The necessity to develop a national classification system for Iranian traditional medicine

Abstract

Background:

Classification of disease and interventions in traditional medicine (TM) is necessary for standardised coding of information. Currently, in Iran, there is no standard electronic classification system for disease and interventions in TM.

Objective:

The current study aimed to develop a national framework for the classification of disease and intervention in Persian medicine based on expert opinion.

Method:

A descriptive cross-sectional study was carried out in 2018. The existing systems for the classification of disease and interventions in TM were reviewed in detail, and some of the structural and content characteristics were extracted for the development of the classification of Iranian traditional medicine. Based on these features, a self-administered questionnaire was developed. Study participants (25) were experts in the field of Persian medicine and health information management in Tehran medical universities.

Results:

Main axes for the classification of disease and interventions were determined. The most important applications of the classification system were related to clinical coding, policymaking, reporting of mortality and morbidity data, cost analysis and determining the quality indicators. Half of the participants (50%) stated that the classification system should be designed by maintaining the main axis of the World Health Organization classification system and changing the subgroups if necessary. A computer-assisted coding system for TM was proposed for the current study.

Conclusion:

Development of this classification system will provide nationally comparable data that can be widely used by governments, national organisations and academic researchers.

Keywords

classification traditional medicine disease classification coding system health information management

Introduction

The International Classification of Diseases (ICD) is generally defined as a de facto standard in disease classification for epidemiological and clinical purposes (Tu et al., 2010). Currently, the 10th revision of ICD is supported by the World Health Organization (WHO) and provides alphanumeric codes for statistical uses, and the ICD-11 was released for field trials in 2018 (National Health Services, 2018). International classification systems are considered essential tools for the storage, retrieval, analysis and interpretation of the health data of different populations simultaneously (Bickenbach et al., 2012; Jakob et al., 2007). Furthermore, the best method for transmission of healthcare data is by means of a standard and consistent acquisition of mortality and morbidity data according to a set of classified lists of codes (Fekadu et al., 1999). The WHO Family of International Classification (FIC) created a conceptual structure that enables data collection and aggregation across different levels of health systems (Svestková, 2008). Currently, 153 countries have adopted the ICD-10 system, which not only increases the specificity of diagnosis codes but also accelerates the sharing of health information (Coustasse and Paul III, 2013; Quan et al., 2008).

The 11th revision of ICD has been developed in a Web-based format (National Health Services, 2018; WHO, 2019a). Unlike previous revisions that were created manually using the list of codes, the development of ICD-11 is based on knowledge engineering methods by means of software tools (Reed, 2010; Tu et al., 2010). The most important characteristic of the current revision is its application information infrastructure, which enables the definition of each disease, determining the aetiology, anatomical and physiological dimension. Furthermore, each concept is mapped with other terminology and ontologies such as Systematized Nomenclature of Medicine – Clinical Terms and International Classification of Functioning Disability and Health (Kostanjsek et al., 2011; Tudorache et al., 2011).

Traditional medicine (TM) is one of the accepted and integrated forms of healthcare in many areas of the world. Its vast use has had a great impact on patients, healthcare providers, researchers and policymakers, but it has never been incorporated into the ICD code set. The involvement of TM in FIC may enable the comparison of diagnostic, clinical and epidemiological data across the whole health system (Morris et al., 2012). The affordability of TM makes it more attractive for individual consumers, and there is an increasing tendency to use TM around the world (WHO, 2013). According to the WHO, 82% of the population throughout the world utilise some form of TM products and services (Morris et al., 2012; WHO, 2013).

The International Classification of Traditional Medicine (ICTM) was created by the WHO as part of the ICD-11 project and the aim of ICTM is to report various practices of TM in order to strengthen the quality of healthcare and affordable resource allocation. The beta version of ICD-11 contains a TM Module 1 chapter (East Asian TM) consisting of two sections: TM disorders, and TM patterns. China, Korea and Japan have contributed to the development of this classification system by referencing their own national standards. Although there is some overlap in Chinese, Korean and Japanese TM practices because of their origins and evolution (Gao and Watanabe, 2011; Watanabe et al., 2011), all of the abovementioned TM practices tend to be determined by a holistic and highly individualised approach to a patient’s treatment (Ikram et al., 2015). Overall, there are many types of TM practices all over the world, which may be substantially different from each other in theory and practice. Some of these types of TM practice include traditional Ayurvedic medicine, traditional Malay medicine, traditional African medicine and Persian medicine.

Theoretical background

Review of TM systems

TM systems vary greatly across different countries and regions, as they are influenced by factors such as culture, history, personal attitudes and philosophy. Furthermore, the theory and application of TM in various parts of the world may differ. Some forms of TM include traditional Chinese medicine (TCM), Ayurveda, Kampo and Persian medicine, which have been practised all over the world for thousands of years and are valuable repositories of human knowledge.

