The Kindness of Strangers: Kinds and Politics in Classification Systems - administrative history of large-scale classification systems

Library Trends, Fall, 1998 by Geoffrey C. Bowker

[Figure 1 ILLUSTRATION OMITTED]

The family itself is a diverse one: there are various standard modifications of the ICD. The most significant is the ICD-9-CM (1996) where CM stands for "clinical modification." This has a complex history, originating in the development of modifications of the ICD for use in hospital information systems. It is now the classification of record in a wide variety of medical settings and is used for billing, insurance, and administration as well as in-patient medical records. This institutional entrenchment has made it very difficult for ICD-10 (1992) to be fully adopted in the United States with the clinical modification necessarily lagging behind the production of the classification itself.

When we observe the ways in which culture and practice interweave in the text of the ICD, we are not unmasking a false pretender to the crown of science. We are drawing attention to an explicit positive feature of ICD design: "The ICD has developed as a practical, rather than a purely theoretical classification.... There have ... been adjustments to meet the variety of statistical applications for which the ICD is designed, such as mortality, morbidity, social security and other types of health statistics and surveys" (ICD-10, 1992, vol. 2, p. 12). The preamble to the classification defines a classification of diseases as "a system of categories to which morbid entities are assigned according to established criteria" (ICD-10, 1992, vol. 1, p. 1). A statistical classification, such as the ICD, "must encompass the entire range of morbid conditions within a manageable number of categories" (ICD-10, vol. 2, p. 1). It is not meant to be a net to capture all knowledge but a workable epidemiological tool. This practical goal does not make it less scientific, of course; all classification systems are developed within a context of organizational practice. The goal of the ICD's designers is to create what Latour (1988) has called immutable mobiles--inscriptions that may travel unchanged and be combinable and comparable. Indeed, the term "immutable mobile" might almost have been in the designers' minds when they wrote:

   The purpose of the ICD is to permit the systematic recording, analysis,
   interpretation, and comparison of mortality and morbidity data collected in
   different countries or areas and at different times. The ICD is used to
   translate diagnoses of diseases and other health problems from words into
   an alphanumeric code, which permits easy storage, retrieval, and analysis
   of the data. (ICD-10, 1992, vol. 2, p. 2)

The ICD has become the international tool for "standard diagnostic classification for all general epidemiological and many health management purposes" (p. 2).

The world has changed since the ICD was first introduced, and the classification scheme has evolved to try to encompass these changes. The ICD is thus both highly responsive and tightly constrained. A large-scale change in the way that people die (Israel, Rosenberg, & Curtin, 1986, p. 161) has led to an alteration in one line in the internationally recommended Death Certificate. This is, of course, one of the main bureaucratic uses of the ICD--i.e., the recording and compiling of causes of death from bureaus of vital statistics via coroners, hospitals, doctors, or priests: