新版ICD-11扩展码在卫生健康信息领域应用的优势与挑战  

The Advantages and Challenges of Applying the New ICD-11 Extension Codes in the Field of Health Information Industry

作　　者：周婧雅[1] 廖爱民[1] 张萌[1] 许毅从[2] 周炯[3] Zhou Jingya;Liao Aimin;Zhang Meng;Xu Yicong;Zhou Jiong(Department of Medical Records,Peking Union Medical College Hospital&World Health Organization International Classification Family China Cooperation Center,Beijing 100730,China;不详)

机构地区：[1]北京协和医院病案科&世界卫生组织国际分类家族中国合作中心,北京市100730 [2]浙江大学医学院附属第二医院医务部病案室 [3]北京协和医院医务处,北京市100730

出　　处：《中国病案》2023年第9期35-39,共5页Chinese Medical Record

基　　金：中央高水平医院临床科研业务费资助(2022-PUMCHA-085);中央高校基本科研业务费专项资金资助(3332021017)。

摘　　要：ICD-11扩展码章节的引入有利于解决既往ICD-10本土化应用造成的编码冗余、分类结构破坏及国家间难以广泛比较等问题,并着重与其他分类体系保持统一性和兼容性。ICD-11通过组配式结构化编码模式使扩展码与主干码形成清晰的逻辑关联,更利于数据解读、分析处理及智能编码。2类扩展码的设置有力提升医疗卫生数据采集细粒度,进一步扩大ICD-11在更多领域的应用优势,在实现附加信息的标准化和精细化采集的同时,更能满足临床科研、医疗精细化管理、医疗质量与患者安全、医保支付等方面的需要。扩展码章节具有明显应用优势的同时也面临诸多挑战。扩展码种类及内涵的丰富性对临床医师诊断信息表达的完整性、编码员医学素养的提升提出更高要求;ICD-11编码组配方式更加依赖数字化编码工具的智能性以及配套信息系统的改造;编码数据应用模型亦需重构以适应编码结构及存储方式的改变。此外扩展码选择性使用的特点将影响数据采集的细粒度的统一。建议组建由临床医师、病案统计、医政管理者及信息技术人员多方参与的多学科合作团队,在国家管理与应用层面开展ICD-11扩展码准确性和适用性的评价,形成ICD-11扩展码应用规范,深度参与ICD-11维护更新工作,从而使ICD-11扩展码更加符合本土应用的需要,切实发挥其在卫生健康信息领域应用中的优势。The introduction of the ICD-11 extension code chapter contributes to solving problems of code redundancy,destruction of classification structure,and difficulty of extensive comparison among countries caused by the localized application of ICD-10.ICD-11 is designed to maintain uniformity and compatibility with other classification systems.The combined structured coding mode adopted by ICD-11 makes a clear relationship between the extension code and the stem code,which is more suitable for the needs of big data interpretation,analysis,and intelligent coding.The two types of extension codes can effectively improve the fine-grained collection of medical and health data,which further expands the application advantages of ICD-11 in more fields.While realizing the standardization and refined collection of additional information,it can better meet the needs of clinical research,refined medical management,medical quality and patient safety,and medical insurance payment.The application of extension code chapter has obvious advantages but also faces great challenges.The richness and diversity of extension codes put forward higher requirements for the complete documentation of clinical details by clinicians and the improvement of medical literacy of clinical coders.Implementing post coordination in ICD-11 is highly dependent on the intelligence of digital coding tools and transformation of information system and it is necessary to modify the present coded data application models to accommodate changes in coding structure and storage methods.Furthermore,the feature of optional use of extension codes will affect the unification and standardization in collected data granularity nationwide.In an effort to meet the local needs and to give full play to ICD-11 extension codes,close multidisciplinary collaboration among clinicians,medical record managers,statisticians,medical care administrators,and information technologists is strongly suggested in the work of ICD-11 accuracy and feasibility evaluation,setting extension code applic

关 键 词：国际疾病分类 ICD-10 ICD-11 扩展码 后组配 

分 类 号：R197.3[医药卫生—卫生事业管理]