Traditional Chinese medicine

The majority of people in developing societies use TM in primary healthcare (Chaudhury and Rafei, 2002). In China, most people rely on TCM to cover their health needs (Yang et al., 2017b). The TCM system provides different interventions such as Chinese medication, acupuncture, moxibustion, massotherapy, diet and Qigong. TCM uses Zang-Fu and the meridians as its theoretical basis and yin–yang and five elements as its theoretical tools. Based on TCM, Qi, blood and body fluids are considered the most important substances, which constitute the body’s system and maintain its normal physiological functions (Yang et al., 2017a). The main characteristic of TCM in the diagnosis and treatment of diseases is syndrome differentiation. A syndrome has been defined as a categorised pattern of symptoms and signs in a patient at a specific stage during the course of diagnosis (Cheng et al., 2014). A syndrome may be affected by various elements, such as climate, demographic characteristics and life situations. TCM diagnostic methods (e.g. inspection, auscultation, olfaction, inquiry and palpation) are usually used for syndrome differentiation (Wen et al., 2018). TCM patterns are comprised of yin–yang, deficiency–excess, cold–heat, six stages of acute febrile diseases and Qi, blood and fluids (Yan et al., 2018). Because of the overlap in origin and evolution of Chinese, Korean and Japanese TM practices, we have not examined the basic principles of these systems individually.

Traditional Ayurveda Medicine

The term Ayurveda is a Sanskrit word, which translates into knowledge (Veda) of life (Ayur) (Chopra and Doiphode, 2002). Ayurveda is based on a philosophy that links the universe with all material and non-material phenomena. According to the Ayurveda hypothesis, diversity in the universe is often based on changes to material matter by fire energy, and all changes in the body are based on natural fire. The ultimate goal of this method of practice is to maintain stability in the body to ensure optimal health conditions (Aldridge, 2002; Dumoff, 2002). The manifest world is traced to an unmanifest world called Prakruti. The overall Prakruti remains stable during life and is comprised of physical, psychological and functional (Dosha) features. Based on this definition, Dosha consists of three main parts: Vata, Pitta and Kapha. The Vata material is mostly related to a nervous and musculoskeletal system and controls cell division, impulse transmission and movement of body fluids. The Pitta manages the metabolism and formation of tissues and is mainly associated with digestive and endocrine systems. The Kapha is responsible for body growth and prevents the destruction of tissues (Chopra and Doiphode, 2002; Garodia et al., 2007). Ayurveda principles are mainly based on the examination of body systems and evaluation of symptoms and providing personalised treatment. Ayurveda is prevalent not only in India but also in Nepal, Sri Lanka, Mauritius, Bangladesh, Pakistan, Indonesia, Malaysia, Singapore and the Maldives (Chaudhury and Rafei, 2002).

Persian medicine

Persian medicine was established according to the basic concept of Mizaj (temperament). Mizaj is created by the interaction of various elements in the human body and influences normal physical, emotional and physiological features (Emtiazy et al., 2012; Mojahedi et al., 2014). According to Persian medicine, stability among four humours (phlegm, bile, black bile and sanguine) in the body maintains good health, while any disturbance in this balance leads to disease and disorders (Emtiazy et al., 2012). Based on this approach, diseases were divided into Sue-Mizaj (dystemperament), which is attributable to inequality in the four types of humours, and Taforrogh-E-Ettesaal (separation of organs) due to various traumas (Nimrouzi et al., 2014; Shirbeigi et al., 2015). In Persian medicine, each person has an exclusive Mizaj, which is usually recognised based on morphological, physiological and psychological characteristics. Iranian medicine has divided the different kinds of Mizaj into nine main groups. These nine groups are differentiated according to a spectrum of different degrees of warmness and wetness. These elements include one central equilibrium region, four simple Mizajes (warm, cold, moist and dry) and four combined Mizajes (warm and moist, warm and dry, cold and moist and cold and dry) (Parvizi et al., 2017). According to this theory, every person is susceptible to specific diseases related to his or her Mizaj and may require various treatment approaches for the same disease and even different lifestyle recommendations. In this way, the Mizaj is considered as a road map to the preservation of a person’s health status (Arji et al., 2019; Mojahedi et al., 2014). Based on Persian medicine, it is essential for each person to have his or her own lifestyle and nutrition according to his or her characteristics. Persian medicine and Iranian medicine are used in the current article interchangeably.

TM standardisation efforts: Terminologies and classifications

The main benefits of a common terminology in TM include empowering practitioners to document the type and frequency of health conditions, increasing communication with patients and physicians, facilitating outcome measurement and enabling data sharing between different parties (Kalenderian et al., 2011). Furthermore, standardised terms would allow the epidemiologist to analyse disease patterns, and researchers could use these terms to assess healthcare quality, to determine costs and to evaluate treatment efficiency (Colquhoun et al., 2014). In addition, these terms could be used as a resource for the development of standards. Conversely, the use of different terminologies by various communities makes data integration difficult across different fields (Brinkman et al., 2010).

