edicine and Rehabilitation

Archives of Physical M journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2014;95(1 Suppl 1):S91-3

INVITED COMMENTARY

Rehabilitation Treatment Taxonomy and the

International Classification of Health Interventions

Catherine R. Sykes, MSc MCSP Grad Dip Phys

From the World Confederation for Physical Therapy, London, UK; and Health Systems and Global Populations Group, Faculty of Health Sciences,University of Sydney, Sydney, Australia.

Abstract

This commentary provides some reactions to the rehabilitation treatment taxonomy project in relation to work already underway to develop an

International Classification of Health Interventions. This commentary also includes some comments in response to questions posed by the

authors.

Archives of Physical Medicine and Rehabilitation 2014;95(1 Suppl 1):S91-3

ª 2014 by the American Congress of Rehabilitation Medicine

Since the turn of the century, the World Health Organization(WHO) has supported a Family of International Classifications.1

The International Classification of Diseases2 is the best knownand widely used member of the family. The use of the Interna-tional Classification of Functioning, Disability and Health (ICF),3

published in 2001, is increasing. Although it is recognized as anessential member of the family, the International Classification ofHealth Interventions (ICHI) has not been developed.1 Since 2007,a multidisciplinary group, members of the WHO’s Network forthe Family of International Classifications, has defined the scopeand purpose of the ICHI, developed a structure and level ofgranularity, and embarked on the development of the content,with diagnostic, medical, and surgical interventions best devel-oped. An alpha version of the classification was published inOctober 2012. The next steps are to further refine the content,including extensive work on interventions targeted at humanfunctioning, including those generally provided by rehabilitationprofessionals.

The international professional organizations for physical ther-apists (World Confederation for Physical Therapy), occupationaltherapists (World Federation of Occupational Therapists), reha-bilitation physicians (International Society of Physical andRehabilitation Medicine), orthotists and prosthetists (InternationalSociety for Prosthetics and Orthotics), speech language therapists(International Association of Logopedics and Phoniatrics),

No commercial party having a direct financial interest in the results of the research supporting

this article has conferred or will confer a benefit on the authors or on any organization with which

the authors are associated.

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Re

http://dx.doi.org/10.1016/j.apmr.2013.10.008

chiropractors (World Federation of Chiropractic), and Rehabili-tation International have been invited to provide comment on theICHI and take part in pilot testing. Psychologists and psychiatristshave been involved in developing the mental health interventions,and the International Council of Nurses has provided input onbehalf of nurses.

The rehabilitation treatment taxonomy (RTT) proposed in thesupplement4 represents a more discrete and detailed set of in-terventions with the intent of describing the clinical practice ofrehabilitation. The scope of the ICHI is broader, covering medi-cal, surgical, diagnostic, primary care, mental health and publichealth interventions; also interventions generally provided bynurses and by rehabilitation professionals. The purposes of theICHI are also broader than capturing clinical information in onesphere of practice. The purposes of the ICHI are to provide aclassification of appropriate scope and detail for use by countrieswithout a national classification of health care interventions,provide a base that can be extended to develop more finelygrained national or specialty classifications, establish a frameworkfor comparisons of the use of health interventions in differentcountries, provide a building block for international case-mixdevelopment, and avoid duplication of effort at a national level.

Similarities and Differences Between the RTT andthe ICHI

There are commonalities between the proposed RTT and the ICHI.For example, both have a tripartite structure, use the ICF to informthe classification, are profession and setting neutral, and propose

habilitation Medicine

S92 C.R. Sykes

methods to deal with some of the additional information requiredwhen describing treatments/interventions. In the RTT, brackets areproposed for inclusion of information that either adds to orchanges the meaning of the tripartite code. In the ICHI, this isdone by means of extension codes or qualifiers.

Both teams have encountered gray areas, that is, areas ofoverlap between concepts and instances where the placement of aconcept could be in >1 section of the classification. In the ICHI,these are being addressed by the use of coding rules.

Because the ICHI is broader in both scope and purpose, there isthe question as to whether it can provide the backbone on which todevelop the more detailed RTT in the relevant categories, thusfulfilling one of the purposes of the ICHI. The authors areencouraged to test whether the ICHI structure and coarse-grainedcategories fulfill the purpose of providing a base, which can beextended to develop a finer-grained rehabilitation specialty clas-sification. If successful, the ICHI will have fulfilled a secondpurpose, that of avoiding duplication of effort. New knowledgearising out of such an exercise has the potential to both benefit theICHI development and inform the RTT project.

The authors of the RTT supplement articles have at times foundfaultwith the ICF.Recognizing that all classifications are designed fora purpose and that classifications change as new knowledge and de-ficiencies become apparent, the WHO has established a process formaking proposals for change to the ICF. This international peer re-view process is the means by which any enhancements can be made,and failings or omissions in the ICF corrected. The authors may re-view current proposals for updates to the ICF and add new proposals.The ICF update and revision platform is available online(https://extranet.who.int/icfrevision/nr/loginICF.aspx?ReturnUrlZ%2ficfrevision%2fDefault.aspx). An online user guide explains theprocess and registration requirements.

Responses to Questions Posed by the RTT Authors

Focus/boundaries

The scope and boundaries of the RTT seem to be within the realmof the broader ICHI, with treatments being a subset of health in-terventions. The elements of rehabilitation practice that are pur-posely excluded from the RTT, such as diagnostic interventions,may be found in chapters of the ICHI.

