Mar Jamoulle, long time member of WICC, also writes a story on WCC in 1998.

The WONCA Classification Committee, 1972-1997, 25 years in the service of family practice  

By Marc Jamoulle, 1998

The WONCA Classification Committee, a multinational working group

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.

Computers 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⁾. 

This judicious assembling enabled to set up the structure of the ICPC, a global categorization tool that makes it possible to define those three major components of any consultation.

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.

• EncodeFM is a system driven by Dr. Bob Bernstein, Ottawa, that offers an extensive terminology in English and in French, with the ICD-10 crossmappings.⁽³⁵⁾

   

• In Quebec, the team of Guy Lavoie has developed for the Régie d'Assurance Maladie du Québec a ICPC-CISP terminological databank (14.000 termes) ⁽³⁶⁾currently in use in the smartcard « Carte Santé».
  

   

• ICPC-Plus is produced by the Family Medicine Research Unit, under the supervision of Ms. Helena Britt, University of Sydney. Besides an extensive terminological data bank⁽³⁷⁾in English and a crossmapping, the ICPC-Plus provides help to coding and information processing.
  

   

• LOCAS is a terminological data bank ⁽³⁸⁾ in French developed by Michel Roland, Marc Jamoulle et Bernard Dendeau within the scope of their research activities within the Fédération des Maisons Médicales de Belgique. The distinctive feature of this data bank is that the terms classified according to the CISP (French ICPC) are standardized.

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.

• The International Glossary for General/Family Practice was published on behalf of the Classification Committee in the journal by Niels Bentzen and Charles Bridges-Webb in 1995. It has already been translated in Portuguese. The need to develop a specific terminology had made itself felt along the whole development process of the ICPC. The first elements of the glossary had been published in 1983 in the International Classification of Health Problems in Primary Care (ICHPPC-2d). The currently available glossary is the prelude to a genuine dictionary of general practice.⁽⁴⁰⁾Family Practice⁽⁴¹⁾
• The Committee is also concerned by the indicators of the patients' functional status. The COOP/WONCA maps. Initially developed by the COOP Primary Care Network, a group of family physicians of Dartmouth (USA), to assess the health status of elderly people, the COOP maps have been tested, endorsed and published by the Classification Committee⁽⁴²⁾. They are available in more than twenty languages ⁽⁴³⁾ . The French version is available at the CISP-Club.
• The DUSOI assessment form is a tool for assessing the severity of the health problems, that can be used in clinical practice ⁽⁴⁴⁾. It is a complex index, the first attempt to quantify what can be described in family practice. It was developed by Georges Parkerson Jr, Duke University (Durham, North Carolina, USA), then tested and published by the Committee.

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.

• Bentsen BG. Illness and general practice. A survey of medical care in an island population in South-East Norway. Oslo: Oslo University Press, 1970
• Bridges-Webb C.Classification of disease in general practice. Paper presented at the International Workshop on General Practice Research, Melbourne, 1972.
• Westbury RC.A plan to develop an international classification of disease in family medicine. Paper presented at the International Workshop on General Practice Research, Melbourne, 1972.
• Sive P & Spencer T. Classification for cooperative morbidity survey, Unpublished, 1972.
• Nelson EC, Wasson J, Kirk J et al. Assessment of function in routine clinical practice. Description of the COOP Chart method and preliminary findings. J. Chron. Dis. 1987(40(suppl.1)): 55S-66S.
• Parkerson GR Jr, Broadhead WE, Tse C-KJ. The Duke Severity of Illnes Checklist (DUSOI) for measurement of severity and comorbidity. J. Clin.Epidemiol. 1993;46:379-393
• Engel J L. How much longer must medicine's science be bound by a seventeenth century world view. in: White K L. The task of medicine. Dialogue at Wickenbourg. The Henry J. Kaiser Family Foundation ed. Menlo Park, California; 1988: 113-136.
• Bentsen BG Classifying of health problems in primary medical care, in : An international classification of the health problems of primary care (ICHPPC). The Journal of the Royal College of General Practitioners. Occasional paper 1; 1976 Dec.
• Classification Committee of WONCA, An international classification of the health problems of primary care (ICHPPC). The Journal of the Royal College of General Practitioners. Occasional paper 1; 1976 Dec.
• World Health OrganisationManual of the International Statistical Classificcation of Diseases, Injuries and Causes of Death. (8th revision). Geneva;WHO, 1967.
• Classification Committee of WONCA WONCA. International Classification of Health Problems in Primary Care, 2nd ed.,defined (ICHPPC-2d). Oxford University Press; 1979.
• Lamberts H; Meads S; Wood M. Classification of reasons why persons seek primary care: pilot study of a new system. Public Health Report.; 99: 597-605. 1984
• Classification Committee of WONCA. International Classification of Process in Primary Care (IC-Process-PC). Oxford: Oxford University Press; 1986.
• Lamberts H; Wood M (eds). International Classification of Primary Care (ICPC) :Oxford University Press; 1987.
• Hofmans-Okkes I M. Op het spreekuur. Ordelen van patiënten over huisartsconsulten. (At the GP's surgery. View of patients about seeing their GP; with a summary in english) [Ph.D Thesis.University of Amsterdam]. Meditext, Lelystad; 1991.
• De Maeseneer J. The ICPC Classification of Drugs. in: Lamberts H, Wood M. ,. Hofmans-Okkes I. (Editors). The International Classification of Primary Care in the European Community. : Oxford Medical Publication; 1993: 163-170.
• Lamberts H; Wood M; Hofmans-Okkes I (Editors). The International Classification of Primary Care in the European Community. : Oxford Medical Publication, 1993.
• Lamberts H. In het huis van de huisarts. Verslag van het Transitie project.(In the GP's home. A report of the Transition project). Lelystad: Meditekst; 1991.
• Lamberts H ; Hofmans-Okkes I. The core of computer based patient records in family practice;episodes of care classified with ICPC. Int J. Biomed Comp, 1996;42;35-41
• Oskam SK. TRANS. An interactional access programme for the standard reason for encounter, diagnosis and process output of the Transition Project. Department of general practice/family medicine, University of Amsterdam, 1992
• Oskam SK. ? Transhis. Department of general practice.University of Amsterdam?
• Metsemakers JFM et al. Health problems and diagnoses in family practice. Registration network family practice. [Monography]. Department of General Practice: University of Limburg; 1992 Mar. 23p.
• Bridges-Webb C. Assessing health status in general practice. The Medical Journal of Australia. 1992 Sep 7; 157: 321-328.
• Jamoulle M; Roland M. Classification Internationale des Soins Primaires (CISP). (traduite de l'anglais, annotée et mise à jour): WONCA ed. Lyon: Lacassagne; 1992.
• Jamoulle M. Nomenclature abrégée de la CISP extraite du "Multilanguage layer of ICPC" [sous forme imprimée et électronique]. in: Lamberts H; Wood M; Hofmans-Okkes I (Editors). The International Classification of Primary Care in the European Community. : Oxford Medical Publication; 1993: 174-219.
• Equipo Cesca, Classificación Internacional en Atención Primaria (CIAP) Masson, Barcelona, 1990
• APMCG Classificação Internacional de Cuidados Primários, 1995.
  