Based on accepted definitions, classification involves the application of exclusive categories to the accumulation of data for a specific purpose (Madden et al., 2007); the application of pertinent concepts according to logical rules (Simeonsson et al., 2006). Classification systems are essential to adapt terminologies for standardised coding of information for statistical use (Chute et al., 2012). In TM, a number of standardised terminologies have been created to assist data transmission between different parties. Recently, the WHO initiated some attempts at standardisation in TM terminology and classification for data collection and comparison at an international level (Gao and Watanabe, 2011).

Mortality data have been widely used to describe and compare health characteristics between countries (Johansson and Pavillon, 2005). Valid and comparable cause of death statistics are essential to identify emerging public health challenges, to inform and assist in priority setting and health services planning and to evaluate health policies and interventions (Zhao et al., 2017). An important input to national and international health decision-making and planning processes is a consistent and comparative analysis of the causes of death across different population groups (Mathers et al., 2009). Mortality statistics are mainly based on the underlying cause of death, as defined by the WHO in the ICD rules and guidelines. The United States National Centre for Health Statistics introduced an automated selection of the underlying cause in the late 1960s. This system, the Mortality Medical Data System, has now also been used by many other countries (Johansson and Pavillon, 2005). The inclusion of TM classification systems such as Persian medicine classification into ICD mortality reporting system is essential for reporting mortality statistics.

The first attempt at standardisation in TM included 361 standardised locations in acupuncture (Morris et al., 2012; World Health Organization, 2007). The second involved the generation of more than 4000 terms in TM (Morris et al., 2012; World Health Organization, 2008). The third attempt was the development of the ICTM, which included diagnostic codes (Morris et al., 2012). China, Japan and Korea were the three main countries involved in developing this system (Morris et al., 2012). The main aim of the ICTM project is to provide consistency with other types of medicines, to collect data related to TM diseases and patterns and to enable interoperability and compatibility with other systems. Furthermore, providing integration with health information systems and electronic health records (EHRs) is among the essential objectives for implementation of ICTM.

Existing resources for TM terminology and classification in some countries include classification and codes of diseases and ZHENG (pattern/syndrome) of TCM in China. This national standard includes disease and pattern names (Wang et al., 2016). Another resource is clinical terminology of traditional Chinese medical diagnosis and treatment, which includes diseases and the names of syndromes, therapeutic methods and terminology for the basic theory of TCM. Furthermore, the use of ICD codes is prevalent in Japan for Western and Kampo medicine classification and insurance claims. Japan also applied disease patterns for establishing 148 formulae in Kampo medicine (Gao and Watanabe, 2011). While Korea uses the Korea Classification of Diseases and Causes of Death, 7th edition, this system is based on the ICD-10 codes, which concentrate on disease patterns (Gao and Watanabe, 2011; Yoon and Ahn, 2015). India has developed English equivalents of Ayurveda diseases, which translate directly into modern ICD equivalents (Gao and Watanabe, 2011).

Necessity to develop a national classification system in Persian medicine

According to the medical historian, Cyril Elgood, Persian medicine existed before Greek medicine (Rezaeizadeh et al., 2009). The historian and writer of the book “History of Islamic civilization and medicine” Kingstone (cited by Naseri et al., 2015: 11) wrote:

For a long time it has been thought that Muslims were the followers of the Greeks in science and philosophy and the only thing they did was to protect these resources and did not make any changes to them. But this theory is completely wrong because when the Muslims held superior status in the world, Greek medicine was limited to spells, magic and fetishes. In this period, Muslims not only protected, translated and applied these valuable documents of the ancient Greeks but also civilized them by adding logical commentaries and explanation to them and established the first scientific and experimental methods in medicine.

In 1972, in the WHO Journal, Dr Norman Howard (cited by Naseri et al., 2015) stated that the most important writer of medical books in Islam was Abu Ali al-Hossein Ibn Sina¹ and his medical book, Canon, is the most famous book of the times and has been used for 500 years in medical universities of Europe and Asia (Movahhed et al., 2013; Naseri et al., 2015). Furthermore, the origin of the four-element theory seems to be Persian, not Greek (Habashi, 2000). Thus, Persian medicine has its own special theories and principles and in order to properly apply this practice, it is necessary to become familiar with relevant terminologies, vocabularies and theories (Shirbeigi et al., 2015; Pasalar and Nayernouri, 2014). Box 1 shows the main characteristics of Persian medicine based on the main four elements. The disorders and patterns that originated in ancient Chinese medicine, and commonly used in China, Japan, Korea and elsewhere around the world (Patwardhan et al., 2005), are shown in Box 2, which also includes characteristics of TCM based on the five-element theory.

Box 1.

Main characteristics of Persian medicine based on four elements.

