Marc Jamoulle & Michel Roland,July 1997
Summary / Key-words / The WONCA Classification Committee, a multinational working group / Working-out of the ICPC Classification / From ICHPPC (1976) to ICPC (1987) / The ICPC and the episode of care / From ICPC (1987) to ICPC-2 (1997) / Other research tools developed or tested by the WONCA Classification Committee / References
|Since 1972, the WONCA Classification Committee develops research instruments for general practice. Its main realization, the International Classification of Primary Care (ICPC), is available in more than twenty languages and has reached its second edition. The Committee, a real research laboratory for methodology, has produced or validated other tools either in the field of outcome measures or in the field of severity indicators. After the publication of a Glossary of Family Practice, the Committee develops a real dictionary of the discipline. The history of that unremitting quest is related here.|
Key words ;
Primary care - Family practice - Research methodology - Classification - ICPC - CISP - COOP/WONCA Charts - DUSOI
The WONCA Classification Committee was set up by the WONCA Council in Melbourne in 1972 on the occasion of the Fifth World Conference of General Practice. General and family practice needed tools of its own knowledge, and various authors such as Bentsen (1) , Bridges-Webb(2) , Westbury (3) , Sive (4) and many others had already begun working in that field.
It was necessary to apply in family practice the thought that describing and transforming reality can only be done by relying on facts. Such statement requires that facts be put to the fore, identified, counted, and submitted to the law of large numbers before being analyzed. Identification, gathering and counting are processes that can be carried out only on delimited, pre-organized and structured elements.
The first working group consisted of Charles Bridges-Webb (Australia), Robert Westbury (Canada), Philip Sive (Israel), Derek Callagher (New Zealand), Donald Crombie (United Kingdom) and Jack Froom (United States). From the works of this small group, a tool was progressively developed that is now recognized as a standard for information processing in primary health care.
The WONCA International Classification Committee (WICC) currently consists of about thirty family physicians from 25 countries; they meet every year in a different place. Most of the members own an e-mail, and a mailing list enables all the practitioners to get and exchange information on classifications.
The Committee was named Classification Committee because classification is its major and perennial work. However, it would be more accurate to call it Methodology Committee. Indeed, it contributes to developing and validating research tools necessary for the development of family practice. The Committee also reacts to the request of its members to test internationally research tools that have already been tested locally, such as the COOP charts (5) and the DUSOI (6).
The transnational, multicentre field test outcomes sometimes resulting from more than one hundred thousand patient-contacts are then discussed at the annual meetings. If the product is accepted, sometimes transformed following members observations, it can wear the WONCA stamp while remaining the property of the initial group. It is impossible to list here all the publications the Committee's works gave rise to in the last 25 years. The most important ones appear on this web site in the bibliography.
One of the most prominent features of the current classification is the inclusion of the complaints of the patients (symptoms and complaints) and the social problems ( Chapter Z. It is the paradigmatic change that occurred in medicine, especially in family practice, that allowed that the patient's own words enter a system of daily information filing (7). The legitimization of considering the social field is also due to the same evolution of ideas that puts the patient instead of the physician in the very heart of the problem of caregiving.
When the Committee started working, nobody had imagined the dazzling development of computing. The first authors were paper and pencil enthusiasts who got epidemiology into everyday practice with much difficulty. The classification system was not developed with a view to a large-scale computerized use. The paper and pencil technique requires a good mnemotechnical capacity and this is a characteristic of the classification that retains its full value even now when it is included in many softwares.
may process large numbers, but you still have to feed the computers
with analyzable matter. The aim of those family doctors, experts of the
World Organization of Family Doctors, was to make analyzable the
content of a human diagnostic and therapeutic relationship followed in
time and specific of family practice.
Dr Bent Bentsen, Professor of General Practice, University of Trondheim, Norway, was one of the initiators of the first works (8) published in 1976 by the WONCA Classification Committee under the name of International Classification of Health Problems in Primary Care (ICHPPC)(9)
. In reality, the ICHPPC was a list of the most common diagnoses met in family practice, very carefully worked out from the eighth revision of the International Classification of Diseases (ICD) (10).
From that time and at the rate of the Committee's meetings, research tools followed one another and were improved. The ICHPPC was revised, the terms were defined, and the ICHPPC-2 (11) was published in 1983. Two further classifications were developed: they dealt with the reasons of contact ( Reason for Encounter Classification) (12) and the processes (International Classification of Health Process in Primary Care or IC-Process-PC) (13). At last, the three classifications developed by the Committee or its members were merged into a single classification, the International Classification of Primary Care (ICPC) (14).
The ICPC tabular list was tested on the field by hundreds of general practitioners and several thousands of consultations were recorded worldwide and served as a basis to refine the tool. In 1987, the Committee published the International Classification of Primary Care at Oxford Medical Publication under the editorial responsibility of H. Lamberts, Maurice Wood and Inge Hoffmans-Okkes. The work contained a conversion table to the International Classification of Diseases, 9th and 10th revisions.
