There is lots of interest in Information, Communication and Technology (ICT) within health. Africans are looking at it to develop effective and efficient health systems within poorly resourced environments. There is an opportunity in Africa to leap ahead of the developed world with its problems of change and to use newer technologies to create a more integrated system that reaches out into communities.
Computer systems in general practice have traditionally focused on management of practice billing. Systems in (South) Africa are grouped as a) Practice Management Systems (PMS) e.g. Medemass and Turbomed b) Electronic Data Interchange (EDI) or Healthcare Information Switches e.g. Healthbridge and Switch for speedier claims and c) Pricing Support eg MedPrax. There is an international shift to clinically practice systems with Electronic Medical Records (EMR). These are mostly in the developed world eg EMIS in the UK. There are useful options available to the developing world eg OSCAR (including ICPC) here and OpenMRS 1 2 3 (not including ICPC currently). The Transition Project is particularly useful for Family Physicians with its strong integration of ICPC.
ICT systems are not just about the infrastructure but how information is communicated with coding creating a standard 'language'. South African health information is currently premised on the National Health Reference Pricing List (NHRPL) for consultations- procedures, ICD10 coding for diseases and NAPPI codes for medicines.
There are three systems broadly that are relevant to Primary Health Care
1. Systematised Nomenclature of Medicine - Clinical Terms (SNOMED-CT) as a very large and unwieldy database of clinical terms (±250 000). See here for more. SNOMED-CT is managed by the International Health Terminology Standards Development Organisation (IHTSDO).
2. International Classification of Disease (ICD) as a still fairly large but disease-focused database managed by the World Health Organisation (WHO). This is currently as the ICD10 with revisions in process for ICD11 (more). There are also additions to this by the WHO - International Classification of Functioning, Disability and Health (ICF) and International Classifications of Health Interventions (ICHI).
3. International Classification of Primary Care (ICPC) is a small but astute approach to organise information in the Primary Care Context. ICPC was developed and is managed by the World Organisation of Family Doctors (WONCA) via the WONCA International Classification Committee (WICC). The current list of WICC members (and their countries) are attached below. Prof Klinkman is current chairman. They are contactable for support.
The ICPC is very important to Family Medicine as it provides a useful organisation to the complexity of primary care information. WICC is a committee of volunteer experts who have set up and maintain the International Classification of Primary Care (ICPC). Prof Jan de Maeseneer of Ghent has long included the ICPC in the VLIR and Primafamed Projects and meetings in Africa. This included an orientation to the Transhis software (which includes ICPC and ICD10) at the Primafamed Meeting in Kampala 2009. The chance of a team of three (Dr S. Moosa (South Africa), Dr P. Chege (Kenya) and Dr A. Essuman (Ghana)) to join the WICC meeting in Ghent Oct 2010 was a very useful orientation to WICC workings.. Dr O. Aya
nkgobe (Nigeria) was invited but could not attend.
There have been various revisions to the ICPC (see history / short version / publications / English 2-pager and other language 2-pagers / repository of latest versions at KITH with tutorial and brochure) and work is underway for ICPC3. The ICPC was first published in 1987 as a book with the latest version of ICPC2 in 2005 (ICPC2-R book /-E electronic version). ICPC classifies three important elements of the health care Encounter - Reasons For Encounter (RFE) (Symptoms or diagnoses or process issues as patient view), the assessment (Diagnoses or problems as health provider view) and Process Of Care (decision, action or plans). This allows linkages of these and analysis of the dynamic of several problems or Episodes Of Care (EOC) within one Encounter as well as a problem or Episode Of Care (EOC) that may overlap several Encounters. WHO has accepted ICPC as part of its family of international classifications. Its strength has been its simplicity.
The data model of ICPC is Biaxial Alpha-Numeric. There are 17 Chapters as the Alpha (from A-General, B - Blood, D-Digestive..... to Z-Social Problems in a pneumonic approach). There are then 7 Components which are based on the different groups of numbers as the Numeric (from 01 to 99: 01-29 are Symptoms and 70-99 are Diagnoses. Components 2 to 6 are Process codes (eg Component 2 is Diagnostic and Preventive with the codes 30-49 with for example -37 the code for Histology / Cytology). This matrix of Chapters and Components creates a chessboard and is viewed as a 1A2N model with the Component implicit within the grouping of numbers. The revisions planned for ICPC3 are that the Component be added clearly as a 2nd Alpha (eg S for Symptoms and D for Diagnoses) with the Numeric thus potentially expandable in each Component from 01 to 99. It also allows additional Components eg for Risk Factors. This is the newer 2A2N model.
This is viewed as necessary to make the coding more flexible to allow additional common diagnoses across the world to be included and to allow other issues to be incorporated eg risk factors, preventive efforts and perhaps patient issues. This might be viewed as encompassing Non-Episode Related Issues (NERI). There is a tension between retaining the simplicity ICPC (and even extending its simplicity to allow all clinical team members to use it eg Community Care Workers) versus ensuring that the ICPC coding is cutting edge, robust and inclusive. The X and Y Chapters are being combined into a G Chapter. There are also issues such as patient goals vs disease goals. chronicity, severity as well as impact on function that need to be accommodated easily in the system of collecting data in primary health care especially with multimorbidity and the need to be more person-centred and preventive. The idea is to use the ICPC as organising tool superimposed on ICD and SNOMED-CT as large, clumsy but necessary systems. ICPC should be a tool especially suited to the complexity of primary care and a necessary part of all Electronic Medical Record keeping systems in Primary Care.
There are some useful resources to learn how to use the ICPC. It does not need a computer and in fact can be used with pencil and paper on small samples of patients to provide some very useful insights. See the 2 pager and a data collection sheet attached. Have a look at the following pages to begin to learn how to use it. There are instances below. More that will be shared with you in time.
The learning resources on this page will be built up progressively with more links / attachments in time.