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Bogazici ICF 2015

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ICF provides domains of functioning as body functions, personal activities and societal participation to classifiy what a person can do in a certain environment. It provides a common language for communication and meaningful exchange of data.

DSM5 has changed the requirements for describing the clinical significance of a DSM category. Now there it is required that "impairment" criteria is specified in accordance with the ICF ( International Classification of Functioning Disability and Health ) and operationally measured with the WHODAS 2.0;

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Bogazici ICF 2015

  1. 1. Dr. T. Bedirhan Üstün World Health Organization Classifications, Terminologies, Standards What is “Health Information”? What is “Health” ? What is “Health Information System” ?
  2. 2. a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity Source: WHO’s Constitution, 1948 Health is…
  3. 3. History of Health in the World • 243 BC: plague in China • 800 s : smallpox in Japan • 1090s: dysentery in Palestine • 1340s: "Black Death" in Europe • 1830s: cholera worldwide • 1917–19: influenza worldwide • 1996- 2015 SARS, H1N1, Ebola … http://www.mla-hhss.org/histlink.htm
  4. 4. Health Indicators • Maternal Mortality • Neonatal Mortality • Infant Mortality • Child Mortality • Adult Mortality • A g e -specific Mortality • Cause-specific Mortality • Stillbirth rate • Risk factors… http://www.who.int/gho/publications/world_health_statistics
  5. 5. Death - Life CLASSIFICATIONS ,TERMINOLOGIES, STANDARDS … BUILDING BLOCKS OF HEALTH INFORMATION …
  6. 6. Between BIRTH a n d DEATH © NewYorker – Jack Ziegler (2000)
  7. 7. “Definition” of an Elephant • A pillar • A huge fan • A rope • A huge mass • A pointed hard horn • A bad smell • …
  8. 8. “Health” as a C o n t i n u u m in M u l t i p l e Dimensions 10/20 2/20 1/20 Mild-Moderate vision impairment: Needs eye glasses, contact lenses… Severe vision impairment: Needs operation Complete vision impairment (blind): Needs assistance – pension, device, assistant environmental modifications Seeing Functions
  9. 9. A vector model combination of multiple vectors of functioning Vision Hearing Mobility Social Activities Work Cognition Selfcare
  10. 10. Mobility Spectrum M u l t i p l e S U B Dimensions • Sitting • Crawling • Getting out of the bed • Bending body parts • Standing • Walking – long distance – inside the house/residence • Running – long distance • Climbing • Lifting objects • Using tools - vehicles – Assistive devices
  11. 11. Health C o n t i n u u m can be used for interventions Vision 0 10 20 30 40 50 60 1 2 3 4 5 6 7 8 Functioning level Population Eyeglasses/ Contact lenses Cataract Operation Blind
  12. 12. Functioning ≡ Health
  13. 13. Health ≡ Functioning • Health IS NOT opposite of DEATH – DISEASE • Health is about your LIFE » How do you life your life – How are you ? » How do you FUNCTION?  H e a l t h i s F U N C T I O N I N G
  14. 14. Out of Plato's Cave • Measuring "latent" traits – Mobility – Seeing – Hearing – Cognition – Communication – …
  15. 15. Health / Functioning has Mul t i pl e DIMENSIONs • Moving • Seeing • Hearing • Eating • …. • …. • Relating • Socializing
  16. 16. World Health Assembly, 2001  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
  17. 17. CLASSIFICATIONS& TERMINOLOGY ICF 1. Main volume with glossary - Full version 9999 cat. - Short version 99 cat. 2. Clinical Descriptions & Assessment Guidelines 3. Online access - CD Rom 4. Other versions - Children and Youth 5. Dedicated Assessment Tools - Checklists - WHO DAS 2.0
  18. 18. Principles of ICF • Universality – Not particular impairment groups – Equally applicable to everyone – Represents health as multi-dimensional construct • Body Functions – Impairments – Scientific basis • Activities – What the individual can do / does do • Participation – Active performance in society • Environment – Interaction of person with the environment • Identification of barriers • Identification of facilitators
  19. 19. BODY PERSON SOCIETY Function/ Activities Participation Structure (impairment) (limitation) (restriction) BODY functions ACTIVITIES PARTICIPATION & Structures Key Concepts of Functioning & Disability
  20. 20. BODY Function/ Structure (impairment) PERSON Activities (limitation) SOCIETY Participation (restriction) ICF: MULTIDIMENSIONAL Functioning / disability concept
  21. 21. Minority Model vs Universal Model Everyone may have disability Continuum Multi-dimensional Certain impairment groups Categorical Uni-dimensional
  22. 22. ICF Concepts Impairment Activities Participation (function/structure) (Activity Limitation) (Participation Restriction) Health Condition (disorder/disease) Environmental Personal Factors Factors
  23. 23. What should this audience NOT be told? • 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
  24. 24. ICF as the Rosetta Stone • Operational definitions • Mapping across instruments • Anchoring extent of difficulty with known calibrators • Distinguishing health states, symptoms, functional abilities and performance • International comparability
  25. 25. Clinical Language "… have been speaking prose without knowing it …" • Everything that is not poetry is prose • "Good Heavens! For more than forty years I have been speaking prose without knowing it." Le Bourgeois Gentilhomme Molière (1670) Act 2 Scene 4 • Theory • Tools • Practice
