ICPC use in the European Community

Prepared by Dr Marc Jamoulle for the WONCA International Classification Committee at the 16th WONCA World Congress of Family Doctors, Durban, South Africa,13th to the 17th May 2001.

Family Medicine and Primary Care unit, Public health school, Free University of Brussels, May 2001
Paper edited on http://www.ulb.ac.be/esp/wicc/icpc_2001.html

Links to ICPC bibliography, to the WICC Glossary                                                                                                                                   Updated : June 2001



ICPC use is rapidly growing in Europe and is now implemented in many EMR's. It is also used at national level in Norway, The Netherlands and Belgium. Listed below are the main initiatives and known research projects and applications in Europe. Research using ICPC has been well developed for many years in The Netherlands and is rapidly growing in France and Romania. It's difficult to give a precise estimate of the use of ICPC in day to day practice. ICPC is the de facto standard for Primary Care and for emergency out patient clinics data retrieval. Underreporting of its use is therefore expected. Please have a look at the ICPC bibliography (http://www.ulb.ac.be/esp/wicc/icpc_ref.html ) to obtain a deeper understanding of ICPC. Please feel free to contact the author (marc.jamoulle@ulb.ac.be) in order to modify the Internet published text or to add your contribution.

Be Belgium / Dk Denmark / Fi Suomi/Finland / Fr France / Gr Greece / Ma Malta / Nl The Netherlands / No Norway / Ro Romania / Sp Spain / Ch Switzerland

ICPC / CISP has been chosen by the Belgian Federal Ministry of Health as a criteria of first importance for the labelling process of Electronic Medical Records (EMR) for general practice in Belgium. ICPC use will not be mandatory but will become a deciding factor in obtaining the Federal quality label for GP's EMR systems. The Federal ministry of health as also given a grant to two university departments of general practice (RUG and ULB) for them to develop and implement a bilingual (French and Dutch ) ICPC coded and ICD9 / ICD10 mapped electronic terminology. The Belgian state is considering the purchase of a WONCA licence for ICPC

Contact ; Dr Marc Jamoulle, rue Frere Orban 94, B-6040 Jumet, Belgium
Mail :

o        ICPC in Belgian national health interview surveys (1997 and 2001)

The objectives of the national health interview surveys organised in 1997 and 2001 are identification of health problems, description of the health status and health needs of the population, estimation of prevalence and distribution of health indicators, analysis of social (in)equality in health and access to the health services, study of health consumption and its determinants, study of possible trends in the health status of the population ICPC-1 has been in use in the 1997 study and ICPC-2 (French and Dutch version) shall be in use in the 2001 survey performed by the epidemiology section of the Belgian Scientific Institute Of Public Health

Contact ; Dr J. Tafforeau
Mail ;

In 1989 Jan De Maeseneer published his Ph.D. thesis "General practice: an exploration: an exploratory, descriptive study". In this thesis, for the first time in Belgium, ICPC-1 has been used for description of the activities in general practice. In 1992, Anselm Derese published his thesis on the work of trainees in general practice, and used also ICPC-1 for description of the encounters. At the level of the practice-registration, some EMD-software packages are using ICPC-1.

In the year 2000, the Department of General Practice and Primary Health Care, Ghent University, has contributed to the Dutch translation of ICPC-2, published actually as a book (Anonymous. ICPC-2-NL: Nederlandse versie - Utrecht, Nederlands Huisartsengenootschap, 2000).

In March 2001 an educational package has been developed together with the scientific organisation of Flemish general practitioners (WVVH) and the universities. The package follows the implementation-rules for GP-software as they are actually discussed at the level of the federal government. The aim is to train medical students, trainee general practitioners and the GPs themselves in the use of the electronic medical record, using episode based registration and ICPC-2 classification. There is also a link to ICD-10.

