An increasing number of countries are adopting Wonca's International Classification of Primary Care (ICPC) as one of its diagnostic and data collection systems. The growing global acceptance of ICPC is due to the outstanding leadership of Wonca's International Classification Committee and its dedicated advocates in numerous countries around the world. The following is a brief status report on the use of the latest version, ICPC-2, and the family doctors leading these efforts in selected countries around the world in 2003.

Australia

The Family Medicine Research Centre (FMRC) and General Practice Statistics and Classification Unit (GPSCU) at the University of Sydney are at the forefront of development and promotion of ICPC in Australia. FMRC is a Wonca Collaborating Centre and distributor for ICPC-2 in Australia and the Asia Pacific region, and continues to use ICPC-2 in the national general practice data collection program (BEACH).

WICC on Top of the Harbour Bridge in Sydney, Australia

Jane Marshall, Ian Marshall. Leslie Kaye and Nick Booth relaxing during the WICC Meeting in Sydney

ICPC-2 is increasingly used with ICPC-2 Plus in electronic health record systems. Thirty-two software developers are currently licensed to include ICPC-2 in their software and approximately 1500 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 Expert Group on Classification has recommended that the International Classification of Primary Care, Version 2 (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 Health Terminology and Classification 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 - an Australian terminology classified to ICPC-2, SNOMED and several others.

Australian members of the Wonca International Classification Committee, Associate Professor Helena Britt and Dr Graeme Miller, are advising the Australian Government on these issues through a number of committees and working groups. Further information is available on the FMRC web site: www.fmrc.org.au

Classification Internationale des Soins de Santé Primaires (CISP - ICPC in French)

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 Federation des Maisons Medicales 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.

In 2002, the Belgian Ministry of Health acquired an ICPC license from Wonca for use in Electronic Medical Records. The Ministry has convened a National Classification Committee and a Label Committee and a WICC member has been invited to join both. An additional payment is made to Belgian general practitioners using Electronic Medical Records accredited with a Quality Label, and inclusion of ICPC is part of the accreditation process.
Further information about the CISP-Club, please see the accompanying article in this issue of Wonca News. The CISP-Club web site is http://www.wbcispclub.be and its Chairman, Dr Marc Jamoulle, is at marc.jamoulle@brutele.be or http://docpatient.net/mj.

Denmark

In Denmark, the use of ICPC is widely accepted as the structure able to provide a professional overview. 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 ICPC2-E to a user-friendly electronic Extended Danish ICPC-2 with auxiliary registers. This work is expected to be finalised by the end of 2003. Further information about ICPC in Denmark can be obtained from Dr Eric Falkoe at e-falkoe@dadlnet.dk.

Malta

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 this year, the database will span three years of continuous registration. 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.
Further information about ICPC in Malta can be obtained from Dr Jean Karl Soler at jksoler@synapse.net.mt.

Wonca Chair Neils Bentzen

WICC Member Mike Klinkman Solving a Technical Problem

Netherlands

In the Netherlands, ICPC increasingly forms the lynchpin of electronic patient records in family practice. Its use is mandatory also in electronic prescribing systems, and all family practice research in the Netherlands is, if at all feasible, based on ICPC. Practically all official data on morbidity in family practice in the Netherlands are coded with ICPC. The official Dutch clinical database now includes selected ICPC coded information from the Transition Project.

Based on the four language ICPC-2/ICD-10 thesaurus close co-operation has been established with the Flemish Department of General Practice in Ghent and the (French speaking) Department of the Free University in Brussels. It is the intention of the Belgian government to provide a real two-language thesaurus for use in this bi-lingual country. The four-language thesaurus, is likely to be expanded with other languages such as German.

The ICPC-2/ICD-10-thesaurus, prepared together with the Dutch College with a Ministry of Health grant, has become available in a working version, including a diagnostic terminology with 80.000 entries for use by family physicians and specialists is available. The Dutch College of General Practitioners continues to make their products (e.g. lab tests, protocols, patient education letters, recall systems) accessible through ICPC.

The available translations of ICPC-1-short titles, respectively 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 the 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 chapter 10 of ICPC-2. Further information about ICPC in the Netherlands can be obtained from either Dr Inge Okkes at i.m.okkes@amc.uva.nl, or Professor Henk Lamberts at h.lamberts@amc.uva.nl.

Norway

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 now used in regular official statistics about general practice and social security in Norway. It is also one of the main tools in audit and quality assurance and has been applied in many projects.

A new extended alphabetical index of more than 3.000 terms was introduced in 2002. The Health and Social Directorate has also granted EUR 450.000 for the translation and implementation of ICPC-2, including an ICPC-2 - ICD10 conversion structure. ICPC-2 will be released in 2003. Further information about ICPC in Norway can be obtained from Dr Anders Grimsmo at anders.grimsmo@medisin.ntnu.no.

Portugal

ICPC-2 was translated into Portuguese in 1999 and published with sponsorship by Associação Portuguesa dos Médicos de Clínica 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 little 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 by residents of family medicine. Further information about ICPC in Portugal can be obtained from Dr Nuno Sousa at Nop07823@mail.telepac.pt.

Slovenia

In Slovenia general practitioners are free to use any classification, but reports to government bodies must be in ICD-10. A translation of Chapter 10 of ICPC has been made into Slovenian, which 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. Dr Gojimir Zorz has been heavily involved as adviser to promote and introduce ICPC-2 in Serbia. ICPC-2 has been translated into Serbian and software based on Transhis, originally developed by the Department of Family Practice of the Academic Medical Centre, University of Amsterdam, has been adapted and is in use for data collection. Further information about ICPC in Slovenia or Serbia can be obtained from Dr Zorz at gojo@s5.net.

Spain

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 Minimum Basic Data Set in hospitals, for medical records, but nothing similar in primary care. Confidentiality of electronic medical records and a central database are key issues this year in Spain, as two Basque general practitioners have been punished after informing their patients about a new database without informed consent. Further information about ICPC in Spain can be obtained from Dr Juan Gervas at jgervasc@meditex.es.

Sri Lanka

ICPC was first used in Sri Lanka in the National GP survey in 1996. This work 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 addition, ICPC was used as the primary coding system with employment of the BEACH methodology from Australia. The final report on ICPC and the GP 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 Family Medicine two lectures are devoted to classification and coding systems from ICHPPC to ICPC2. The College promotes ICPC at every forum where the Government Health Ministry is trying to dominate with 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 ICT 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.
Further information about ICPC in Sri Lanka can be obtained from Dr Kumara Mendis at kmendis@sltnet.lk.

Russia

ICPC has been translated into Russian and published with financial assistance from the Development of Community Medicine in Northern-West-Russia, Barents Health Programme, Ministry of Health, Norway.

At the moment the 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 in 2003. As new generations of doctors are trained in general/family practice it is expected that ICPC use will become more widespread. Further information about ICPC in Russia can be obtained from Professor Elena V Kazakevitch at kazelas@atnet.ru.

United States of America

It has been difficult to have ICPC accepted in the USA because of a 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 published in 2004 and individuals representing the Agency for Health Care Research and Quality (AHRQ), the National Center for Health Statistics (NCHS), the National Library of Medicine (NLM), the Subcommittee on Standards and Security of the NCVHS, as well as representatives of the AAFP, members of the NAPCRG Special Interest Group on ICPC, and the Wonca International Classification Committee (WICC) have been invited to collaborate, and to help develop a strategy to safeguard family practice research.

Further information about the most up to date developments can be obtained from Professor Maurice Wood at wood150w@earthlink.net.

Dr Ian Marshall
Member, Wonca International Classification Committee
ianm@ocea.es