Dr KEES VAN BOVEN Dutch College of General Practitioners The Dutch Family of International Classifications: ICPC-2, ICD-10, and ICF

Roles of the Dutch family members In general practice electronic patient records diagnostic ordering principle for the GP: ICPC-2 diagnostic specificity: ICD-10 (combined in one tool: ICPC2-ICD10 thesaurus) additional data on functioning and disability: ICF

INTERNATIONAL CLASSIFICATION OF PRIMARY CARE ICPC-1: 1987 ICPC-2:1998 ICPC-2-E: 2000

A classification is the ordering principle of a defined domain

ICPC: THE DOMAIN OF FAMILY PRACTICE… quantitatively…..

SYMPTOMS DIAGNOSES ICPC: > 1 PER 1000 PPY ICD: <1 PER 1000 PY

and qualitatively…..

DESCRIBES THE CONTENT OF PATIENT-FP ENCOUNTERS localization before etiology symptoms AND diagnoses -28 impairment category -27 fear of.. category -64 category (FP’s initiative) social problems patient and FP oriented

What is the unit of observation in family medicine? Patients? Doctors? Encounters? Diagnoses? Episodes: the patient with his/her problem over time

episode of care health problem from the first encounter for it with a health care provider till the last one

EPISODE OF CARE Perceived health problem Perceived need for care RFE, demand for care DiagnosisProcess RFE, demand for care DiagnosisProcess RFE, demand for care DiagnosisProcess

ICPC bi-axial structure 17 alpha-coded chapters based on body systems/problem areas 7 identical components, with rubrics bearing a two-digit numeric code

ICPC Chapters (Systems) A General and unspecified B Blood/bloodforming organs, lymphatics (spleen, bone marrow) D Digestive F Eye (Focal) H Ear (Hearing) K Circulatory L Musculoskeletal (Locomotion) N Neurological P Psychological R Respiratory S Skin T Endocrine, metabolic and nutritional (Thyroid) U Urological W Pregnancy, child bearing, family planning (Women) X Female genital (X-chromosome) Y Male genital (Y-chromosome) Z Social problems

ICPC Components Components (standard for each chapter) CODES 1.Complaints and symptoms Diagnostic and preventive Treatment, procedures and medication Test results Administrative 62 6.Referral and other reasons for encounter63-69 (64!!) 7.Diagnoses/diseases: infectious diseases - neoplasms - injuries - congenital anomalies - other

Episode of care Core Elements Reasons for encounter Health problems/diagnoses = Episode Title Process of care/interventions (Outcomes) Transitions One or more encounters, including changes in their relations over time

Episodes of care Reason for encounter (RFE) The agreed statement of the reason(s) why a patient enters the health care system, the demand for care by that person. Symptoms or complaints (headache, tiredness, feeling depressed, having fear of cancer) Known diseases (diabetes, hay fever) Requests: for preventive or diagnostic services (a blood pressure check or an ECG), a request for treatment (repeat prescription), getting information, or test results, or administrative procedure (a medical certificate). It is the PATIENT’S statement, clarified by the doctor.

Episodes of care Reason for encounter (RFE) This is a true primary care concept Primary Care is RFE driven, not diagnosis driven

Episodes of care Health problem: the diagnosis Certainty Status Clinical findings No coding (yet) for everything in primary care

TOOLS ICPC terms including all process codes Acts as ordering principle Common entities have distinct codes Surprisingly complete given small size Context of episode adds specificity ICD-10 14,000 terms Adds clinical specificity to ICPC

Episodes of care Processes of care Diagnostic/preventive procedures Treatment, procedures and medication Tests and results Administrative Referrals Outcome Functional status, ICF, WONCA/COOP indicators Severity of illness, DUSOI

Episode example 23 yr old woman typist, tennis player ICPC code? RFE: pain R elbow for 10 days, and can’t use R arm at work: ICPC code? L10 & L28 L10 & L28 ICPC code? Process: Tenderness R lat. Epicondyle: ICPC code? L31 Partial examination L31 Partial examination ICPC code? Diagnosis: Tennis elbow: ICPC code? L93 L93 ICPC code? Process: Steroid injection: ICPC code? L55 L55

Episode of care Intervention Hb Intervention Hb Intervention barium enema Intervention barium enema Intervention referral Intervention referral RFE feeling tired RFE feeling tired Health Problem fatigue Health Problem fatigue RFE test result RFE test result Health Problem anemia Health Problem anemia Health Problem Ca colon Health Problem Ca colon RFE test result RFE test result 1st visit 2nd visit 3rd visit

Episodes of care Transitions An episode may occur over many encounters  Diabetes is a lifelong episode Each encounter may have more then one episode assessed Many to many relationship between episodes and encounters

Possibilities for data on functioning & disability Classification of Body Functions in patients’ Reasons for Encounter, as symptoms and complaints, in GP’s clinical observations, as extension of ICPC process mode Classification of Activities and Participation involves clinical consequences of a specific episode of care, resulting in limitations, as extension of ICPC process mode Qualifiers for Function and Activities & Participation might be quite useful for family practice

Health condition (disorder or disease) Body function Activities Participation and structures Environmental Personal Factors

COPD (ICPC/ICD code) Breathlessness Can`t get upstairs No work Poor condition Living in a flat Smoking

Case history Mr De Vries, age 72 Present complaints Shortness of breath Palpitations Findings Hypotension Bradycardia Can’t get upstairs Walking difficulties ICPC code R02 K04 ICPC - ICF code K43 - B4201 K43 - B410 K48 - D460 K48 - D450

ICFORDENING ICF RELATION WITH ICPC Body FunctionsPhysiological Chapters In each chapter: 1st component: -28 code as RFE; 2nd component, the -43 code as process code Body StructuresAnatomical Chapters None Activities & Participation9 domainsIn each chapter: 2nd component, the -48 code as process code Contextual Factors (environmental and personal) 5 domainsChapter Z: social problems; especially as RFE Relation ICF and ICPC

Activities and Participation and ICPC chapters Learning/knowledge General tasks Communication Mobility Selfcare Domestic life Interpersonal interactivity Major life areas Community, social life Chapters K,N,P and Z Chapters F,K,N,P and Z Chapters F,H,K,N and P Chapters F,K,L and N ? Chapters P and Z ?

GE GGEENERAL.NERAL.PPRRAACCT.T.GGEENERAL.NERAL.PPRRAACCT.T.PRAC REFERRAL WITH ICPC2-ICD10-DIAGNOSIS AND A SELECTION OF THE ICF CLASSIFICATION: BODY FUNCTIONS AND ACTIVITIES/PARTICIPATION PHYS.THERAPISTPHYS.THERAPIST INTAKE, SELECTION OF B.F. and A/P, ADDITIONAL INFORMATION RESULTS ADDED FINAL REPORT POSSIBLY: REQUEST FOR FURTHER TREATMENT

Future University of Ghent: relation between ICF- functions and components 1 and 2 of ICPC University of Amsterdam: relation between ICF-activities/participation and component 2 of ICPC WICC: relation between ICF-external factors and chapter Z of ICPC?

Data Model Basic Unit: The episode at an encounter RFE: Sympt. Complt. Problem RFE: Inter- vention Clinical Findings ICF? Health Problem + Certainty & Status Intermediate Intervention Subsequent Inter- vention Repeated for each episode at that encounter Repeated at each encounter for that health problem Outcome COOP ICF DUSOI