In Flanders there is a consensus that in the future all registration in general practice and all GP-software packages will be structured based on ICPC-2, in the framework of episode-oriented registration. Actually the Department of General Practice and Primary Health Care contributes the development of a Flemish thesaurus for the ICPC-2

Contact ; Dr Jan De Maeseneer
Mail ;

o        ICPC in day to day care in French speaking Belgium

ICPC is currently included in several EMRs. Various health centres, participating to the Belgian French speaking organisation " Fédération des Maisons Médicales" are using ICPC as a quality assurance and research tool in day to day practice

Contact ; Dr Michel Roland, Fédération des Maisons médicales, Bld du Midi 25, B-1000 Brussels Belgium
Mail : Michel.Roland@ulb.ac.be

o        The CISP-2 (French ICPC-2) book is published in Belgium

The non profit association "Care Editions, asbl", based in Waterloo, Belgium, has recently (Jan. 2001) published the CISP-2 book (M.Jamoulle, M.Roland, J.Humbert, JF.Brûlet. (Eds)). Traitement de l'information médicale par la Classification Internationale des Soins Primaires 2ème version (CISP-2), assorti d'un glossaire de médecine générale, préparé par le Comité International de Classification de la WONCA. Care Edition, Bruxelles, 2000

Contact : This book is available through the website; http://docpatient.net/care

o        The CISP-Club, the club of the ICPC fans

The French speaking association of the users of CISP (French ICPC) is located in France but its president, Dr. Marc Jamoulle, works in Belgium. The CISP Club is a meeting point for researchers in data gathering and coding in Primary Care in the French speaking world. The CISP Club has members in France, Belgium, Tunisia, Rumania and Switzerland. The CISP club is very active though its mailing list, its website and its annual workshop. Please refer to www.ulb.ac.be/esp/cisp for more information.

·         Denmark

o        Extended Danish ICPC (ICPC-E).

A small part of ICD-10, that is relevant to general practise, has been accommodated within ICPC .This is a useful tool for diagnosis registration and quality development using the Extended Danish International Classification of Primary Care (a pilot study).

o        Continuous morbidity registration

Aim: To describe the disease patterns in general practice using ICPC coding and at the same time make it possible for individual general practitioners (GP) to compare practice pattern with each other and compare their management as exemplified by diabetic patients. Method: In a 3 month period in 1999, 14 GPs from 6 practices coded all their patient encounters with diagnosis, using ICPC. Feedback was given to each GP about disease- and contact pattern of their patients and selected parameters as for instance HbA1c, serum cholesterol and blood pressure. A list of identified patients with sub-optimal management was send to the GP as well.

o        Perspectives.

When using ICPC-2-E every diagnoses has an ICPC code as well as a corresponding ICD-10 code in the electronic medical record. This provides good opportunities for research and quality development across the primary and secondary health sector

Contact : Dr Eric Falkoe University of Odense, Dep. of General practice Winslowparken 19 3rd floor Dk-500O Odense

·         Finland

o        ICPC has been used in research and demonstration projects from 1985 to 1998. Through these demonstration projects over half of Finnish GPs have tried ICPC. According to a survey among GPs in 1998, ICPC works well in primary health care and is more feasible than ICD-10. In the demonstration projects and in health centres actively using ICPC, over 95 % of the encounters get coded, whereas 50 % or less are coded in centres using ICD-10.

ICPC is used in Finland in 5-10 Healthcare Centres which are responsible for the public primary health care in the areas where they are located. This is only a few percent of the population. The Student health care organisation, which is a private fund which gives health services to the majority of university students in Finland for a very low yearly charge, is using a combination of ICPC and ICD-10 for diagnosis coding.

Helsinki, Espoo and Vantaa the tree largest cities have been interested in ICPC, but for technical reasons the pilot projects have not been very successful. It is important to note that it is not obligatory on a national level to collect any diagnostic information from primary care. The units using ICPC are a substantial proportion of the primary care units collecting diagnostic information systematically.

