Bangladesh Core FHIR Implementation Guide
0.4.0 - Published by DGHS, MoHFW

Bangladesh Core FHIR Implementation Guide - Published by Ministry of Health and Family Welfare. See the Directory of published versions

## Spec sub-page

Page standards status: Trial-use

## ICD-11 Implementation

### Overview

The Bangladesh Core FHIR Implementation Guide uses ICD-11 Mortality and Morbidity Statistics (MMS) as the mandatory coding system for clinical conditions. This page documents the system URI, terminology infrastructure, conformance requirements, and postcoordination conventions for implementers.

### System URI

All ICD-11 MMS codes SHALL use the WHO canonical system URI:

    http://id.who.int/icd/release/11/mms

The preferred code form is the short stem code (e.g. `1A00`, `NC72.Z`). Linearization URIs are not used as code identifiers in this IG.

### Terminology Infrastructure

#### National OCL Terminology Server

Runtime code validation and lookup are delegated to the national OpenConceptLab (OCL) terminology server operated by DGHS/MoHFW:

Public FHIR R4 endpoint: `https://tr.ocl.dghs.gov.bd`

OCL hosts ICD-11 MMS version 2025-01 with 36,941 concepts across the following concept classes: Diagnosis, Finding, Substance, Organism, Device, Anatomy, and Misc.

Vendors do not interact with OCL directly. All vendor submissions are validated at the HIE boundary via the Bangladesh ICD-11 Cluster Validator (see Cluster Expressions below).

#### Supported OCL Operations

The following FHIR terminology operations are supported. The `system=` parameter must be used — `url=` is not supported by OCL.

CodeSystem $validate-code

    GET https://tr.ocl.dghs.gov.bd/api/fhir/CodeSystem/$validate-code
        ?system=http://id.who.int/icd/release/11/mms&code={code}

CodeSystem $lookup

    GET https://tr.ocl.dghs.gov.bd/api/fhir/CodeSystem/$lookup
        ?system=http://id.who.int/icd/release/11/mms&code={code}

ValueSet $validate-code

    GET https://tr.ocl.dghs.gov.bd/api/fhir/ValueSet/$validate-code
        ?url=https://fhir.dghs.gov.bd/core/ValueSet/bd-condition-icd11-diagnosis-valueset
        &system=http://id.who.int/icd/release/11/mms&code={code}

#### Unsupported OCL Operations

`$expand` is not supported — this is a known limitation of the national OCL instance. Build-time expansion is suppressed. Implementers SHALL NOT depend on `$expand` for ICD-11 ValueSets in this IG.

#### Local ICD-11 Docker Instance

A local WHO ICD-11 Docker instance is maintained internally by DGHS at `https://icd11.dghs.gov.bd` running release 2025-01. This instance is internal only and is not exposed to vendors. It serves as the import source for OCL and as the backend for the cluster validator.

### Condition.code Binding and Class Restriction

`Condition.code` is bound to the Bangladesh ICD-11 MMS Condition ValueSet at `preferred` strength. This ValueSet includes only Diagnosis (14,071) and Finding (5,590) class concepts — 19,661 concepts total as of version 2025-01.

`Condition.code` SHALL contain at least one coding conforming to the `coding[stem]` slice with `system = http://id.who.int/icd/release/11/mms`. Vendors cannot omit ICD-11 by substituting a local code.

The following concept classes SHALL NOT appear as standalone stem codes in `Condition.code`: Substance, Organism, Device, Anatomy, Misc.

This restriction exists because these classes represent entities that are not themselves diagnoses or clinical findings — they are axes used in postcoordination (e.g. a causative substance, an affected anatomy site). Their correct use is as satellite codes within a cluster expression, not as standalone condition codes.

Class restriction is enforced at runtime via OCL ValueSet `$validate-code` against the Bangladesh ICD-11 MMS Condition ValueSet. At the HAPI FHIR layer, enforcement is via `RemoteTerminologyServiceValidationSupport` configured to call OCL. HAPI FHIR deployment will be completed before vendor onboarding.

The `coding[stem]` slice is open (`#open`) — additional local codings are permitted alongside the mandatory ICD-11 stem.

### Cluster Expressions

#### Background

ICD-11 supports postcoordination — the combination of a stem code with one or more satellite codes to precisely represent a clinical concept that cannot be expressed by a stem code alone. A postcoordinated expression is called a cluster expression.