Four elements	Earth	Water	Air	Fire
Primary quality	Cold and dry	Cold and moist	Hot and moist	Hot and dry
Main temperaments	Melancholic	Phlegmatic	Sanguineous	Choleric
Season	Autumn	Winter	Spring	Summer
Age	40–60	>60	0–-30	30–40
Humours	Black bile	Phlegm	Blood	Yellow bile
Organs	Bone	Brain	Liver	Heart
Taste	Sour	Tasteless	Sweat	Bitter, salty, spicy
Emotional states	Depression, sadness	Fear	Anxiety	Anger, excitement
Related tissues	Nerves	Nerves	Muscles	Vessels

Box 2.

Main characteristics of Chinese traditional medicine based on five elements.

Five elements	Fire	Water	Earth	Metal	Wood
Primary quality	Heat, flaring, ascendance, movement	Cold, descending (downward flowing)	Moisture, growing, changing, nourishing, producing	Strength, cleaning up	Extension, softness, harmony, flexibility
Season	Summer	Winter	End of summer	Autumn	Spring
Senses	Tongue	Ear	Mouth	Nose	Eye
Taste	Bitter	Tasteless	Sweat	Pungent	Sour
Emotional states	Happiness	Fear	Anxiety	Depression, sadness	Anger
Related tissues	Vessels	Bone	Muscles	Hair/Skin	Tendon
Zang organs	Vessel	Kidney	Spleen	Lung	Liver
Fu organs	Small intestine	Urinary	Stomach	Large intestine	Gall bladder
Geographical location	South	North	Middle	West	East

The current research

As Persian medicine has its own historical structure, theory, method, terminology and concepts, it is necessary to include it in the WHO classification in a separate module. This may offer a foundation for comparison of clinical and epidemiological data across health systems, promote standardisation of TM and accelerate communication, sharing of knowledge and resources, health data analysis and reporting (WHO, 2019a). The current research aimed to achieve two essential objectives: (i) establish a national standard for terminology and classification in Persian medicine and create a representation format for each TM entity characteristic and (ii) create tools for collecting TM-related statistics from health information systems, such as EHRs, insurance, billing and reimbursement systems. This article is dedicated to demonstrating the overall process of development of the classification of the Persian medicine system based on expert opinion.

Method

Research design

The research presented in this article comes from a descriptive cross-sectional study, conducted in 2018 with the support of the Ministry of Health in Iran. This particular article focuses on part of that study, namely the design and development of a computerised coding system for the classification of Persian medicine. First, we reviewed existing TM classification systems, the most important being the system provided by the WHO. We examined in detail all sections, classes and main axes; hierarchical structure; and the possibility of expanding the groups and subgroups, the structure of the codes and maintenance and updating program for the classification systems. A set of structural and content features were extracted to determine the most appropriate characteristics for the development of the classification of Persian medicine.

Participants

To obtain the views of the research community, a survey was conducted to collect information for the development of a national classification system. As the research population was expected to include the group of experts with the greatest degree of familiarity with the classification of diseases in TM, the study sample included faculty members of Persian medicine and health information management in Tehran medical universities. Due to limited numbers of potential participants in the research community population, the census method was used to ensure all segments of the population were considered for inclusion in the sample. The number of faculty members invited to participate was 38 in total, 28 from Persian medicine and 10 from the health information management.

Instrument

Based on defined measures, a research-based questionnaire was developed that included four main sections: (1) demographic data, (2) most important axes of disease and intervention classification in Persian medicine, (3) main application domains of a Persian medicine classification system and (4) general specifications of a computerised coding system and evaluation framework questions. The second and third sections of the questionnaire were designed according to a five-point Likert-type scale (1 = lowest level of importance; 5 = highest level of importance). The fourth section contained multiple-choice questions.

Procedure and data analysis

Validity and reliability of the questionnaire were evaluated. To confirm validity, the questionnaire was submitted to five faculty members for approval: three from the field of health information management and two with a Persian medicine background. To ensure reliability of the tool, it was completed by 10 of the aforementioned experts (Cronbach’s α = 83.6). Statistical analyses were conducted using SPSS 19. Determining the main axes of disease and intervention classification in Persian medicine was based on participant agreement level. In this way, axes with less than 50% agreement were excluded and those with more than 75% agreement were included in the final model. As all axes received 75% agreement, the Delphi technique was conducted in one round.

Results

Demographic characteristics

In the current study, 25 of the 38 experts (65.8%) participated, of whom 64% were Persian medicine experts and 36% were health information management experts; 10 (40%) were male and 15 (60%) were female. The mean age of participants was the 46.72 ± 5.4 years (minimum age = 39, maximum age = 58 years) and mean duration of employment was 14.64 ± 5.7 years (from 5 years to 26 years). Distribution of participants’ views on the different axes of the classification system for disease and interventions is presented separately in Table 1. Classification of diseases in Persian medicine was consistent with different body systems and classification of interventions including nutritional therapy, herbal drug therapy, manual therapy and modification of lifestyle and self-care principles.