Contact : Dr Martti Virtanen (martti.virtanen@nordclass.uu.se) or Dr Matti Liukko (Matti.Liukko@Kuntaliitto.fi)

·         France

o        The Sentinel Surveillance of Referral to Hospital in French Primary Care

Methods: A follow-up outcome study nested within a surveillance system of hospital referrals performed by GPs from the French Sentinel network since July 1997. Data on each referral to hospital are collected by Sentinel GPs and transmitted on a weekly basis via tele-informatics (Internet or Minitel) to the database centre, where systematic quality control is performed. In particular, reason(s) for referral are entered in a free-text format, and subsequently coded according to the ICPC classification, using an automated tool based on string matching specifically developed to that end. Each reported case of complication that occurred within 30 days of discharge has been investigated through a telephone interview with the GP and the responsible hospital physician. This project was covered by an overall approval of the French Commission Nationale de l'Informatique et des Libertés (CNIL) allowing surveys to be conducted on the Sentinel system.
Results: Since July 1997, 12 000 referrals to hospital have been individually described by 305 GPs. This system provides information on the characteristics of patients referred to hospital and on the circumstances of the referral, including the reason(s) for referral. By using the statistical procedures applied on the Sentinel system for the incidence estimation of communicable disease, we could estimate that around 1.3 million hospital admissions result each year from GPs' referrals, which accounts for 10 % of all admissions in French hospitals. Moreover, we observed a seasonal variation in GPs' hospital referrals, with a regular increase during summer. Ninety-two cases of nosocomial complications have been reported and investigated during the first two years of the project, including 21 nosocomial infections, 31 adverse drug reactions and 40 complications of other type. We estimated at 1.2 per thousand admissions (95%CI, 1.0-1.5 per thousand) the rate of nosocomial adverse events detected in general practice within 30 days of discharge.

Contact Dr Laurent Letrilliard
Mail : l.letrilliart@wanadoo.fr

o        The ICPC in an emergency call centre in Bordeaux

Medical practitioners of "Centre 15 Gironde" has studied the feasibility of using CISP (French ICPC) in an emergency call centre as a coding an assessment tool . A terminological database of the usual emergency term has been extensively developed and tested.
The study has been presented at the recent Congrès de recherche en Médecine générale in Biarritz under the title ;

Maryse Bonnet, Arnaud Castets, Philippe Moreaud, Philippe Souleau, médecins régulateurs libéraux de l'ASSUM 33. Adaptation de la CISP (Classification Internationale des Soins Primaires) au travail de régulation médicale du Centre 15 Gironde (http://www.urmla.org/programme.htm)

Contact Dr Maryse Bonnet or Dr Luc Ribeton
Mail : m.bonnet33@wanadoo.fr    luc.Ribeton@wanadoo.fr

o        Classification survey in Paris

Studying ICPC as a coding tool is on the agenda of the URML IDF the French medical professional association "Unions Régionales des Médecins Libéraux de l'Ile de France" That's means that GPs should begin to classify and code data in general practice in 2001 with the help of various members of the CISP Club.

Contact : Dr Bernard Ortolan URML IDF Bld Montparnasse Paris
Mail :

o        Episodus in Lyon

The Episodus project is the fruit of research on classifications, semantic, ergonomic medical data gathering and epidemiological treatment of data. Episodus is being developed by the French medical professional association "Unions Régionales des Médecins Libéraux" of Lyon and will be placed under Open Source Licence.
It encompasses the gathering, organisation and treatment of information recorded during the medical consultation. This information,  classified primarily with ICPC, is organised into episodes of care. The episodes are entered into a central computer, and are then ready for use in quality assurance by feedback to the practitioner and for epidemiological research.
The practitioner would have many rewards from Episodus to assist his work, the first being the very short time spent for gathering, coding and organising the data, and the second the ergonomic and user friendly software system.

Contact : Dr Jean François BRÛLET Union Professionnelle des Médecins de la Région Rhône-Alpes 20, rue Barrier 69006 LYON
Mail : jean.francois.brulet@freesbee.fr

·         Greece

o        The use of classification systems is generally quite limited in general practice in Greece. ICPC-1 was translated into Greek in 1992. As a result of the continuing efforts of the Clinic of Social and Family Medicine, University of Crete and the Anogia Health Centre, an electronic patient record database named "Fakelos" was created and used in several primary care centres in Crete and in Greece. ICPC-1 together with ICD-9 is used in this program. Recently, another joint effort of the University of Crete and the Greek Association of General Practitioners aims to translate the ICPC-2-E into Greek. The evaluation of a computer program based on the ICPC-2 and Episodes of Care is also in progress. The objective of this latter effort is for it to be implemented in all Primary Health Centres of Greece. A general conclusion is that the ICPC-2E is the most suitable classification for general practice in Greece. Special cases, like referrals to hospitals and specific diseases, are very well handled with the ICPC-2 to ICD10 conversion.