The ICHI also excludes elements that can be classified usingexisting classifications. For example, the health condition and/orhuman functioning deficit that are the reason(s) for the interven-tion can be classified using the International Classification ofDiseases and/or the ICF. The provider of the intervention can berecorded using a classification in the System of Health Accounts5

or the International Standard Classification of Occupation.6 Aclassification of service types can be used to record setting of theintervention.5

How to handle devices was raised as an issue in the RTTarticlesin this supplement. Devices implanted during the intervention can

List of abbreviations:

ICF International Classification of Functioning, Disability and

Health

ICHI International Classification of Health Interventions

RTT rehabilitation treatment taxonomy

WHO World Health Organization

be described using the Global Medical Device Nomenclature,7 andassistive devices can be described using ISO 9999.8 Medicines orother substances administered through the intervention can berecorded using the Anatomical and Therapeutic Chemical classifi-cation.9 As such, the importance of a family of classifications torecord a range of information and build a more complete picture ofhealth and health services is illustrated.

The outstanding question is whether the ICHI can provide thebackbone on which to build. Ideally, the microprocess of the RTTshould be able to be aggregated to the backbone for statistical andadministrative purposes. Also to be considered is whether theproject should proceed as an independent project or ally with theWHO project, thus meeting the ICHI purposes and broadening theapplicability of the RTT from the United States to the world, andenhancing the capacity for international analyses of rehabilitationdata. Working collaboratively, there is the potential to add value toboth projects.

Defining treatments

The tripartite structure proposed for the RTT is essentiallyconsistent with the ICHI structure, where target is the entity onwhich the action is carried out, action is a deed done by an actor toa target during a health intervention, and means are the processesand methods by which the action is carried out. Though the ICHIis not complete, so far the structure has worked, with the additionof qualifiers and moderators to extend the meaning of a code. Atest of the ICHI might be to build the RTT microprocess on theICHI backbone.

Groupings

The groupings of treatment categories described in the articles inthis supplement do make sense. In effect, the treatments that alterthe structure of tissues relate to the body structure component ofthe ICF; likewise, the treatments that alter or replace functionsrelate to the body functions component. Skilled performancesrelate to the life areas classified in the activities and participationcomponent. In the ICHI, the actions that address the life areas aredifferent for skilled performances and the acquisition and inter-pretation of knowledge. Analysis of the ICHI interventions ac-cording to these groupings could be done.

Addressing assistive devices

The ICHI has addressed issues of assistive devices through therange of actions available; therefore, there are actions to prescribe,fit, and teach about assistive devices and qualifiers to indicatewhether it is the individual, caregiver or other individual or groupthat is being taught. The training in the use of a device can betackled by adding a qualifier to indicate that the training of afunction is with the use of an assistive device, and a code alsoinstruction is added to indicate the type of assistive device fromISO 9999. Training in the care and maintenance of an assistivedevice is addressed in a separate category.

Objects of volitional treatments

The RTT defines treatments as interventions that take(s) placeunder the purview of the clinician, as such volitional treatmentsseem not to be included. The prescription, instruction, and review

www.archives-pmr.org

Interventions taxonomy for rehabilitation S93

of a program to be performed outside of the clinical situation doseem to fit with the definition, whereas the conduct of the programitself does not. This is consistent with the ICHI approach.

Congratulations to the authors. The considerable thinkingbehind this suite of supplement articles is commended. The arti-cles in this supplement are likely to be discussed by the ICHIproject team and may well enhance the development of theclassification.

Keywords

Classification; Rehabilitation; Terminology as topic; Therapeutics

Corresponding author

Catherine Sykes, MSc MCSP Grad Dip Phys, World Confedera-tion for Physical Therapy, Victoria Charity Centre, 11 BelgraveRd, London, SW1V 2RB, UK. E-mail address: csykes@wcpt.org.

Acknowledgments

The author thanks Richard C. Madden, BSc PhD Prin FIAA, fromthe National Centre for Classification in Health, University ofSydney, who has led ICHI development. The author also thanks allmembers of the ICHI development team; it is their combinedthoughts and efforts that underpin this commentary.

www.archives-pmr.org

References

1. Madden R, Sykes C, Bedirhan Ustun T. World Health Organization

Family of International Classifications: definition, scope and purpose

[World Health Organization Web site]. Available at: http://www.who.

int/classifications/en/FamilyDocument2007.pdf. Accessed June 26,

2013.

2. World Health Organization. International Statistical Classification of

Diseases and Related Health Problems. 10th revision. 2010 ed.

Geneva: World Health Organization; 2011.

3. World Health Organization. International Classification of Func-

tioning, Disability and Health (ICF). Geneva: WHO; 2001.

4. Dijkers MP, Hart T, Tsaousides T, Whyte J, Zanca JM. Treatment

taxonomy for rehabilitation: past, present, and prospects. Arch Phys

Med Rehabil 2014;95(1 Suppl 1):S6-16.

5. Organization for Economic Co-operation and Development, Eurostat,

World Health Organization. A system of health accounts. Paris: OECD

Publishing; 2011.

6. International Labour Office. International Standard Classification of

Occupations 2008 (ISCO-08). Geneva: International Labour Office;

2012.

7. Global Medical Device Nomenclature Agency. The global medical

device nomenclature. Available at: http://www.gmdnagency.com/Info.

aspx?pageidZ2. Accessed October 7, 2013.

8. AbleData. ISO 9999d Classes. Available at: http://www.abledata.com/

abledata.cfm?pageidZ194670&ksectionidZ19327. Accessed October

7, 2013.

9. WHO Collaborating Centre for Drug Statistics Methodology.

ATC/DDD Index 2013. Available at: http://www.whocc.no/atc_ddd_

index/. Accessed October 7, 2013.