ICPC-2 - Use around the world
An increasing number of countries are adopting ICPC as one of their diagnostic and data collection systems. The growing global acceptance of ICPC is due to rapidly increasing use in research and dedicated advocates in numerous countries around the world. The following is a year 2004 brief status report on the use of the latest version, ICPC-2.
Classification Internationale des Soins Primaires (CISP – French Language Version)
The development of ICPC in French-speaking countries came from a group of people working in primary care in the French-speaking part of Belgium. In 1988 a group from the Fédération des maisons médicales in Brussels translated ICPC nomenclature into French and this led to the full translation of ICPC and its publication as CISP-1 in 1992.
A number of interested general practitioners started to use CISP in electronic health records, and it was validated as a useful tool in a number of research projects in Belgium and France. The CISP-Club, based in France, was formed to coordinate, develop and promote ICPC in French-speaking countries. ICPC-2 has been translated as CISP-2 and an electronic version, CISP-2-E, is also available. The CISP-Club meets regularly and has members from a number of French-speaking countries and regions and is active in the development of Electronic Medical Records, medical informatics, data management, confidentiality and privacy issues as well as ICPC.
Individual Country usage
The Hospital Italiano de Buenos Aires has developed a problem oriented ambulatory electronic medical record (EMR). More than 1,500 physicians use the EMR, including general practitioners and specialists. All components of the problem list (diagnosis, reasons for encounter, and risk factors) are coded using ICPC-2-E, ICD-10 and Snomed CT.A centralised coding department uses the free-text physician input to encode problems. The coders have already coded more than one million problems, assisted in this process by a text-matching algorithm that automatically codes more than 70% of the problems. While private institutions are not required to code diagnosis in Argentina, the International Classification of Health Problems in Primary Care (ICHPPC) is still being used in the Public Health System, for coding diagnosis from ambulatory visits.
The Family Medicine Research Centre and General Practice Statistics and Classification Unit at the University of Sydney are at the forefront of development and promotion of ICPC in Australia. FMRC The Family Medicine Research Centre uses ICPC-2 in the national general practice data collection program (BEACH) under the auspice of the Australian Institute of Health and Welfare.
ICPC-2 as the classification for ICPC-2 PLUS, an Australian interface terminology (PLUS term), in electronic health record systems. Thirty-two software developers are currently licensed to include ICPC-2 in their software and approximately 1800 general practitioners are using ICPC-2 in electronic health records in their practices.
Australia is moving rapidly with the development of standards for electronic health records and other aspects of eHealth such as HL7 communication standards. Australian Government efforts in this area are being consolidated in a new Information and Communication Division of the Department of Health and Ageing. The Australian Government is currently negotiating with Wonca for a national license for ICPC-2.
The Australian Government Expert Group on Classification recommended that ICPC-2 be the standard classification for general practice and patient self reported health problems. The National Health Information Management Group endorsed this recommendation. A Health Data Standards Committee and a Classification and Terminology Working Group have now replaced these groups. The latter will integrate work on terminologies and classifications to ensure consistent health concept representation and classification.
A 3-year work plan has been developed by the National Centre for Classification in Health (NCCH) outlining a development program to integrate terminologies and their relationship to classifications. In order to assess the use of terminologies and classifications the Australian Government has purchased evaluation licenses for a range of terminologies and classifications including ICPC-2, ICPC-2 PLUS, SNOMED and several others.
In Belgium, the initial experience with the utilisation of ICPC were in the late eighties, in Flanders, within a framework of Ph.D research projects, and in Wallonia within a framework of morbidity recording projects by the Federation of Health Centers.
In 2002, the Belgium Minister of Health acquired a licence from Wonca for use of ICPC-2-E in electronic medical records. The ministry has convened a National Classification Committee, and a Label Committee. WICC representatives from Flanders and Wallonia have been invited to join both committees. In 2005 the inclusion of ICPC will be a requirement for diagnosis/problem labels in Belgian general practitioners’ electronic medical records accredited with a Quality Label. An additional payment is made to Belgian general practitioners using such accredited electronic medical records.