Table 1.

Participants’ views regarding the classification of diseases and interventions axes by gender.

		Male	Female	Total
		Mean score of importance ± SD	Mean score of importance ± SD	Mean score of importance ± SD
Traditional medicine disease classification axes
1	Certain infectious and parasitic diseases	4.56 ± 0.726	4.67 ± 0.617	4.63 ± 0.647
2	Neoplasms	4.44 ± 1.014	4.60 ± 0.828	4.54 ± 0.884
3	Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism	4.22 ± 1.394	4.80 ± 0.414	4.58 ± 0.929
4	Endocrine, nutritional and metabolic diseases	4.33 ± 1.323	4.60 ± 0.828	4.50 ± 1.022
5	Mental, behavioural and neurodevelopmental disorders	4.78 ± 0.441	4.67 ± 0.488	4.71 ± 0.464
6	Diseases of the nervous system	4.67 ± 0.500	4.80 ± 0.414	4.75 ± 0.442
7	Diseases of the eye and adnexa	4.78 ± 0.441	4.87 ± 0.352	4.83 ± 0.381
8	Diseases of the ear and mastoid process	4.78 ± 0.441	4.87 ± 0.352	4.83 ± 0.381
9	Disease of circulatory system	4.67 ± 0.500	4.80 ± 0.414	4.75 ± 0.442
10	Diseases of the respiratory system	4.67 ± 0.500	4.80 ± 0.414	4.75 ± 0.442
11	Diseases of the digestive system	4.78 ± 0.441	4.87 ± 0.352	4.83 ± 0.381
12	Diseases of the skin and subcutaneous tissue	4.44 ± 1.014	4.67 ± 0.488	4.58 ± 0.717
13	Diseases of the musculoskeletal system and connective tissue	4.74 ± 0.441	4.67 ± 0.617	4.71 ± 0.550
14	Diseases of the genitourinary system	4.67 ± 0.500	4.73 ± 0.458	4.71 ± 0.464
15	Pregnancy, childbirth and the puerperium	4.78 ± 0.441	4.60 ± 0.632	4.67 ± 0.565
16	Certain condition originating in the perinatal period	4.44 ± 1.014	4.60 ± 0.828	4.54 ± 0.884
17	Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified	4.44 ± 1.014	4.60 ± 0.828	4.54 ± 0.884
18	Injury, poisoning and certain other consequences of external causes	4.67 ± 0.500	4.80 ± 0.414	4.75 ± 0.442
Traditional medicine interventions classification axis
1	Interventions related to nutritional therapy	4.89 ± 0.333	4.80 ± 0.414	4.83 ± 0.381
2	Interventions related to herbal drug therapy	4.78 ± 0.441	4.73 ± 0.458	4.75 ± 0.442
3	Interventions related to manual therapy	4.78 ± 0.441	4.80 ± 0.414	4.79 ± 0.415
4	Interventions related to the modification of lifestyle and self-care principles	4.78 ± 0.441	4.80 ± 0.414	4.79 ± 0.415

SD: standard deviation.

In all axes for classification of diseases and interventions in Persian medicine, the mean score was greater than four. Therefore, it was concluded that diseases of these body systems should be included in the design of the classification system, based on data collected from Persian medicine literature (Table 1).

Distribution of participants’ responses regarding the most important applications of the classification system; training, maintenance and updating of the system; method of adopting classification of Persian medicine from the classification system provided by the WHO; and organisational readiness for a field trial of the classification system are presented in Table 2.

Table 2.

Distribution of participants’ responses regarding the applications of the classification system, maintenance, method of adoption and organisational readiness for field trial.

		Male^a	Female	Total
		n (%), 10(40)	n (%), 15 (60)	n (%), 25 (100)
The most important application of the classification system	Coding (using the classification system for research, management and clinical purposes)	3 (12.5)	1 (4)	4 (17)
	Analysis (using the classification system for analysis and research)	0	1 (4)	1 (4)
	Policymaking and planning (using the classification system for mortality and morbidity reporting, cost analysis and determining quality and safety indicators)	0	7 (29)	7 (29)
	All the above	6 (25)	6 (25)	12 (50)
The organisation responsible for training, maintenance and updating of the classification system	Ministry of health and medical education Iran	3 (12.5)	5 (21)	8 (33)
	Iranian medicine faculty	0	0	0
	An expert team comprised of Persian medicine, health information management and medical informatics specialists	6 (25)	10 (42)	16 (67)
	Other	0	0	0
Method of adoption of the classification system provided by the WHO	Using the classification system provided by the WHO	0	1 (4)	1 (4)
	Maintaining the main axis of the WHO classification system and changing subgroups as needed	5 (21)	7 (29)	12 (50)
	Change in main axes and subgroups, if necessary	2 (8)	2 (8)	4 (17)
	Establishment of a national classification system distinct from the system provided by the WHO	2 (8)	5 (21)	7 (29)
Organisational readiness for the field trial of the classification system	Yes	2 (8)	6 (25)	12 (50)
	No	0	1 (4)	1 (4)
	I don’t know	6 (25)	8 (33)	14 (58)
	This classification system is not applicable to our field	1 (4)	0	1 (4)

WHO: World Health Organization.

