Harmonizing WHO’s International Classification of Diseases (ICD) and International Classification of Functioning, Disability and Health (ICF): importance and methods to link disease and functioning

  • Reuben Escorpizo1, 2, 3Email author,

    Affiliated with

    • Nenad Kostanjsek4,

      Affiliated with

      • Cille Kennedy5,

        Affiliated with

        • Molly Meri Robinson Nicol4,

          Affiliated with

          • Gerold Stucki2, 3, 6,

            Affiliated with

            • Tevfik Bedirhan Üstün4 and

              Affiliated with

              • on behalf of the Functioning Topic Advisory Group (fTAG) of the ICD-11 Revision

                Affiliated with

                BMC Public Health201313:742

                DOI: 10.1186/1471-2458-13-742

                Received: 11 March 2013

                Accepted: 5 August 2013

                Published: 12 August 2013

                Abstract

                Background

                To understand the full burden of a health condition, we need the information on the disease and the information on how that disease impacts the functioning of an individual. The ongoing revision of the International Classification of Diseases (ICD) provides an opportunity to integrate functioning information through the International Classification of Functioning, Disability and Health (ICF).

                Discussion

                Part of the ICD revision process includes adding information from the ICF by way of “functioning properties” to capture the impact of the disease on functioning. The ICD content model was developed to provide the structure of information required for each ICD-11 disease entity and one component of this content model is functioning properties. The activities and participation domains from ICF are to be included as the value set for functioning properties in the ICD revision process.

                Summary

                The joint use of ICD and ICF could create an integrated health information system that would benefit the implementation of a standard language-based electronic health record to better capture and understand disease and functioning in healthcare.

                Keywords

                International classification of diseases ICF Classification Functioning ICD revision Disability

                Background

                Describing and understanding the relationship between disease and functioning requires the use of two of the World Health Organization’s classifications systems: the International Classification of Diseases (ICD) [1] and the International Classification of Functioning, Disability and Health (ICF) [2]. The ICD classifies disease entities and other health conditions to gather diagnostic information, while the ICF classifies domains of functioning and disability in terms of body functions and structures or activities and participation at the body, person and societal levels. The ICD and the ICF classification systems are intended by WHO to complement each other so as to capture and provide the full picture of health or health-related state of an individual. Currently, however, there is no standard platform in which the disease and its impact on functioning are concurrently used within an integrated health information system. Efforts to capture the impact of a disease in a structured and systematic way have so far been hampered by the failure to link the ICD and the ICF at a conceptual and operational level.

                ICD revision

                The ICD is undergoing its 11th revision (ICD-11) [3] wherein part of the process is to add information from the ICF to the classification of diseases by adding “functioning properties” (i.e. ICF domains or codes) to capture the impact of the disease on functioning. In this integrated system, we want to be able to use universal domains (functioning properties) that depict the functioning of an individual by way of the ICF and also use information related to disease entities (ICD codes).

                The process of revising the ICD is coordinated through Topic Advisory Groups (TAGs), each of which is responsible for different content areas. Responsible for the appropriate integration of the functioning properties is the Functioning Topic Advisory Group (fTAG), which consults with each of the TAGs regarding how to deal with functioning properties for their assigned ICD entities.

                Functioning properties of the ICD-11 content model

                The ICD-11 Content Model (Table 1) provides the structure of information detail required for each ICD-11 code included through the revision process [3, 4]. In the ICF, “functioning” is an encompassing term for body functions, body structures, and activities and participation. In the ICD Content Model at this time, functioning properties only include the activities and participation component of the ICF. Activity is defined in the ICF as the “execution of a task or action by an individual”, while participation is defined as “involvement in a life situation” [2]. Activities and participation are important in describing the impact of a disease because they capture the broad and relevant aspects of activity and involvement with society and life in general. Table 2 lists the ICF categories that are included in the value set for functioning properties. Hence, an ICD code would have a corresponding value set of functioning properties.
                Table 1

                The Content Model of the ICD 11 [4]

                Any category in ICD is represented by: TITLE of ENTITY: Name of disease, disorder, or syndrome

                1. ICD Concept Title

                8. Temporal Properties

                  1.1 Fully Specified Name

                  8.1 Age of Occurrence & Occurrence Frequency

                 

                  8.2 Development Course / Stage

                2. Classification Properties

                9. Severity of Subtypes Properties

                  2.1 Parents

                 

                  2.2 Type

                 

                  2.3 Use and Linearization(s)

                 

                3. Textual Definition(s)

                10. Functioning Properties

                 

                  10.1 Impact on Activities and Participation

                 

                  10.2 Contextual Factors

                 

