The United States Department of Health and Human Services should take immediate steps to make Wonca's International Classification of Primary Care (ICPC) the basis for primary care classification. So urged the North American Primary Care Research Group at its 2003 annual meeting in Banff in the Canadian province of British Columbia.

In this so-called Banff Declaration, ICPC advocates in the United States, North America and around the world called attention to the need to integrate this newly recognized WHO classification system into the nation with the largest numbers of family doctors in the world.

The year 2003 marked a historic milestone for the Wonca International Classification Committee when the WHO recognized Wonca's International Classification of Primary Care (ICPC) as an essential part of health care systems around the world. As reported in the February 2004 issue of Wonca News, ICPC was accepted into the WHO's Family of International Classifications (FIC) as 'a related classification for registration in primary care'. In addition, the WHO established a joint working group to further work on the relationship between the ICPC and other WHO-FIC systems, especially the ICD-10 and the International Classification of Functioning, Disability and Health.

In the United States, SNOMED-(CT) was recently adopted as the standard vocabulary for U.S. health information systems. This is significant for family doctors and other primary care providers, as SNOMED's diagnostic codes are mapped to both ICD-10(-CM) and ICPC. Based on the conviction that for primary care and family medicine, the International Classification of Primary Care (ICPC) with its mapping to ICD-10(-CM) is the best available tool for capturing, structuring, and retrieving reason for encounter and diagnostic data, an ICPC workshop was organized at the 2003 North American Primary Care Research Group (NAPCRG) Annual Meeting.

The BANFF Declaration

The workshop led to the 'Banff Declaration', calling for the US Department of Health and Human Services to adopt and implement ICPC as a classification system for primary care. The Banff Declaration, which was subsequently endorsed by the NAPCRG Board, is duplicated below.

At the Special NAPCRG Preconference Meeting convened by Doctors Okkes IM, Lamberts H, Wood M, and Green LA, and held October 25th, 2003 in Banff, Alberta, Canada, the participants formulated the following Conclusions and Recommendations

Conclusions

1. The United States is about to establish standards that will determine information processes that the entire health care enterprise will use for years to come. The data standards needed for primary care have not yet been sufficiently addressed, but now can be, to the benefit of millions of people. Indeed, the single largest setting of health care delivery is the physician's office (not the hospital), and a majority of the visits people make to physicians in the United States are made to primary care physicians, specifically family physicians, general pediatricians, and general internists. Thus, the work of primary care physicians in their offices is a large, dominant portion of health care delivery, and their offices are the place where many people bring their troubles for sorting and response.

2. A classification relevant to primary care is necessary in the United Sates. It should be logically organized to (1) reflect the concerns of patients (not the immediate assumptions or beliefs of their doctors), (2) characterize episodes of care, (3) be easy to routinely use, (4) be inexpensive, (5) be honest (not requiring premature closure or misclassification), (6) be relevant to any primary care setting, (7) be expandable, (8) be connected existing coding and other classification approaches, (9) be readily deployed in the evolving electronic health record, and (10) be sanctioned by the US government and other insurers. The International Classification of Primary Care (ICPC) with its linkage to ICD-10 to be used as a nomenclature, which is sanctioned by World Health Organization and included in the US National Library of Medicine's Unified Medical Language System (UMLS), is the only existing classification scheme that meets these standards.

3. When primary care data standards are established and fully incorporated into routine, front line practice, important policy objectives will be enabled. These include (a) operationalizing patient centered care and care based on a continuous relationship, (b) enhancing quality of care, (c) controlling costs (or: reducing waste), and (d) responding to the threat of bioterrorism. Examples of how appropriate taxonomy and data standards in primary care will benefit the nation include: (a) new knowledge about the earliest manifestations of diseases as experienced and expressed by people, (b) use of routinely collected data to identify potential threats of bioterrorism, and (c) quantitative estimates of the probabilities that various patient symptoms and concerns transition into particular diseases.

4. Primary care physicians in the United States have an immediate need for a simple and honest way to routinely record and retrieve data reflecting their perspective. The primary care perspective must be incorporated into the nation's data standards and electronic health records. Clinical research and a fully integrated health information system cannot be sustained without practical, easily used primary care data standards.

Recommendations

1. We recommend that the US Secretary of Health and Human Services immediately incorporate data standards for the routine documentation of the essential content of primary care.

2. These standards should include: (a) the simultaneous recording of both the patient's perspective represented by reasons for encounter, and the primary care provider's clinical perspective, and (b) the requirement that primary care data should be ordered in an episode of care structure.

3. The International Classification of Primary Care (ICPC-2-E, with its linkage to ICD-10 as an underlying nomenclature) should be accepted and used as the initial basis for classification in US primary care settings.

4. In order to facilitate linkage between ICPC-2-E and reference terminologies we recommend that primary care representatives be appointed to NCVHS and the SNOMED Editorial Board.

Both the inclusion of ICPC in the WHO Family of International Classifications, and the endorsement by NAPCRG Board of the Banff Declaration are very important for the daily use of electronic health records (EHRs) in family practice, and for family practice research. Also, the WHO's recognition and appreciation is quite rewarding for Wonca, and especially for the Wonca International Classification Committee that develops and maintains ICPC, and has worked so hard for its global recognition. There is no reason, however, to rest on our laurels, as there still is a long way to go to adopt ICPC in each country's health system. More information about the Banff Declaration is published at www.annfammed.org.

Inge M. Okkes, PhD
Academic Medical Center/University of Amsterdam
Division Clinical Methods & Public Health,
Department of Family Practice
i.m.okkes@amc.uva.nl