   

• IBentsen BG, (ed), ICPC. ICHPPC-2-Defined. IC-Process-PC. Klassifikasjoner og definisjoner for primærhelsetjenesten (Classifications and definitions for primary health care). Oslo: Tano Forlag, Norsk selskap for almenmedisin, 1991.
• Jamoulle M; Roland M; Beaulieu MD.Entraînement à la CISP, Cassette vidéo,1h10'. Department of Family Practice, Amsterdam, 1993. (Training videos also available in English and Dutch)
• Bentsen BGInternational Classification of Primary care, A newlanguage for general practice/family medicine, Department of General Practice, University of Trondheim, 1994, Video,30'
• Hofmans-Okkes IM; Lamberts H. The Classification of mental health problems in family medicine and in psychiatry. in: State of the art in clinical psychiatry. Amsterdam: Benecke consultants; 1996 Feb: 4-28.
• Jamoulle M; Roland M. Santé mentale en soins primaires, une autre santé mentale ? Exposé présenté au National Institute of Mental Health (NIMH), Defining mental health problems in primary care, working meeting, Washington, July 21-22, 1994. Courrier de la Fédération des Maisons Médicales. 1994 Nov(97): 18-23.
• Organisation Mondiale de la Santé. Classification statistique internationale des maladies et des problèmes de santé connexes. Dixième révision. Volume 1. Genève; 1993.
• Wood M, Lamberts H, Meijer JS, Hofmans-Okkes I. The conversion between ICPC and ICD-10. Requirements for a family of classification systems in the next decade. Fam Pract. 1992;9(3):340-8.
• Bernstein WMEncode-Fm. Version 2.0. Ottawa,Canada: Insite-Family Medicine Inc.; 1996.
• Lavoie G, Tremblay L, Durant P, Papillon MJ, Berube J, Fortin JP. Medicarte software developed for the Quebec microprocessor health card project. Medinfo 1995;8 Pt 2:1662
• Britt H, Miller G. ICPC Plus, Family Medicine Research Unit, Department of general practice, University of Sydney, Australia ,1996.
• Roland M., Jamoulle M., Dendeau B., Approche taxinomiques en médecine de famille assorties d'une terminologie standardisée et classifiée selon la CISP à usage informatique en soins de santé primaires, Care Editions, Bruxelles, 1996.
• Classification Committee of WONCAInternational Classification of Primary care Second Edition (ICPC-2), Oxford University Press, 1998 (Forthcoming)
• Bentzen N (Editor),Wonca Classification Committee. An International Glossary for General/ Family Practice. Family Practice. 1995 Sep; 12(3): 341-369.
• Comissão de Classficações da WONCA Glossário para Medicina Geral e Familiar, APMCG, 1997
• WONCA Classification Commitee. Functional Status Measurement in Primary Care. : Springer-verlag; 1990.
• Scholten JHG., Van Weel C. Functional Status Assessment in Family practice. The Dartmouth COOP Functional Health Assessment Charts/WONCA. Lelystad: MEDItekst; 1992
• Parkerson GR Jr, Bridges-Webb C, Gervas J, Hofmans-Okkes I, lamberts H, Froom J, Fischer G, Meyboom-de Jong B, Bentsen B, Klinkman M and De Measeneer J. Classification of severity of health problems in family/general practice : an international trial; Fam. Pract. 1996;13:303-309