Cluster expressions are typically sourced from the WHO Electronic Coding Tool (ECT) at the point of care.

#### Syntax

A cluster expression combines a stem code with satellite codes using the `&` operator (combination) or `/` operator (specificity):

    NC72.Z&XK8G&XJ7ZH&XJ7YM

Where:

- `NC72.Z` — stem code: Fracture of femur, unspecified
- `XK8G` — satellite: laterality
- `XJ7ZH` — satellite: fracture subtype
- `XJ7YM` — satellite: fracture open or closed

#### FHIR Representation

The stem code is carried in `Coding.code`. The full cluster expression is carried in the ICD-11 Cluster Expression extension on the same `Coding` element:

    "code": {
      "coding": [
        {
          "system": "http://id.who.int/icd/release/11/mms",
          "code": "NC72.Z",
          "display": "Fracture of femur, unspecified",
          "extension": [
            {
              "url": "https://fhir.dghs.gov.bd/core/StructureDefinition/icd11-cluster-expression",
              "valueString": "NC72.Z&XK8G&XJ7ZH&XJ7YM"
            }
          ]
        }
      ],
      "text": "Fracture of femur, unspecified — left, transverse, closed"
    }

The stem code in `Coding.code` SHALL match the leading stem code in the cluster expression string.

#### Stem-Only vs Cluster

Scenario | Representation | Validation
--- | --- | ---
Single stem code | `Coding.code` only | OCL `$validate-code`
Postcoordinated expression | `Coding.code` + cluster extension | Cluster Validator

The cluster validator explicitly rejects stem-only expressions. Single stem codes SHALL be represented in `Coding.code` only and validated via OCL `$validate-code`.

#### Satellite Code Class Restriction Exemption

Satellite codes in a cluster expression are exempt from the Diagnosis/Finding class restriction that applies to stem codes in `Condition.code`. Substance, Anatomy, Organism, and other axis codes are valid and expected as satellites.

#### Bangladesh ICD-11 Cluster Validator

All postcoordinated cluster expressions SHALL be validated against the Bangladesh ICD-11 Cluster Validator prior to submission to the HIE:

    POST https://icd11.dghs.gov.bd/cluster/validate
    Content-Type: application/json

    {"expression": "NC72.Z&XK8G&XJ7ZH&XJ7YM"}

Example response:

    {
      "valid": true,
      "stem": {
        "code": "NC72.Z",
        "display": "Fracture of femur, unspecified",
        "ocl_validated": true
      },
      "satellites": [
        {"code": "XK8G",  "axis": "laterality",           "valid": true},
        {"code": "XJ7ZH", "axis": "fractureSubtype",       "valid": true},
        {"code": "XJ7YM", "axis": "fractureOpenOrClosed",  "valid": true}
      ],
      "errors": []
    }

The cluster validator is a mandatory HIE boundary gate. All vendor submissions containing postcoordinated ICD-11 expressions pass through it.

### Conformance Statements

ICD-11-CONF-01: ICD-11 MMS codes SHALL use system URI `http://id.who.int/icd/release/11/mms`. Stem code validation is available via OCL at: `https://tr.ocl.dghs.gov.bd/api/fhir/CodeSystem/$validate-code?system=http://id.who.int/icd/release/11/mms&code={code}`

ICD-11-CONF-02: The `icd11-cluster-expression` extension SHALL only be present when the expression contains at least one postcoordination satellite code using `&` or `/` operators. Single stem codes SHALL be represented in `Coding.code` only and validated via OCL `$validate-code`.

ICD-11-CONF-03: Postcoordinated cluster expressions SHALL be validated against the Bangladesh ICD-11 Cluster Validator at `https://icd11.dghs.gov.bd/cluster/validate` prior to submission to the HIE.

ICD-11-CONF-04: `Condition.code` SHALL contain at least one coding conforming to the `coding[stem]` slice with `system = http://id.who.int/icd/release/11/mms`. The stem code SHALL be a member of the Bangladesh ICD-11 MMS Condition ValueSet, which includes only Diagnosis and Finding class concepts. This restriction is enforced at runtime via OCL ValueSet `$validate-code`.

ICD-11-CONF-05: Substance, Organism, Device, Anatomy, and Misc class ICD-11 concepts SHALL NOT appear as standalone stem codes in `Condition.code`. This restriction does not apply to satellite codes carried in the `icd11-cluster-expression` extension.