ICPC, used in an electronic medical record system in primary care settings in a low resource country like Cameroon, appears as a challenge. ICPC has great flexibility and the ability to keep track of symptoms and diagnosis in an environment where, very often due to poor availability of investigation techniques, the patient diagnosis is labelled at a symptom level. A patient coming for cough, fever, sharp lower chest pain and dyspnoea will probably be assigned the diagnosis of pneumonia in a primary health care setting in Africa. In a more advance country, after thorough investigations, the patient could end up with a more precise diagnosis such as acute basal lobe pneumococcal pneumonia. Such a diagnosis will not be reached very often in this environment. Another example is of a patient coming with a ‘reason for encounter’ of headache and ending up with a diagnosis of headache. This is not unusual so it is quite important for public health professionals to keep track of these symptom diagnoses. An advancement in the system would be to equip health care facilities of a country with an ICPC reporting system so that diagnosis and reasons for encounter are directly sent through network to a remote server at the central level. This would allow public health professionals to get real time information on why people are consulting and what problems are treated.
For the moment 14 primary health care providers, all belonging to the MedCab User's group, have been trained in the used of ICPC and are now participating in an experiment using an electronic medical recording system to collect data generated during patient/doctor encounter in routine consultations.
A collaboration between the Clinic of Social and Family Medicine of the University of Crete and the Ministry of Health has been established for research purposes. Among other projects, two primary health care centers are using ICPC-2 in an EMR system in a pilot study for Cyprus with license from Wonca.
In Denmark, the use of ICPC is widely accepted as the structure able to provide a professional overview of patient care. The table of contents of the General Practitioners' Journal in Denmark (Månedsskrift for Praktisk Lægegerning) is based on the ICPC structure. The counties' information systems for the primary and secondary health-care sectors have adopted ICPC. Extended Danish ICPC-1 is increasingly being used in everyday work. A random check showed that 40% use the classification on a daily basis.
The ICPC-2 book has been translated into Danish, and work continues, supported by the Danish College of General Practitioners, to convert ICPC-2-E to a user-friendly electronic Extended Danish ICPC-2 with auxiliary registers. This work is expected to be finalised in 2005.
At end of August 2002, the League of Local Authorities (Kuntaliitto) persuaded a group of 10 bigger municipalities to fund a project to translate ICPC-2 to both Finnish and Swedish and to provide the municipalities with the appropriate software. In May 2003 there was a national seminar on classification issues in primary health care. It was jointly organized by the Classification Centre at the National Agency for Health and Social Welfare, the Finnish Association for General Practice and Kuntaliitto.
Within the framework of the project, a smaller group was appointed to do the translation work. The group convened three times and also kept regular email correspondence ongoing between the meetings. It was decided to use professional translation companies for the textual part of the book, but to do the translation of Chapter 10 without external assistance. All the rubrics are by now translated into both Finnish and Swedish and are made available in electronic format.
The German Ministry of Education and Research has funded the Department of General Practice and Health Services Research at Heidelberg University to undertake a large research project for a general practice morbidity registration network using ICPC-2-E. ICPC-2-E has been translated into German and a German two page ICPC-2-E summary has been prepared. Currently an episode based and problem oriented documentation software for GPs is being developed based on ICPC-2-E. These tools will serve to establish ICPC-2-E in a German GP network and in future practice and research. The project and ICPC-2-E experience has caused massive interest from all relevant German General Practice Associations. Germany is faced with ongoing health care system reforms that go beyond cost containment and include ambitious plans for mandatory quality management and EMR both in hospitals and doctors’ offices. In these circumstances the existing ICD-10 based documentation that mostly serves billing purposes represents a risk for GPs. Hence ICPC-2-E should help to better demonstrate the patient and morbidity care by GPs in the German health care system.
The Greek Association of General Practice has translated ICPC-2 into the Greek language and in collaboration with the Clinic of Social and Family Medicine of the University of Crete they are utilizing several implementations of ICPC-2 in Greece. Several practices in Greece are using ICPC-2 and there is a growing interest for the use of ICPC-2 for research and clinical purposes. Greece has experienced during the last two years a health reform where ICPC-2 has received significant attention. A committee has been established by the Minister of Health and Welfare and it is working on the classifications that will be included in the EMR systems that are planned for the next two years. The recommended classifications were ICD-10 and ICPC-2 with possible modifications for the Greek context.
ICPC-2 and ICPC-2-E was translated into Japanese in 2002 and published with sponsorship by Japanese Academy of Primary Care Physicians (JAPCP).JAPCP has organized a local committee to promote ICPC-2 in Japan. The committee will provide a training workshop for ICPC-2 and is also starting to organize a research network using ICPC-2.
