, including the recent conferences, but also noted significant challenges.

The mandates, organizational requirements, and interests of WHO and APA do not overlap entirely and cannot be put aside. The constitutional responsibility of WHO for ICD is a unique and serious one. As the ICD process goes forward, there will be a demand for increasing specificity, which will create more difficulties if uniformity is seen as the most important goal.

There are also issues related to copyright and publication revenues. There was a Memorandum of Understanding between APA and WHO in 1990 regarding ICD-10 and DSM-IV, which seems to have worked well. However, changes in organizational priorities, global health care, and technology suggest that it may not be a simple matter to achieve a similarly workable agreement in the current context. Commercial issues may become more prominent the greater the degree of harmonization achieved…

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There are some interesting insights in Exhibit 2: History of APA relation with WHO and IUPsyS relation with WHO around harmonization of ICD-11 with DSM-5 and the roles, relationships and perceived dynamics between the WHO and the American Psychiatric Association, the American Psychological Association and the International Union of Psychological Science (IUPsyS), as bodies invested in the ICD-11 development process:

International Union of Psychological Science COMMITTEE ON INTERNATIONAL RELATIONS ACTION, March 28–30, 2008, Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology

Full document:

    IUPsyS Mar 08 Agenda Item 25 ICD-10

Extracts from Page 6, Exhibit 2: History of APA relation with WHO and IUPsyS relation with WHO

    Extracts Letter IUSPsyS

The letter is authored by Pierre L.-J Ritchie, PhD, C.Psych. Secretary-General, International Union of Psychological Science (IUPsyS).

Note: The “APA” referred to throughout this letter is the American Psychological Association. American Psychiatric Association, where referenced, is spelled out in full. This document dates from 2007, at which point it was envisaged ICD-11 would be ready for WHA approval/dissemination by 2011/12, later shifted to 2014/15, now 2015/2016+.

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ICD-11-CM: ETA: Unknown

There’s been a good deal of conjecture around whether the US could jettison the substantial investment by clinical practices and the health coding industry in tooling up for transitioning to ICD-10-CM and wait, instead, for ICD-11.

I am in the UK and I don’t have a horse in this race. But reading the arguments on websites and blogs in favour of the US “leapfrogging over ICD-10-CM” because by late 2014, “ICD-11 will be just around the corner,” and the polls asking readers to vote on whether the US should skip ICD-10-CM and move straight from ICD-9-CM to ICD-11, I see little consideration of how long a wait there might be before the US can roll out a clinical modification of ICD-11.

Assuming ICD Revision does complete its targets for presentation for WHA approval in 2015, with pilot dissemination of ICD-11 (or an ICD-11 lite) in 2016 – a US clinical modification isn’t going to unpack overnight.

The US might be looking at another 8 to 10 years or more down the road from where we are today before an ICD-11-CM/PCS version has been developed and is ready for implementation for US specific healthcare use.

According to Page 3332 of this DHSS Office of Secretary Final Rule document, “We estimated that the earliest projected date to begin rulemaking for implementation of a U.S. clinical modification of ICD–11 would be the year 2020.” (Document dated January 16, 2009, at which point ICD-11 had been scheduled for WHA approval by 2014.)

…We [ICD-9-CM Coordination and Maintenance Committee] discussed waiting to adopt the ICD-11 code set in the August 22, 2008 proposed rule (73 FR 49805)…

However, work cannot begin on developing the necessary U.S. clinical modification to the ICD–11 diagnosis codes or the ICD–11 companion procedure codes until ICD–11 is officially released. Development and testing of a clinical modification to ICD–11 to make it usable in the United States will take an estimated additional 5 to 6 years. We estimated that the earliest projected date to begin rulemaking for implementation of a U.S. clinical modification of ICD–11 would be the year 2020.

The suggestion that we wait and adopt ICD–11 instead of ICD–10–CM and ICD–10–PCS does not consider that the alpha-numeric structural format of ICD–11 is based on that of ICD–10, making a transition directly from ICD–9 to ICD–11 more complex and potentially more costly. Nor would waiting until we could adopt ICD–11 in place of the adopted standards address the more pressing problem of running out of space in ICD–9–CM Volume 3 to accommodate new procedure codes…

Source: Page 3332, Federal Register/Vol. 74, No. 11/Friday, January 16, 2009/Rules and Regulations DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of the Secretary [6]

There is considerably more on ICD-10-CM implementation and the rulemaking process, including the Committee’s responses to public submissions on proposed delay, in document [6]. Further responses from CMS in document [7].