Within a few years, the ICPC rapidly emerged as a standard for information categorization in Primary Health Care. The works of the ICPC European Workshop carried out from 1986 to 1991 by H.Lamberts and supported by the European Community enabled tenths of European general practitioners to confront their respective experiences.
From Faro to London, from Padua to Madrid, experiences were exchanged and the tool was refined. Those workshops were determining factors for the circulation of the ICPC in Europe. They made it possible to test the ICPC in the most varied circumstances. A multicenter trial conducted by Inge Okkes led to the validation of the reason for encounter concept (15) , and a drug classification (16) was developed and tested by Jan De Maeseneer (ICPC Drug Classification).
Within the scope of the European Workshop, a multilingual translation of the list was performed in 1991 at a meeting of about twenty general practitioners from ten countries. This was the Tower of Babel in a London hotel. The multilingual translation provided the basis of the Multi-language layer published in 1993 in " The ICPC in the European Community" (17). The latter work gathers the experiences of the European general practitioners, especially the first results of the Transition Project (18) conducted in Amsterdam.
Although the ICPC is presented as a classification, it also is a dynamic tool for episode data analysis. The most remarkable fact is the possibility to follow the time course of a health problem within a contact and between contacts. It is this notion of episode that best reveals all the power of the ICPC. The episode of care (19) actually is the unit of data analysis in family practice and primary care. This becomes obvious when the softwares Trans and Transhis are used.
The learning program Trans (20) makes the results of the encoding of more than 100,000 contacts in family practice in Amsterdam available to general practitioners.
Also in Amsterdam, the software Transhis (21) developed by the General Practice Department (Professor Lamberts) provides a real-time consultation of the activities of family practices in the Netherlands, but also in Japan, Poland or the United States
At the University of Maastricht, a team of the Family Practice Department under the leadership of Job Metsemakers uses the ICPC to establish a diagnosis index (22) of the population, and the resulting data bank is literally assailed by researchers and people who prepare a doctorate dissertation. In Norway, the ICPC is the codification tool for all the invalidity and sick leave form sheets. In Australia, a survey (23) was carried out by several hundreds of general practitioners, and provides sensitive information on the reasons why the population turns to the health system.
Thus, and for the first time, the demand of patients may be assessed such as it is expressed in the reality. The bibliography of the publications, dissertations and educational articles based on the ICPC grows richer every day. The ICPC list is now an international standard whose validity is not questioned any more. It is translated in more than twenty different languages.
The ICPC book was translated into French and published in 1992 under the title "Classification Internationale des Soins Primaires" (CISP) (24) . The list of the CISP had already been revised in 1991 by a group of Quebec, Belgian and French physicians on the occasion of a meeting organized in Brussels by the Fédération des Maisons Médicales (25) . The ICPC book has also been translated and published in various languages, including Portuguese (26), Spanish (27), Norwegian (28) , etc.
Besides these works, educational tools were developed as video cassettes, either for physicians' training (29) (The Netherlands) or for the public (30) (Norway).
The interpenetration of mental health and primary care is a constant and the ICPC appears particularly suitable to deal with that problem (31) . A very productive working meeting was held in 1994 in Washington at the NIMH (32). The ICPC really appears complementary to and compatible with the specific tools of the mental health field such as the DSM IV PC and the ICD-10 PHC.
The matter of the comparability of the ICPC to the International Classification of Diseases (ICD)(33) has always preoccupied the Committee. Although both classifications have vastly different aims, all efforts were made to maintain such comparability. The 1987 version already contained a crossmapping table (34) with the ICD-10 developed by Lamberts & Wood. The version to be published ( ICPC-2) will also contain a table with the best crossmapping codes one for one.
On the other hand, the need to reduce the user's constraint forces to make coding itself accessory or even transparent. The solution is to develop the terminology to make the interface user-friendly in the daily use of the computerized medical record. Researchers have studied this difficulty in Canada, Australia and Belgium.
It is the problem of definitions that was the most demanding for the Committee's members. Since five years, annual meetings are largely dedicated to the revision of each code and the working-out of inclusion and exclusion criteria. Such a considerable work was carried through to a successful conclusion thanks to the tenacity of Professor Charles Bridges-Webb, University of Sidney, chairman of the Classification Committee, and gives a new dimension to the International Classification of Primary Care Second edition(39) (ICPC-2).
The Classification Committee has also produced and validated other research tools in family practice.
There is still a lot of work to be done, either in the field of crossmapping or of procedures. In the future, the Committee will keep on expending a lot of effort to provide family physicians with relevant high-quality tools, as well for research as for the general organization of clinical practice.