  26. 26. "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”. Dr Gro Harlem Brundtland Director General Emeritus, WHO “The ICF is the ruler…”
  27. 27. 0 5 10 15 20 25 30 35 M a lta Ita ly G e rm a n y P o la n d N e th erlan d s S w ed e n S p ain N o rw ay Prevalencein%/YLDs Disability Prevalence in selected EU countries
  28. 28. Health Information Exchange • Map Questions to ICF • Map response scale to ICF Qualifiers – seek equivalence – Use Modern Item Response Theory to achieve comparability between different tools
  29. 29. WHODAS 2.0 ICF based assessment instrument for measuring health and disability  Developed after extensive cross-cultural and psychometric testing  6 Domains  Understanding the world around you  Getting Around  Self-Care  Getting along with people  Life activities (household, work)  Participation in Society  Advanced Scoring  Domain and summary score  Population norms  No. of disability days in last month  Available as  Short version (12 items)  Long version (36 items)
  30. 30. 0.8 1.07 0.44 0.72 0.74 0.81 0.23 1.32 0 0.5 1 1.5 Outpatient care (Mexico City) Outpatient care (Ibadan, Nigeria) Outpatient care of elderly (London, UK) Primary health care (Seattle, USA) WHO DAS II Comparator WHO DAS 2.0 Responsiveness in subjects with depression Effect size ( mean/ SD1) LHS LHS SF-36 (MCS) SF-36 (MCS) N = 100 N = 60 N = 40 N = 73
  31. 31. ICD-10 B24 HIV disease B24 HIV disease ICF activity limitations performance restriction in: Moving around (d455.44) Washing (d510.33) Education (d830.44) … Almost fully functional moderate participation restriction in Higher education (d830.03)
  32. 32. Separate Classification of Disease and Disability + = case Diagnosis Disability => better formulation of caseness
  33. 33. Operationalization of Diagnosis ICD A Specific phenomenology B Signs and Symptoms C …. D Exclusion rules DSM A Specific phenomenology B Signs and Symptoms C DISABILITY & DISTRESS D Exclusion rules
  34. 34. How do we optimize our health services Health Systems & Information Systems: Analog to Digital
  35. 35. Placing WHO Classifications in HIS & IT Population Health • Births • Deaths • Diseases • Disability • Risk factors e-Health Record Systems ICD ICF ICHI Classifications Mappings Terminologies Clinical • Decision Support • Integration of care • Outcome Administration • Scheduling • Resources • Billing Reporting • Cost • Needs • Outcome
  36. 36. ICF Ontology: Knowledge Representation Common sense/intuition  Disciplined definitions "One day I read a book and whole my life changed " Orhan Pamuk, Nobel Literature Laurate, 2006
  37. 37. Ontology (philosophy) • Being And Nothingness An Essay in Phenomenological Ontology • the Organization of Reality • is an oxymoron  !!!
  38. 38.  Ontology (computer science) – the explicit – operational description of the conceptualization of a domain • Entities • Atributes • Values • An ontology defines: – a common vocabulary – a shared understanding/exchange: • among software agents • between software and People – to reuse data - information – to introduce standards to allow interoperability – among People ? What is “NOntology” ?
  39. 39. Knowledge Representation the triad of things, thoughts and words (Ogden & Richards, 1923 ) APPLE TERM
  40. 40. Conclusion # ICFOntology • Development of Health Information Systems is the second most critical issue in Health Care today • Integration of Functioning and Disability Information in HIS essential – Mapping of Assessment Instruments to ICF – Mapping between ICF and clinical terminologies (SNOMED-CT)
  41. 41. • Placing ICF in the Health Information Systems & IT • Real on-line data capture & analysis for: • clients • providers • decision-makers • Develop linkages to health information bases: • Population registry • Insurance systems • Health services • Develop relation-standards, tools & exchange platforms • Demonstrate feasibility and utility • direct consumer access • Service provision: volume and flow management, resource allocation • Reporting: Needs, Outcomes, Costs ICF Vision
  42. 42. This can also help close the information gaps with digital outreach
  43. 43. Interoperability
  44. 44. Stock Exchange Health Information Exchange
  45. 45. Questions & Answers ustunb@who.int @ustunb
  46. 46. “Diagnosis” alone fails to predict: • service needs (National Advisory Mental Health Council 1993) • length of hospitalisation (McCrone and Phelan, 1994) • level of care (Burns, 1991) • outcome of hospitalization (Rabinowitz et al, 1994) • receipt of disability benefits (Massel et al, 1990; Segal and Choi, 1991; Basset and Regier) • work performance (Gatchel et al, 1994; Massel et al, 1990) • social integration (Ormel et al, 1993)
  47. 47. Dx + “Disability” can predict: • health service utilization (Hoeper et al 1979; Regier et al, 1985; Basset and Folstein, 1991; Von Korff et al, 1992; Ormel et al, 1993) • Length of Hospitalization (Horn, 1990) • Outcome after hospitalization (Rabinowitz et al, 1994) • return to work (Hlatky et al, 1986) • work performance (Massel et al, 1990) • recovery of social integration (Tate, 1989)
  48. 48. Added Value of Disability Information Predictive power 13% 8% 19% 28% 100% 100% 150% 123% OR 1 OR 1 OR 1 OR 14 OR 4 OR 15 Functioning Information

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