Contact, Kounalakis Dimitris Mail : dcoun@galinos.med.uoc.gr

·         Malta

o        The Malta College of Family Doctors has accepted ICPC and ICPC-2 as the standard classification for Maltese General Practice. The College is currently encouraging use of ICPC in electronic medical records. A group of doctors is using TRANSHIS, an ICPC based software in their day-to-day practice.

Contact : Dr. Jean Karl Soler MD "Josephine", St. Catherine Street, Attard BZN 04, Malta.
Mail: jksoler@synapse.net.mt

·         The Netherlands

o        National level

ICPC has been mandatory in EMRs for several years. In the Netherlands more and more GP's are familiar with and use ICPC. It is obligatory for GP trainees to learn about it. Education materials and examinations for GP qualification are organised around ICPC codes. When research is done in practices it is not difficult to get the data from the GPs and they are willing to code the data in ICPC. For example research to the health effects of the firework-disaster in 'Enschede' had all 40 GP's there code all their consultations. There is ICPC training available across the country. The NHG published a new CD-rom called EVS (electronic prescription system), which is based on ICPC codes and many GP's are happy to use it. See NHG website http://www.artsennet.nl/ (click NHG click EVS) Computer software systems are a major problem. Almost all developers are threatened with bankruptcy and therefore the national GP organisation is considering the development of a non commercial software system. This is still under consideration.. Meanwhile no new updates are available for commercial systems and GPs have to manage with out-dated systems.

Note by Marga Vintges, MD
Mail :

o        The Transhis project, Department of General practice, University of Amsterdam

TRANSHIS is an episode oriented, ICPC based software developed at the Department of General practice of the UVA (Prof Henk Lamberts). TRANSHIS is currently implemented in research centres in The Netherlands, Malta, Poland, Greece, Japan and USA.

Contact : Prof Lamberts, MD, Phd. Meibergdreef 15, AZ Amsterdam
Mail :

o        The Registration Network Family Practices

On 1 December 2000, the RNH (Registration Network Family Practices)(www.unimaas.nl/~rnh) consisted of 55 general practitioners in 21 practices covering approximately 100.000 patients. In all practices computerised health information systems were installed, replacing the hand written records. Classification: The set of patient characteristics to be registered is well defined. There is a clear definition of "a relevant health problem". All problems are coded using the International Classification of Primary Care (ICPC) using the criteria of the International Classification of Health Problems in Primary Care (ICHPPC-2 Defined), if appropriate. Structure of the data: On 1 September 2000 patient characteristics and problem lists for 82.411 patients (women 51.2%) had been entered in the database. A total of 341.800 problems have been identified for these patients: 188.219 (55.1%) active and 153.381 (44.9%) inactive.

Contact: Dr Job Metsemakers, Department of General Practice, Maastricht University PO 616, 6200 Maastricht, The Netherlands
Mail :

o        Netherlands Information Network in General Practice (NIN GP)

Aim of NIN GP ( http://www.linh.nl/index.htm ) is to collect national, representative data on GP care. The data are used for health services research and quality-of-care research. Continuously, morbidity data are gathered on GP's patient list, consultations, prescriptions and referrals. Ad hoc extra registrations around specific subjects also take place (influenza vaccination, cervical screening, low back pain, diabetes). 123 computerized practices using five different GP information systems participate in NIN GP involving 228 general practitioners with a total of about 450.000 listed patients. The network mirrors the national distribution of the population according to age, sex, type of insurance, region and degree of urbanization. Morbidity is classified with the ICPC, prescriptions with the ATC classification system.
Data are used in several monitoring projects: process data in general practice, influenza vaccination, cervical cancer screening and the introduction of electronic formularies. Other types of studies that take place are state-of-the-art studies (prescribing of Ritalin, repeat prescribing, prescribing of benzodiazepines in general practice), guideline adherence studies (low back pain, diabetes), development of quality indicators, evaluation of policy measures (i.e. reduction of insurance coverage for self care medication). In 2000/2001 the Second Dutch Morbidity study is undertaken within the framework of NIN GP (in 104 practices). Based on an extensive research program extra data are collected on: morbidity in all consultations during one year (with episode construction), socio-demographic data of all listed patients, experienced health and health behaviour among a sample of patients and doctor-patient communication by video taping one day per GP.

