Dr Islam Ibrahim, MB BCh, MPH, PhD, National Center for Health Information (WHO-FIC CC) Ministry of Health, Kuwait

What is ICD-11 and why do we need it?

Ever wondered how we obtain information on diseases and health-related problems that cause morbidity and mortality? How can diseases like Covid-19, Ebola, diabetes, obesity, or harmful health effects of environmental pollutants be reported from different parts of the world, irrespective of differences in language and abbreviations, to be quantified and compared across different settings and over time?

How do governments measure the incidence and prevalence of diseases for planning and resource allocation? How can researchers collect information on health conditions or their risk factors? The answer is the International Classification of Diseases (ICD). ICD translates diagnoses and health-related problems from text (as documented by health professionals) to a common language of alphanumeric codes. These codes are the international standard for systematically recording, reporting, analyzing, interpreting, and comparing mortality and morbidity data.

The world of health information has dramatically changed since the World Health Organization (WHO) released ICD-10 in the early 1990s. Medical records in many health facilities are now electronic, and the exchange of electronic health information between different systems requires semantic interoperability i.e., data is shared in a way that ensures the exact meaning is transferred in a standard unambiguous way.

How is ICD-11 different from its predecessors?

ICD-11 is not merely an upgrade of ICD-10. It’s an entirely new concept. Adopted at the World Health Assembly in May 2019, ICD-11 is completely electronic and works through a user-friendly electronic tool that functions as a flexible search engine. It is developed and maintained by the WHO, and can be embedded in any electronic medical record or health information system using an Application Programming Interface (API).

It is free to use and works online or locally offline. It uses natural language processing, which means clinicians can type in the diagnosis just like they would if they were free texting. ICD-11 content is updated annually and there is a transparent proposal mechanism in place that enables users and experts from all over the world to suggest changes to improve ICD-11 content provided they give a rationale and references for their proposal.

ICD-11 enables its users to add a lot more detail to diagnoses than ever before using extension codes. These are optional add-ons that further refine the granularity of documentation by standardizing the way additional information is added such as anatomy, laterality, infectious agents, substances, appliances, or even the specific part of a place where an injury or event has occurred among many others. ICD-11 is both a classification and a terminology.

Every ICD-11 entity has a Unique Resource Identifier (URI), so although different index terms under one code may all be “classified” under the same category, their URIs ensure the exact term documented by the health professional is not lost. This is very helpful for retaining data on some rare diseases which may not be individually given their own codes in a classification, but can still maintain their uniqueness through their URIs.

URIs are permanent and will not change regardless of subsequent ICD-11 updates. Therefore, ICD-11 data recorded in one version can be easily traced to the following updated version without the need for a map, even if a term is reclassified in a newer version due to updates in medical science. URIs also facilitate links to external terminologies such as SNOMED-CT.

Carbon monoxide and ICD-11

You may be wondering where CO poisoning fits here? To take its place as a public health issue, doctors need to consider CO poisoning as a possibility in the Emergency Department. For that, they need to be aware of the magnitude of the problem and its consequences.

Once identified, they also need to report it by comprehensively documenting the diagnosis and all the circumstances around it (e.g., causes) which is then translated into ICD codes for statistical reporting. Producing evidence-based facts is the best way to raise awareness; the more awareness raised, the fewer cases of CO poisoning missed.

ICD-11 helps improve CO poisoning documentation thanks to the additional level of detail that was not previously possible with ICD-10, and the ease with which the coding tool can be used for doing that through a series of simple clicks.

For example, we are now able to report the exact place in a building where the CO poisoning occurred, so rather than just saying poisoning at home (as we did in ICD-10) we can now report that it happened in a garage or a bathroom at home.

Semantic interoperability also helps the electronic exchange of information between different systems used at different levels of care (paramedics, Emergency Department, ICU… etc.) and across different geographical locations even if different software is used by each.

The ICD-11 implementation case study

ICD-11 has been successfully implemented for documenting final diagnoses by physicians in outpatient clinics & inpatient wards in the largest public hospital in Kuwait by installing the coding tool on the hospital information system. Diagnoses are now automatically ICD-11 coded once the physician documents the diagnosis in the electronic medical record at the point of care.

Leading the morbidity data team behind this implementation has been a challenging and exciting experience for me. Transitioning to ICD-11 is an organizational change process requiring careful planning, and coordination between different stakeholders namely, physicians, Information Technology (I.T.), hospital administration, and health information managers.

The center of excellence leading the change was the National Center for Health Information at the Ministry of Health which also serves as the WHO Family of International Classifications Collaborating Center (WHO-FIC CC) in the Eastern Mediterranean Region.

Our implementation started with a well-planned pilot that proceeded via the following steps: engaging stakeholders, selecting the setting, building a common understanding of the discharge process in the selected setting, evaluating and preparing IT infrastructure, ICD-11 training, pre-pilot testing on a small scale, and implementing the pilot while providing on-site support and collecting data for analysis.

An effective communication strategy is essential when implementing ICD-11. Meetings were held to convince leaders to support the transition using stakeholder-tailored messages. During the pilot, as physicians experimented with using ICD-11 in real-life, a brief user experience survey was used so they could voice their opinion. Physicians are busy, with over-stretched schedules and long working hours, so training was brief and customized to their needs, and interests, and was disseminated using social media to be accessed at their convenience.

Based on physicians’ positive response, and the lessons we learned from the pilot, we were able to go ahead with full-scale implementation in December 2021. The key factors that paved the way for the success of this project include national health system influence, leadership commitment, a multidisciplinary team approach, physician-tailored training, using social media for training, and providing on-site support. The most important challenge we faced was training and engaging physicians.

Finally, it’s important to highlight that with morbidity data, there are health system-specific important issues to consider such as DRG (casemix system) requirements.


1. World Health Organization. ICD-11 Implementation or Transition Guide. Vol. 1, ICD-11 Implementation or Transition Guide. 2019. Available online: https://icd.who.int/docs/ICD-11 Implementation or Transition Guide_v105.pdf (accessed on 3 January 2023).

2. International Classification of Diseases (ICD). Available online: https://www.who.int/classifications/classification-of-diseases (accessed on 3 January 2023).

3. Ibrahim I, Alrashidi M, Al-Salamin M, Kostanjsek N, Jakob R, Azam S, Al-Mazeedi N, Al-Asoomi F. ICD-11 Morbidity Pilot in Kuwait: Methodology and Lessons Learned for Future Implementation. International Journal of Environmental Research and Public Health. 2022; 19(5):3057. https://doi.org/10.3390/ijerph19053057

4. World Health Organization. ICD-11 Reference Guide. 2022. Available online: https://icdcdn.who.int/icd11referenceguide/en/html/index.html (accessed on 3 January 2023).

5. National Center for Health Information Kuwait—YouTube. Available online: https://www.youtube.com/channel/UCDZn35SMKMjW0JpOQTA_Uvg/videos?view=0&sort=p (accessed on 3 January 2023).