In Malta, more than fifteen GPs out of approximately 200, use ICPC-2-E in an electronic patient record for their day-to-day practice. The program, Transhis, donated by the Department of Family Practice of the Academic Medical Center, University of Amsterdam, allows doctors to use ICPC to organize their individual patient records in great detail. It also contributes to improvements in practice management via extensive reports of diagnoses, encounters, interventions, referrals and prescriptions in their practice. The data collected by some of these doctors is collated into a database of episodes of care, which is being used to study Family Practice in Malta. At the end of 2003, the database will span three years of continuous recording. It already contains data for 10,000 patients, 32,000 encounters, 32,000 episodes of care, 57,000 reasons for encounter and 84,000 interventions.
In the Netherlands, ICPC increasingly forms the lynchpin of electronic patient records in family practice. Its use is mandatory in electronic prescribing systems. Family practice research is, if at all feasible, based on ICPC. Virtually all official data on morbidity in family practice in the Netherlands are coded with ICPC. The official Dutch epidemiological database now includes selected ICPC coded information from the Transition Project of the University of Amsterdam and three other family practice networks. The electronic health record based on the comprehensive use of ICPC coding reasons for encounter, assessment and process, used in the Transition Project is, or has been used in Japan, Poland, Malta, Greece, and Serbia.
Based on the four language ICPC-2/ICD-10 thesaurus, a close co-operation has been established between the University of Amsterdam and the Flemish Department of General Practice in Ghent and the (French speaking) Department of the Free University in Brussels. This four-language thesaurus is likely to be expanded with other languages such as German.
The ICPC-2/ICD-10-thesaurus, prepared by the University of Amsterdam together with the Dutch College with a Ministry of Health grant, has recently become available, and includes a diagnostic terminology with 80,000 entries for use by family physicians and specialists. The Dutch College of General Practitioners continues to make their products (e.g. lab tests, protocols, patient education letters, recall systems) accessible through linkages to ICPC.
The available translations of ICPC-1-short titles and of chapter 10 of ICPC-2 have been included in a World Wide Web accessible database, as part of a joint project between the University of Amsterdam and the National Library of Medicine in Washington DC. The multi-language content relies upon an international technical standard known as Unicode, which attempts to provide a means for computer-based representation of the characters of all known living human languages. Rules have been established to designate national or language coordinators. Anyone with an Internet connection can search ICPC, and send comments to its maintainers. This will allow family doctors, researchers and other interested parties to participate in assessing the quality of existing translations, and to contribute to new translations of ICPC-2. The US National Library of Medicine (NLM) in Washington, DC, is in the process of including the ICPC/ICD-10 Thesaurus in Dutch and English into the Unified Medical Language System (UMLS), at the same time allowing a direct mapping to the diagnostic concepts in SNOMED-CT (work to be finished by June, 2004).
ICPC has been the official standard for classification of diagnoses in general practice in Norway since 1992. General practitioners are obliged to label all fee-for-service bills, sick-leaves and social security forms with an ICPC-diagnosis to get them accepted by the health authorities. This way all general practitioners use ICPC. Every patient contact is recorded with at least one ICPC diagnosis from any of the 7 chapters. Software used in electronic patient records has made this an easy and well accepted routine. ICPC is used regularly in official statistics about general practice and social security in Norway. It is also one of the main tools used in audit and quality assurance in general practice and has been applied in many projects.
The Health and Social Directorate granted EUR 450,000 in 2001 for the translation and implementation of ICPC-2, including the ICPC-2 – ICD-10 conversion structure. Norway has purchased a national licence from Wonca for the use of ICPC-2-E. The Norwegian translation of ICPC-2 was released early in 2004.
ICPC-2 was translated into Portuguese in 1999 and published with sponsorship by Associação Portuguesa de Médicos de Cl'nica Geral (APMCG). The book was widely distributed to general practitioners working in the public health system. General practitioners working for the national health system use traditional paper-based records, and electronic medical records are rarely used. As a consequence ICPC is infrequently used in their everyday work. However, ICPC-2 is the classification system most frequently used in research, and is also widely used in family practice training programs.