Contact : Mr Dinny Debakker, Phd Netherlands Network of General Practitioner Drieharingstraat 6 Postbus 1568 Utrecht , The Netherlands
Mail : dinny.debakker@nivel.nl

·         Norway

o        ICPC is in use in GP/FM and Occupational medicine in Norway since 1992.
An official standard for the EMR has been developed, but is only partially implemented. All the information GPs need on the bill to collect money from the social security system, are standardised and in place in all EMR software. These data include: unique person identifier of the patient, sex, date of birth, address, encounter (date, time, type), diagnoses (ICPC) and many processes

o        In October this year Norway Statistics will run a pilot collecting data from EMR in general practice. The project is a continuation of previous work.

Contact : Anders Grimsmo, Dep of Community Health and General Practice, Skei, N-6656 Surnadal Norway

·         Romania

o        The Romanian Society of Family Medicine / General Medicine has received a copyright license to translate and use the ICPC. The book ICPC-2, with corrections from ICPC-2-E has been translated into Romanian and edited. (http://www.ispt.ro/medinet/ press ICPC-2). ICPC-2 is used in the software MEDINS, made and used in the Sentinel Station Network, GP-Medinet, involving 100 GP's from all around the country. The project began with ICPC-2000 (where the infrastructure was prepared for the Sentinel Station Network) and continues with GP-Medinet Project (2000-2002) with registration of patient data. Doctors began the pilot registration of data on 1 April 2001, and continued until 30 September 2001. Data are transferred monthly by each doctor to a central server using the Internet.
The software Medins use ICPC codes for RFE and symptoms. For diagnosis the codification begin with ICPC codes and is finished with ICD-10 codes (double coding, because ICD-10 is more specific). For procedures internal codes are used which are then translated into ICPC-2 codes.

Contact : Marius Marginean: National Coordinator of Romanian Sentinel Station Network Str.Lidia 37 Timisoara Romania
Mail :

·         Spain

o        National level

In Spain ICPC is well known both in practice and research. ICPC-1 is still in use in a software program in public health centres. Some researchers have used it in emergency care. The future is problematic because of the strong influence of case-mix classification with ICD-9-CM. There are translations of ICPC 1 and 2, both published by Masson, into Spanish and Catalan. ICPC-1 is used in Andorra.

Contact : Juan Gervas, MD, PHD Equipo Cesca, Madrid
Mail :

o        ICPC in Catalonia.

ICPC is the most used classification in Primary Care in Catalonia and all around Spain, but this does not mean that is used very much. ICPC is not widely known and used, and research is still the main reason for use. As the telematics is increasingly available in practices, this situation will change dramatically. The most common software programs for managing patients and health centres use ICPC to classify diseases as well as a translating to ICD-9-CM. This will allow large and comparable databases in the near future.

Contact : Sebastian Juncosa
Mail :

·         Switzerland

o        Dr Brunner, president of the Swiss Medical Association has recently (Feb. 2001) announced that ICPC, ICD10 and ICIDH would be the leading coding systems for EMRs in Switzerland. ICPC is used on a daily base in the outpatient clinic of the Hopitaux Cantonaux de Genève. Dr Laura Pult has recently published a paper on this subject in Médecine et Hygiène, a French medical review. After studying 1600 reasons for encounter annotated in free text, a terminological software has been designed allowing to retrieve easily and in a standard way the reasons for encounter in the emergency outpatient clinic of the Hopitaux Cantonaux de Genève. Feasibility study of the day to day coding is under way.

Contact ; Dr Laura Pult
Mail :

o        Dr Vincent Griesser of the Hopitaux Cantonaux de Genève has invited the next CISP Club workshop in Neuchatel in November 2001.

Contact ; Dr Vincent Griesser
Mail : Vincent.Griesser@hcuge.ch