^aMales calculated with denominator of 9; missing = 1 for every question (various participants). Total percentage was therefore calculated with denominator of 24.

Half (50%) of participants reported that the classification system would be beneficial in clinical data analysis and coding, policymaking and planning for Persian medicine. They also agreed that this classification system could be useful in the reporting of mortality and morbidity data, cost analysis and determining of quality and safety indicators. Furthermore, 67% of participants agreed that the classification system should be reviewed and updated by a team of Persian medicine, health information management and medical informatics experts under the supervision of the Ministry of Health and Medical Education in Iran. Half of respondents (50%) thought that the classification of Iranian TM should be adopted by maintaining the main axes of the WHO classification system and changing the subgroups as necessary. The majority (58%) of the participants did not know the level of their organisation’s readiness for field trials of the classification system.

The distribution of participants’ responses regarding the evaluation of the framework developed for classification of Iranian TM is presented in Table 3. The mean score for all of the domains was >4, which indicates the importance of the classification system in terms of its application in a different scope. Distribution of participants’ responses related to computer-assisted coding (CAC) system capabilities and some other general features are presented in Table 4. These questions were arranged in four main categories including software language, the codes search method, the field of application of the classification system and main user group of classification of Persian medicine.

Table 3.

Distribution of participants’ responses regarding the evaluation of the framework developed for classification of Iranian traditional medicine.

	Male	Female	Total
	Mean score of importance ± SD	Mean score of importance ± SD	Mean score of importance ± SD
The classification of Persian medicine could be useful in order to carry out scientific research in this field.	4.56 ± 0.527	4.47 ± 0.516	4.50 ± 0.511
The classification of Persian medicine could be effective in producing standard and comparable national data	4.56 ± 0.527	4.47 ± 0.516	4.50 ± 0.511
The classification of Persian medicine could be used to develop the standard terminology for the development of computer systems.	4.56 ± 0.527	4.47 ± 0.516	4.50 ± 0.511
The classification of Persian medicine could be meet the needs for statistical reporting of diseases.	4.56 ± 0.527	4.40 ± 0.507	4.46 ± 0.509
The classification of Persian medicine could be beneficial for statistical reporting of mortality.	4.56 ± 0.527	4.33 ± 0.617	4.42 ± 0.584
The classification of Persian medicine could respond to the needs of primary care reporting.	4.44 ± 0.527	4.27 ± 0.799	4.33 ± 0.702
The classification of Persian medicine could be meet the needs of clinical care	4.33 ± 0.500	4.40 ± 0.507	4.38 ± 0.495
The classification of Persian medicine could be meet the requirements of insurance systems	4.44 ± 0.527	4.47 ± 0.516	4.46 ± 0.507

SD: standard deviation.

Table 4.

Distribution of participants’ responses related to computer-assisted coding system capabilities and general features.

General features		Male^a	Female	Total
		n (%), 10(40)	n (%), 15 (60)	n (%), 25 (100)
Software language	Persian-English	5 (21)	10 (42)	15 (62.5)
	Persian-Arabic	0	0	0
	English-Arabic	0	0	0
	English-Persian-Arabic	4 (17)	5 (21)	9 (37.5)
The codes search method	Search based on keyword	3 (12.5)	3 (12.5)	6 (25)
	Search based on code	0	1 (4)	1 (4)
	Search based on keyword and code	6 (25)	11 (46)	17 (71)
Field of application of the system	Outpatients	4 (17)	2 (8)	6 (25)
	Inpatients	0	1 (4)	1 (4)
	Outpatients and inpatients	5 (21)	12 (50)	17 (71)
Main user groups	Hospitals and academic centers	0	1 (4)	1 (4)
	Physician offices	0	0	0
	Other health-related facilities	0	0	0
	All	9 (37.5)	14 (58)	23 (96)

^aMales calculated with denominator of 9; missing = 1 for every question (various participants). Total percentage was therefore calculated with denominator of 24.

As shown in Table 4, 62.5% of participants recommended the development of the system in bilingual (Persian-English) format. For the code search method, 71% of participants suggested a combination search method (the search method based on the keyword and disease code). For the field of application of the system, 71% of respondents considered that this classification system could be applied for both inpatients and outpatients’ settings. Furthermore, 96% of participants stated that this classification system will be beneficial for all main user groups – hospitals and academic centres, physician offices and the other health-related facilities.

