1. The WHO Family of International Classifications WHO-FIC
UN Expert Group on International Economic and Social Classifications New York, 8-10 December 2003
The WHO Family of International Classifications
WHO-FIC
Bedirhan Üstün M.D.
Andre L’hours
Nenad Kostanjsek
Classification, Assessment, Surveys & Terminology Group
World Health Organization

2. Need for a Family of Health Classifications
lack of common language
Death, disease, disability,… health
need for health information systems
monitoring MDGs, Life expectancy
electronic health records
identifying needs, uses,
cost and outcome monitoring
health care costs, major projects e.g. 3*5
If we look at the area of disability statistics we are facing a huge problem, which I think is best illustrated with the tower of bable picture in the background. So far we did not have a common language. Many surveys have a very limited focus and domains coverage looking mostly at few impairments. We see that often a priory definition of disability is used and there is no or very little linkage with health surveys.

3. WHO Family of International Classifications
ICD-10
International Statistical Classification of Diseases & Related Health Problems
Interventions
procedures
Primary care adaptations
Reasons for encounter
ICF
International Classification of Functioning, Disability and Health
Speciality
adaptations
The ICF forms part of the WHO-FIC and together with ICD it constitutes the two building blocks of the family.
With more than 150 years the oldest and most well known member of the family is the ICD which classifies health conditions.
The ICF classifies health and health related states.
Next to the ICD and ICF as the main classifications we have the Associated products and Adaptations. [READ SLIDE]. With regard to the ICF we are at the moment working on the development of a Children and youth version and we are also exploring the possibility of developing a ICF Primary Care version.
Vobaularies,
Terminologies.
Nomenclature
Associated Products
Main Classifications
Adaptations

4. classification of causes of death”.
150 years of the ICD
1853 International Statistical Congress
William Farr (UK) and Marc d’Espine (Fr) prepared
“an international
classification of causes of death”.
1893 first ICD adopted
by Intl Statistical
Institute (ISI)

5. ICD-10 international standard diagnostic classification
for all general epidemiological and many health management purposes.
Mortality
Morbidity

6. Purpose of the ICD systematic recording analysis interpretation
comparison
mortality data
morbidity data
within countries
between countries
at a certain point in time
over time

7. Main uses of the ICD MORTALITY: Hospital discharge diagnostic data
Underlying and multiple cause
Hospital discharge diagnostic data
Primary care encounters
Health surveys
Disease registers
Health insurance reimbursement
Resource allocation in health services

8. Specialty-based adaptations
psychiatry
neurology
dentistry
oncology
paediatrics
dermatology

9. The ICD-10 Browser Version 2003 Volumes I – III
Publication in 2004 as CD-ROM (PDF format) & web-based version
Adobe Acrobat Reader
Bookmarks
Hyperlinks
Text Search
Simple Search
Advanced Search (Boolean operators, proximity etc.)

10. WHO Statistical Information System http://www.who.int/whosis
Links to Health Statistics
External sources for health related statistical information
Statistics by disease or condition
Links to national health-related websites
Regional and member state information
Comparison of indicators
All indicators for a member state

11. Periodic updating of ICD-10
Since 1996 a mechanism has been established for the periodic updating of ICD-10
minor updates each year
major updates every three years

12. ICD Revisions

13. Policy for Revision Continuous life cycle systematic evaluation
Knowledge Management
strategic vision - purpose - users - policy
recognition of need & perspective: how & when
Software release methodology
Beyond Prejudgement: conservatism vs novelty
undermining the ICD-10, ICF ?
New = better ?; Old = better ?
Marketing strategy
Credibility management
backward compatibility
real response to need
systematic evaluation
impact, process
serious planning for revision
needs, resources, timeplan, customers, partners

14. ICF in Health & Disability Statistics
What difference does it make?

15. Universal Model vs. Minority Model
So when we say that ICF is based on a Universal Model we mean that that see disability:
as a experience everybody may have in his/her life and NOT trademark of a minority group
Lying on continuum with health and not a category
multi-dimensional experience NOT Uni dimensional
Everyone may have disability
Continuum
Multi-dimensional
Certain impairment groups
Categorical
Uni-dimensional

16. Foundations of ICF Human Functioning - not merely disability
Universal Model not a minority model
Integrative Model not merely medical or social
Interactive Model not linear progressive
Parity not etiological causality
Context - inclusive not person alone
Cultural applicability - not western concepts
Operational not theory driven alone
Life span coverage not adult driven
In summary
1. ICF is focused on Human Func. and not only disability, this is e.g. reflected in the use of neutral language and the in build possibility of the taxonomy to capture also positive aspects of functiong.
2. ICF is based on a Universal model not a…
[READ SLIDE]
"Unless we measure health, we cannot manage and improve health systems. The ICF is the ruler with which we will take precise measurements of health and disability”.