See also: There are important reasons for delaying implementation of the new ICD-10 coding system. Chute CG, Huff SM, Ferguson JA, Walker JM, Halamka JD. Health Aff (Millwood). 2012 Apr;31(4):836-42. Epub 2012 Mar 21 http://www.ncbi.nlm.nih.gov/pubmed/22442180  (Subscription required)

See also: Interview with Christopher Chute, MD, Making the Case for the ICD-10 Compliance Delay April 4, 2012 by Gabriel Perna for Healthcare Informatics:

An argument that the CMS was right in delaying the ICD-10 compliance date

“…Chute is also adamant that there is no possible reason or possibility that the U.S. could just skip over ICD-10 right into ICD-11. Even with his ties to ICD-11, Chute says there it’s not realistic, nor is it plausible, to have seven-to-nine more years of ICD-9 codes, while the medical industry waits for the World Health Organization to finish drafting ICD-11 and then waits for the U.S. to adapt it for its own use.”

See also: There Are Critical Reasons for Not Further Delaying the Implementation of the New ICD-10 Coding System. Richard F. Averill, M.S., Susan E. Bowman, M.J., R.H.I.A., C.C.S.  JOURNAL OF AHIMA/July 2012/Volume 83, Number 7 (No subscription required)

Critical Reasons for Not Further Delaying ICD-10 Implementation

PDF full Averill et al response

This response to the Chute et al March 2012 Health Affairs article, argues, inter alia, that assuming ICD-11 is ready for dissemination in 2016, the earliest the US could move to ICD-11 would be 2025, or 13 years from now.

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References

1] DSM-5 Permissions Policy
http://www.dsm5.org/Pages/PermissionsPolicy.aspx

2] Transition to the ICD-10-CM: What does it mean for psychologists?
Psychologists should be aware of and prepare for the mandatory shift to ICD-10-CM diagnosis codes in October 2013
http://www.apapracticecentral.org/update/2012/02-09/transition.aspx

3] Covered Diagnoses & Crosswalk of DSM-IV Codes to ICD-9-CM Codes by APA Practice Organization, December, 2003 http://www.apapracticecentral.org/reimbursement/billing/icd-9-cm.aspx

4] DSM: Frequently Asked Questions
http://www.psychiatry.org/practice/dsm/dsm-frequently-asked-questions

5] ICD-10 “Blue Book” and “Green Book”
ICD-10 for Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines [PDF]
ICD-10 for Mental and Behavioural Disorders Diagnostic Criteria for Research [PDF]

6] Federal Register / Vol. 74, No. 11 / Friday, January 16, 2009 / Rules and Regulations
DEPARTMENT OF HEALTH AND HUMAN SERVICES, Office of the Secretary, 45 CFR Part 162 [CMS–0013–F] RIN 0958–AN25  HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM and ICD–10–PCS AGENCY: Office of the Secretary, HHS. ACTION: Final rule [Page 3332]
http://www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-743.pdf

7] Federal Register / Vol. 77, No. 74 / Tuesday, April 17, 2012 / Proposed Rules
[Pages 22949-23005] [FR Doc No: 2012-8718] [Page 22949]
http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/html/2012-8718.htm

3. Option 3: Forgo ICD-10 and Wait for ICD-11

“The option of foregoing a transition from ICD-9 to ICD-10, and instead waiting for ICD-11, was another alternative that was considered. This option was eliminated from consideration because the World Health Organization, which creates the basic version of the medical code set from which all countries create their own specialized versions, is not expected to release the basic ICD-11 medical code set until 2015 at the earliest.

“From the time of that release, subject matter experts state that the transition from ICD-9 directly to ICD-11 would be more difficult for industry and it would take anywhere from 5 to 7 years for the United States to develop its own ICD-11 CM and ICD-11-PCS versions.”

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