                  10.3 Body Functions

                4. Terms

                11. Specific Condition Properties

                  4.1 Base Index Terms

                  11.1 Biological Sex

                  4.2 Inclusion Terms

                  11.2 Life-Cycle Properties

                  4.3 Exclusions

                 

                5. Body Structure Description

                12. Treatment Properties

                  5.1 Body System(s)

                 

                  5.2 Body Part(s) [Anatomical Site(s)]

                 

                  5.3 Histopathology

                 

                6. Manifestation Properties

                13. Diagnostic Criteria

                  6.1 Signs and Symptoms

                 

                  6.2 Investigation Findings

                 

                7. Causal Properties

                14. External Causes

                  7.1 Etiology Type

                 

                  7.2 Causal Properties- Agents

                 

                  7.3 Causal Properties- Causal Mechanisms

                 

                  7.4 Genomic Linkages

                 

                  7.5 Risk Factors

                 
                Table 2

                List of ICF-based functioning properties value set for an ICD code

                Domains

                ICF codes

                Understanding

                Watching

                d110

                 

                Listening

                d115

                 

                Learning

                d130-d155

                 

                Focusing attention

                d160

                 

                Reading

                d166

                 

                Writing

                d170

                 

                Calculating

                d172

                 

                Solving problems

                d175

                 

                Other specified

                 

                Communication

                Communicating with others

                d310

                d315

                d320

                d325

                 

                Speaking

                d330

                 

                Starting a conversation

                d3500

                 

                Sustaining a conversation

                d3501

                 

                Other …

                 

                Mobility

                Standing

                d4104

                 

                Bending

                d4105

                 

                Maintaining a body position

                d415

                 

                Transferring oneself

                d420

                 

                Lifting and carrying objects

                d430

                 

                Fine hand use

                d440

                 

                Hand and arm use

                d445

                 

                Walking short distances

                d4500

                 

                Walking long distances

                d4501

                 

                Vigorous activities

                d455

                d4303

                 

                Moving around within home

                d4600

                 

                Moving around outside the home and other buildings

                d4602

                 

                Using transportation

                d470

                 

                Driving

                d475

                 

                Other …

                 

                Self-Care

                Washing oneself

                d510

                 

                Caring for body parts

                d520

                 

                Urination

                d5300

                 

                Defecation

                d5301

                 

                Dressing

                d540

                 

                Eating

                d550

                 

                Drinking

                d560

                 

                Managing one’s health (needs, assistance or oversight)

                d570

                 

                Other …

                 

                Interpersonal Relations

                Making friends

                d7200

                d7500

                 

                Engaging with other people

                d740

                d750

                 

                Maintaining family relationships

                d760

                 

                Dealing with strangers

                d730

                 

                Engaging in sexual relationships

                d7702

                 

                Other …

                 

                Life Activities

                Household

                Shopping

                d620

                 

                Cooking/preparing meals

                d630

                 

                Doing housework

                d640

                 

                Looking after/helping others

                d660

                 

                Other …

                 

                School

                Attending school

                d820

                 

                Learning a job (vocational training, apprenticeship)

                d825

                 

                Going to university

                d830

                 

                Other …

                 

                Work and economic life

                Engaging in paid work

                d850

                 

                Seeking employment

                d8450

                 

                Performing job related tasks

                d8451

                 

                Handling money

                d860

                 

                Other …

                 

                Life management

                Undertaking a single task

                d210

                 

                Undertaking multiple tasks

                d220

                 

                Carrying out daily routine

                d230

                 

                Handling stress and psychological demands

                d240

                 

                Other …

                 

                Social Participation

                Taking part in social life

                d910

                 

                Sports

                d9201

                 

                Travel

                d920

                 

                Visiting friends

                d9205

                 

                Human rights (e.g. self-determination, equal opportunities)

                d940

                 

                Political life and citizenship (e.g. voting)

                d950

                 

                Other …

                 

                Children and Youth

                Learning to read

                d140

                 

                Learning to write

                d145

                 

                Learning to calculate

                d150

                 

                Communicating with others

                d310

                d315

                d320

                d325

                 

                Speaking

                d330

                 

                Attending school

                d8201

                 

                Taking exams

                d8202

                 

                Playing with others

                d880

                d9200

                The task of populating the functioning properties in iCAT

                Before ICD-11 is completed, functioning properties will need to be populated for each ICD code. This task of population is being done and coordinated using the web-based International Collaborative Authoring Tool (iCAT) by content experts worldwide in three steps: [1] selection of functioning properties provided in iCAT (Table 2), [2] if an additional ICF domain or category needs to be added based on a published disease-specific ICF Core Set, then it is entered manually into the iCAT, and [3] use evidence from the literature (i.e. mini-review) by identifying the commonly used measures relevant to the disease of interest, and in those measures identify meaningful concepts of functioning with a focus on activities and participation in life situations, and then subsequently link the identified concepts to a specific domain in the ICF [5].