Discussion

The classification system that most closely aligns with the current study is the ICTM system provided by the WHO. There is a major difference between the classification of disease in the ICTM project and classification of Iranian TM. In the ICTM structure, disease classification was divided into two main sections: disorders and patterns. In the disorders module, body disorders were divided into six main sections including organ system disorder; other body system disorders; Qi, blood and fluid disorders; mental and emotional disorders; external contraction disorders; and childhood and adolescent associated disorders. The patterns module was divided into nine main sections including principle-based patterns, environmental factor patterns, body constituent patterns, organ system patterns, meridian and collateral patterns, six stage patterns, triple energiser stage patterns, four phase patterns and four constitution medicine patterns. On the other hand, in Persian medicine, body organs are divided into two main groups, main organs and other organs. The main organs of the body are those which are vital to the survival of the person and reproduction. These organs include the brain, heart, liver and the testicles in men and the ovaries in women (Ghods et al., 2016).

Classification of disease in Persian medicine is based on the Canon of Medicine (al Qanon fi al Tibb), which is similar to the classification of disease in modern medicine. Avicenna’s masterpiece is divided into five books. The first book relates to principles of medicine and general anatomy (Kolliat), the second is a reference for Materia Medica (Mofradat), the third demonstrates organ-specific diseases, the fourth discusses systemic illnesses (i.e. fevers) and traumatic injuries and the fifth contains descriptions of compound drugs (Qarabadin) (Emtiazy et al., 2013). The Al Qanon fi al Tibb as a medical text of great authority follows the philosophy of the ancient tradition of four elements (air, water, fire and earth) and the four humours (blood, phlegm, yellow bile and black bile) (Emtiazy et al., 2013). Furthermore, classification of disease is demonstrated in different resources such as Zakhireh kharazm shahi, Eksire azam, Tib-Akbari, Hodod-al-amraz, Kholasa-to-Al hekme, Aghraz Altebi and Bahr-Al-javaher.

There are also significant differences between traditional Persian medicine and TCM. A disorder in TCM refers to a series of disturbances in each of the body systems which presents with related manifestations and specific signs and symptoms or findings. Each disorder in TCM is mainly characterised by its symptomology, aetiology and outcome and treatment response. Due to differences in the theories and principles of Persian medicine and Chinese medicine, it is necessary to design a separate classification system for classifying diseases in Persian medicine. Currently, ICD-10 is used for the classification of diseases in Iran, and there is a tendency to use all the chapters of disease along with the module provided for TM in the 11th Edition in our country.

Another axis that has been considered in this article relates to interventions classification in TM. Health intervention refers to all activities related to assessing, and promotion of, health status and health-related functions in the population (Hanser et al., 2006). The intervention data will be used for measuring resource utilisation indicators, evaluating the quality of healthcare services, determining procedure efficacy and allocating resources (Drösler, 2008).

From the literature, attention to the classification of TM intervention codes appeared to be a low priority. Most of the classification systems for intervention do not cover TM concepts and therefore cannot be used directly as a classification system for intervention. Most of the participants in the current study agreed that TM intervention should include nutritional therapy, herbal drug therapy, manual therapy and lifestyle modification and self-care intervention. However, some intervention classification systems such as the Current Procedural Coding (CPT), the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) and the International Classification of Health Interventions (ICHI) (WHO, 2019b) encompass TM concepts minimally. For example, in CPT, only eight codes of its more than 8000 codes are related to alternative medicine and TM (Dumoff, 2002). The Alternative Billing Codes (ABC codes) describe some of the services, supplies or therapy provided by means of nursing and alternative medicine professions (Thede and Schwirian, 2013). Within the MESH thesaurus, the classification of TM is more detailed but the coverage of all relevant interventions is still far from comprehensive (Hongyong et al., 2018). Furthermore, the tabular list of ICD-9-CM procedures includes a limited number of interventions related to TM. ICD-10-PCS provides a multiaxial unique code for some of the TM interventions. The ICHI system, developed by the WHO, was built from three axes including target, action and means. The ICHI system includes most of the TM interventions. The incorporation of interventions in the classification of Persian medicine system will need further detailed consideration.

Maintenance and updating of the TM classification system is vital. In the current study, most participants believed that a combination of experts from health information management, Persian medicine and medical informatics under the supervision of the Ministry of Health and medical education should be responsible for maintenance and revision of classification system. According to Jakob et al. (2007), the updates and revisions process should be coordinated with the custodian of the classification system; and the participants should be informed of the location of persons and committees responsible for the preparation and maintenance of the classification system. Training for users of the coding system should also be considered and requires good planning. Therefore, after the implementation of the classification system, a detailed plan for the education of users and clinical coders should be applied. As coding and working with this classification system will be computerised, the process of user education will be complex and time-consuming.

