ICD-10 or ICD-11? Chaos in draft changes to medical records

More data, more paperwork

The draft requires facilities and medical staff to submit further detailed data to the IT systems, including information on disease diagnosis, comorbidities and medical procedure codes, among others. In practice, doctors will have to enter additional codes - both statistical disease units and codes from the International Classification of Medical Procedures - each time they issue referrals for examinations, consultations or treatment. In addition, each facility would have to supplement the documentation with new elements, such as a departmental identification code, REGON number, e-mail address, telephone number or contract number with the National Health Fund.

ICD-10 or ICD-11? Lack of clarity and the threat of clutter

As PPOZ points out, the draft does not explain which disease classification should be used. "No convincing justification is provided here as to why such a wide range of data should be collected by the public administration. The new regulations mandate the use of the 'current International Classification of Diseases and Health Problems,' but do not clearly indicate whether it is ICD-10 or ICD-11." - Bozena Janicka points out.

The PPOZ president points out that such ambiguity will lead to a situation where some clinics will use the older classification and some will use the newer one, resulting in "incompatible data, i.e. a legal and IT mess." As he recalls, although the WHO has introduced ICD-11, the Health Ministry itself has said that the decision to implement it in Poland has not yet been made. "In this situation, we believe that a possible amendment should be introduced only when the health care system is ready to use the new designations," - he stresses.

Problems with documentation of vaccinations

There are also doubts about documentation related to vaccinations - including COVID-19 vaccination.

"The draft makes changes to the rules for coding diagnoses and procedures, but leaves unchanged the regulations for COVID-19 vaccination referrals and Immunization Cards, which still refer to the outdated ninth revision of the International Classification of Medical Procedures. This is an example of inconsistency in lawmaking," - Janicka points out. In her opinion, the parallel use of new and old classification systems can paralyze the work of facilities and make reporting of immunizations more difficult.

PPOZ calls for withdrawal of draft

PPOZ physicians believe that making such broad changes is pointless and premature. "The draft regulation in its current form, instead of facilitating the functioning of the system, threatens to disorganize the work of doctors, deteriorate the quality of data and reduce the time that can be devoted to the patient." - Janicka warns.

PPOZ appeals to the Minister of Health to abandon further proceedings on the regulation and prepare new regulations - after sound consultations with representatives of the medical community and software providers.

Source: PPOZ