17. Environmental Factors
Use of ICF framework
Body Functions
&
Structures
Activities
&
Participation
Environmental Factors
CAPACITY/ PERFORMANCE PROBLEM
IMPAIRMENT of
Functions & Structure
Barriers
Facilitators
In a moment I will present you the components of the ICF framework in more detail. In this slide I would like to stress the two major advantages of this framework.
The framework allows you to understand the full problem of functioning at body, person and societal level and captures also the impact of the environmental factors on the person's functioning.
and secondly it allows you to identify and compare different types of interventions the focus of the intervention.
Rehab, back to work programme, education
Medical treatment
Destigma. campaign
Support informal care

18. Functioning and Disability
4 Components
1st level: 34 Chapters
ICF
Functioning and Disability
Activities
and
Participation (d)
Environmental
Factors (e)
Personal
Factors
Not classified yet
b1– b8
Contextual Factors
Body Functions (b)
Body Structures (s)
2 Parts
s1– s8
d1– d9
e1– e5
ICIDH categories are organized in a "nested" approach Broader Category  detailed subcategory
The classification has two parts, each with two components.
[An example may help to illustrate the point:
The universe of health and disability is being classified (this is the forest). Within that forest we classify the dimensions of Impairments, Activities and Participation (the trees). In the Activities dimension we have several chapters or domains ranging from simple to complex activities - from sensing and recognizing to interpersonal behaviors (the trunks). Within, for example, the chapter on Interpersonal Behaviors are included activities such as general interactive skills (the branch) and included in that broad category are behaviors such as initiating social contact, responding to cues and so on (the leaves).]
b110 -
b899
s110 -
s899
d110 -
d899
e110 -
e599
2nd level: 362 categories
b1100 –
b7809
b11420
b54509
s1100
s7609
s11000
s76009
d1550
d9309
e1100
e5959
3rd level
and
4th level: 1424 sub-categories

19. Common ‘language’ endorsed by 191 WHO Member States in the 54th WHA
Endorse and publish ICF
Use the ICF in Member States in:
research
surveillance
reporting
Joint use with ICD
Operational subsets:
surveys
clinical encounters
Periodic revision
The ICF was endorsed by the WHA in May 2001 for [READ SLIDE]
Unlike its predecessor the ICIDH, which was endorsed for FT purposes only the ICF has been endorsed by the WHA for use in Member States. This creates a more binding force for the implementation of ICF

20. WHO ICF framework for defining health & disability
places disability as an issue of a threshold on a
continuum of health
clearly recognises the impact of the environment on levels of functioning
destigmatises ‘ill-health’ and ‘disability’ by accepting it as a universal human experience
In summary we believe that the current ICF framework reflects the state of the art thinking about disability and in many ways it is a paradigma shift in the understanding of disability by {READ SLIDE}.

21. The ICF Browser ICF Browser ICF Coding Tool (in development)
Multilingual ( languages)
classification in its tree structure
display two languages at the same time
advanced search function
cross references via hyperlinks
selects and work on subsets
internet based upgrading facilities
ICF Coding Tool (in development)
Case specific recording
ICF Qualifier scale
Customized Assessment scale
Assessment Instrument Crosswalk
ICD Code & socio-demo. Info.

22. The World Health Survey ICF domains used
1. Vision
2. Hearing
3. Digestion
4. Bodily Excretions/ Continence
5. Fertility
6. Skin and Disfiguration
7. Breathing Difficulty
8. Pain and Discomfort
9. Affect
10. Sleep
11. Energy and Vitality
12. Understanding and Interacting
13. Communication
14. Mobility and Physical Activity
15. Dexterity and Fine Motor Activity
16. Self Care
17. Interpersonal Relationships
18. Usual Activities and Roles
19. Social Functioning

23. ICF Implementation 1. Population level 2. Specific Applications
Census questions on health and disability
Health and Disability Surveys
Indicator development & reporting in Health Info. Systems
Health and Social Policy Legislation (UN Disability Convention, Right for Health
2. Specific Applications
Clinical Encounters
Specific populations
Elderly
Administrative Records
3. Other uses
Insurance
Education

24. Information Paradox
What is wrong with this picture

25. Drivers for change Clinical Currency
WHO as a Standards Development Organization
recognizing WHO FIC as “Knowledge Assets”
effectively “owning & managing” them
Client needs & Information technology needs
Electronic Patient Records - billing- outcome evaluation
Clinical Terminology & Vocabulary
SNOMED Int, NLM, HL7 …
Clinical Currency
HIV-AIDS, SARS, …
Diabetes, Hypertension, Coronary disease…
definitions, risk factors
Oncogenes
Single Gene Disorders
Alzheimer’s; Narcolepsia, Huntington’s, Rye Syndrome...
New and expected developments:
Human Genome Project, treatments...
Compatibility within the Family
ICD - XM, updates of AM, CM, CA, DM.
ICF
ICHI
ICECI

26. Further information: Visit the ICF website Contact us via e-mail:
Contact us via
Contact WHO Collaborating Centers for the Family of International Classifications