ICPC-1 was first used in Romania in 1996 by the Romanian Society of Family Medicine(RSFM) in a Morbidity Study where 34 family doctors registered data on paper, during one year. At the end of the project the coordinators concluded it was necessary to develop a sentinel practice network where family doctors could register data using ICPC on computers. In 1999 ICPC-2 was translated and published and used in the projects "ICPC-2000" and "GP-Medinet". One hundred family doctors from the Sentinel Dispensaries Network (Medinet), selected from all over the country, were collecting data using dedicated software MedINS that used ICPC-2. This project was started by RSFM and is currently being managed by the National Centre for Studies in Family Medicine.
ICPC has been translated into Russian and published with financial assistance from the Development of Community Medicine in North West Russia, Barents Health Programme, provided by the Ministry of Health in Norway.
At the moment the Russian Ministry of Health uses ICD-10 only. ICPC will be introduced into several Primary Health Care Centres in the Arkhangelsk region and in the Northern State Medical University. As new generations of doctors are trained in general/family practice it is expected that ICPC use will become more widespread.
In 2002, a project was established between the International Red Cross in Beograd, Serbia, and the Departments of Family Practice of the Universities of Beograd and Amsterdam, to set up primary care recording in Kraljevo, Serbia. This project uses ICPC in Serbian, and the electronic health record (EHR) based on that developed in the University of Amsterdam Transition Project. Over 60 family physicians are using the system, comprehensively coding reasons for encounter, assessment and process with ICPC.
In Slovenia general practitioners are free to use any classification, but reports to government bodies must be in ICD-10. A translation of the ICPC-2 book has been made into Slovenian. This has been subject to a process of verification and field trials with general practitioners interested in research.
The principles of classification using ICPC as a model are taught at undergraduate level in the Department of Family Care at Ljubjana University, and vocational trainees receive both theoretical and practical training in their coursework.
ICPC-1 is the core classification in the more popular electronic medical records in primary care in Spain. Both ICPC-1 and ICPC-2 have been translated and published in Spanish. At the moment ICPC-2 is only a research classification. In hospitals, DRG and ICD-9-CM classifications are widespread, and little is known about ICPC. There is an agreement about the Minimum Basic Data Set for use in hospitals for medical records, but nothing similar in primary care. Confidentiality of electronic medical records and a central Government database are key issues in Spain.
ICPC was first used in Sri Lanka in the National General Practice survey in 1996. This research won a Wonca Regional Research Prize and was subsequently published in Family Practice. This was followed by the most comprehensive GP study done in Sri Lanka by the Institute of Policy Studies. In this study, ICPC was used as the primary coding system with employment of the BEACH methodology from Australia. The final report on this project is now ready for publication.
ICPC is promoted through the College of General Practitioners of Sri Lanka, which has named ICPC as the recommended coding system for medical records. In the Diploma of Family Medicine course two lectures are devoted to classification and coding systems from ICHPPC to ICPC-2. The College promotes ICPC at every forum where the Government Health Ministry is promoting the use of ICD-10 even for primary care.
Sri Lanka is developing e-governance and the health sector has been identified as one of the 5 areas to use information and communications technology to increase efficiency and quality. Much effort has been made to get a primary care electronic record in to this program, involving the use of ICPC for classification.
United States of America
It has been difficult to have ICPC accepted in the USA because of the complexity of the health care system, the number of competing interests and the strong support for hospital-based/specialist classifications. However, recent developments may improve this situation. Government-subsidized licenses for standard clinical terminology, Snomed CT, and the commissioning of the Institute of Medicine (IOM) to design a standardized electronic medical record model are both designed to help create a National Health Information Infrastructure and promote electronic medical records.
The National Library of Medicine has signed a five-year contract to license Snomed International's clinical terminology. This arrangement will make the Snomed CT language available free to health care organizations, allowing them to integrate the terminology into their information systems. As reliable mapping exists of Snomed's diagnostic categories with ICPC, it should be possible to allow Family Physicians to document patient care that characterizes their clinical domain in Electronic Medical Records using Snomed CT.
Standards on patient medical record information are to be published in 2004. Individuals representing the Agency for Health Care Research and Quality, the National Center for Health Statistics, the National Library of Medicine, the Subcommittee on Standards and Security of the National Committee for Vital and Health Statistics, as well as representatives of the American Academy of Family Physicians, members of the North American Primary Care Research Group Special Interest Group on ICPC, and the WICC have been invited to collaborate in developing these standards, and to assist in developing a strategy to enable the recording of valid and reliable clinical data in primary care practice settings, and to safeguard research in family practice.