In this study, half of the participants stated that classification of Persian medicine should be based on the WHO classification of TM by maintaining the main axes of the classification system and changing subgroups if necessary. In the family of ICD, derived classifications are developed either by adopting the reference classification structure and categories and providing more details or prepared through rearrangement or aggregation of items from one or more reference classifications. Derived classifications are often tailored for use at the national or multinational level (Madden et al., 2013).

Health data standards developed for TM based on a particular region cannot be applied to another region without adjustment because of dissimilarities among countries related to basic theories and principles (Alkraiji et al., 2014). One of the roles of national standards is to extend interoperability between the health sectors. Classification standards determine special codes and medical terms for clinical concepts. Currently, there is no classification standard in Iran for TM, thus exchanging medical data among healthcare sectors is awkward. Furthermore, achieving meaningful insight into the medical information through accurate statistics and reports is limited due to the insufficiency of medical data. Therefore, it is essential to develop a national plan in TM for standards for the management of medical data.

Most respondents in the current study reported that they did not know the readiness of their organisation for a field trial of the classification system. Usually, readiness for field trials is mainly related to different elements such as available resources, maturity level and quality of the classification system. Organisational readiness embraces areas such as organisational culture, management and leadership and operational and technical requirements (Ghazisaeidi et al., 2014). Generally, acceptance of the system by stakeholders, participation of leaders in planning, preparing a strategic plan for system implementation, identification of financial and human resources and having a clear policy and training method and techniques are among the essential elements that should be considered for assessment of organisational readiness for system implementation (Ghazisaeidi et al., 2014; Ludwick and Doucette, 2009; McGinn et al., 2011).

The main purpose of ICD is to serve as a classification system for standard and internationally comparable mortality and morbidity statistics (Surján, 1999). The use of the ICD classification system should enhance clinical documentation of the patient’s condition and improve continuity of care. The use of different classification systems presents an opportunity for healthcare providers and policymakers to expand the way in which medical diagnosis and procedures are documented for different purposes. The classification system will be utilised to improve patient health outcomes, reduce medical errors, enhance quality data reporting and increase the accuracy of claim payments (Sanders et al., 2012). Until now, the use of these systems was limited for TM and the related data were never collected at a national level. As a result, these data are often missing and the information cannot be trusted. National comparable data in TM can be widely used by government, national organisations and academic researchers. Such TM data are considered as an essential tool for monitoring public health, allocating financial resources, developing health policies and evaluating the output of TM procedures on health outcomes (Rooney and Smith, 2000). Furthermore, a wide variety of information regarding disease burden, diagnostic and intervention procedures and treatment outcome can be collected (Üstün et al., 2003).

Disease and procedure coding in TM will be used for epidemiological purposes to monitor incidence, prevalence and morbidity statistics in a nationally standardised manner (Weatherspoon and Chattopadhyay, 2013). Adequate monitoring of TM status in Iran and the assurance of high-quality services require that data extraction from clinical health records is performed continually (Bretthauer et al., 2016). Additionally, TM codes can be used by healthcare organisations to capture and retrieve clinical procedural information, for health management and reimbursement purposes, and to provide information that can help with resource allocation decisions.

Participants’ responses regarding the capabilities and features (user language, method of code assignment and main users) for the CAC system are demonstrated in Table 4. Most CAC systems are based on two main methods: natural language processing (NLP) techniques and structured input. NLP-based software programs generate codes by scanning electronic documents and analysing sentences based on a set of underlying rules. On the other hand, structured input software programs create both the text document and generate the appropriate codes. Clinical coders select items from menus, where each choice generates a text phrase. By selecting different items from multiple menus, the user creates the document, and finally, codes are generated by a coding engine (Benson, 2006). In Iran, EHRs have not yet been implemented in hospitals, and in TM clinics, patients’ records are restricted to some administrative and financial data. Clinical data in electronic format are limited and there is no formal language for documentation. Under these circumstances, it seems evident that coding systems cannot readily be built up in a fully automated form or based on NLP techniques. Therefore, we consider designing a semi-automated CAC system for classification of Iranian TM system to be a more suitable option.

Conclusion

The international classification of TM, which is based on Chinese medicine, is considered to be the first standardisation effort in TM. However, this type of TM is not prevalent in countries such as Iran. Persian medicine, the prevalent form of TM in Iran and several other countries, has its own structure, theories and principles that differentiate it from other TM systems. Development of a national classification system for TM based on Persian medicine will be beneficial for comparing the clinical outcomes of different health sectors and will promote health data reporting. Classification of Persian medicine is considered to be one of the national systems that could be applied to clinical coding, research, policymaking and insurance. The standard classification of diseases will become an essential part of capturing clinical patterns of medicine and a systematically organised classification will facilitate objective documentation, production of related statistics and the contribution of traditional medical approaches to the general health of citizens throughout the world.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Goli Arji, PhD

Note

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