                Discussion

                Obtaining information about disease entities and their impact on functioning is not entirely new in the field of medicine and health. While the consideration of the disease and its impact on functioning has been in place, or at least acknowledged, for a long time, [6] there remain prevailing issues, such as the lack of wide dissemination and implementation extending beyond simple awareness [7, 8]. The operationalization of integrated disease-and-functioning models currently varies, is fragmented across healthcare settings, and is perhaps more commonly observed in healthcare systems with medium to advanced infrastructures and access to resources. We can do a better job at facilitating an integrated disease-and-functioning model across systems from low to high resource countries. Moreover, the ongoing ICD revision would make the assessment and documentation of a comprehensive set of information about a disease entity as broad and as inclusive as possible; at the same time utilizing the standard and common language of the ICF on functioning. This information will consist of biomedical and biopsychosocial aspects of the disease that will provide clinicians and users alike an integrated and unified ICD-ICF platform and which will be helpful in interdisciplinary communication towards a concerted planning of care ultimately benefiting the patients.

                The ICD-11 is due to be launched in 2015, and steps toward that goal are being pursued. Certainly there are challenges on our way, but there are also opportunities that are presented for users in the clinical and research communities to actively contribute in this huge endeavor by WHO and its collaborators worldwide. The unified ICD-ICF in the ICD-11 will allow for consistent terminologies to be used and to be harmonized across ICD and ICF and will provide holistic information about a disease entity and its impact on the functioning of an individual. Efforts are also currently being taken to facilitate the identification of the overlaps for ICD-11 disease entities and their titles with their conceptual equivalent in the ICF towards harmonization of ICD and ICF.

                Conclusion

                The joint use of the ICD and ICF towards an integrated health information model would, in our opinion, benefit medicine and health systems and would support the push for the implementation of a standard language-based electronic health record system towards better health services planning and reimbursement.

                Authors’ information

                RE is Assistant Professor, Department of Physical Therapy, School of Allied Health Professions Louisiana State University Health Sciences Center, New Orleans LA USA; adjunct research scientist at the ICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (DIMDI), Nottwil, (Switzerland); and the Swiss Paraplegic Research (SPF), Nottwil, Switzerland.

                NK is technical officer at World Health Organization, Classifications, Terminologies and Standards (CTS), Department of Health Statistics and Informatics (HSI), Geneva, Switzerland.

                CK is with the US Department of Health and Human Services, Office of Health Policy Washington D.C., USA.

                MMRN is technical officer at World Health Organization, Classifications, Terminologies and Standards (CTS), Department of Health Statistics and Informatics (HSI), Geneva, Switzerland.

                GS is director of the ICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (DIMDI), Nottwil, (Switzerland) and the Swiss Paraplegic Research (SPF), Nottwil, Switzerland; is Professor and Chair at the Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland.

                TBU is head of WHO’s Family of International Classifications, Geneva, Switzerland.

                R Escorpizo is an employee of the Louisiana State University Health Sciences Center (LSUHSC). This article was developed in his professional capacity and does not necessarily represent the views of LSUHSC.

                C Kennedy is an employee of the Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS). This article was developed in her professional capacity and does not necessarily represent the views of ASPE or HHS.

                Abbreviations

                fTAG: 

                Functioning Topic Advisory Group

                iCAT: 

                International Collaborative Authoring Tool

                ICD: 

                International Classification of Diseases

                ICF: 

                International Classification of Functioning, Disability and Health

                TAG: 

                Topic Advisory Group

                WHO: 

                World Health Organization.

                Declarations

                Acknowledgements

                Special thanks to Melissa Selb, ICF Research Branch coordinator in Nottwil, Switzerland and members of the functioning Topic Advisory Group.

                Authors’ Affiliations

                (1)
                Department of Physical Therapy, Louisiana State University Health Sciences Center
                (2)
                ICF Research Branch in cooperation with the WHO Collaborating Centre for the Family of International Classifications in Germany (DIMDI)
                (3)
                Swiss Paraplegic Research (SPF)
                (4)
                World Health Organization, Classifications, Terminologies and Standards
                (5)
                US Department of Health and Human Services, Office of Health Policy
                (6)
                Department of Health Sciences and Health Policy, University of Lucerne

                References

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                2. World Health Organization: International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organization; 2001.
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                9. Pre-publication history

                  1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2458/​13/​742/​prepub

                Copyright

                © Escorpizo et al.; licensee BioMed Central Ltd. 2013

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.