In daily practice of Primary Care, Community Care and Public Health many standards are used. In Primary Care the ICPC or ICD is the starting point for registration and documentation: the “data”. Most of the data is for use within the Primary Care setting itself, some data is used for referral, also some data comes back after consultation of a medical specialist or dismissal from a hospital. Data that is received by others or is sent by others in most cases will require more detail or contain more detail. For Primary Care as such, a high level of detail is not required, even not wished for. Adequate is what is needed. No excessive detail, tailored to Primary Care and bridged to classifications with more detail.
The ICPC-3 content therefor will contain linkages to several standardized classifications and clinical terminologies. This is what is generally called a ‘telescopic’ view. Starting with the categories or class in ICPC-3, when more detail is needed zooming-in to either ICD for diagnostic terms, ICF for functioning or ICHI for interventions. The other way around; when detailed data is received, zooming-out to the relevant ICPC-3 categories/classes.
Including these linkages in ICPC supports the principle of continuity of data within and between health-care providers, but also supporting the use of ICPC, or ICD within a country, without losing the possibility to collect or exchange information for different purposes, such as direct patient care, research, reimbursement, aggregation or dis-aggregation of data, etc.
For the information exchange process, standardization is required on a different level: secure the meaning of the content by using the same (clinical) terminologies, e.g. the use of the Foundational Model of Anatomy (FMA) throughout all related classifications and clinical terminologies such as Snomed-CT.
In addition to the ICPC-3, an Interface Terminology (Thesaurus) will be developed.
This Thesaurus is a reference terminology for Primary Care that lists words grouped together according to similarity of meaning (including synonyms, or variants of terms). The main purpose of such a reference work is to help the user “to find the correct word, or words, by which [an] idea may be most fitly and aptly expressed”. In other words it is a controlled vocabulary.
The Thesaurus can be used as an interface-terminology, as it is already used partly in the Netherlands and Belgium in the EHR for GP’s/Primary Care.
The Thesaurus we intend to develop will offer all the options or views that are needed, either to start searching from ICPC, ICD-10 or ICD-11. As Snomed-CT ID’s and possibly terms will be included, future implementations of Snomed-CT can also be supported.
The interface-terminology could also serve as the basis for a coding tool as shown below: