Feature

APA is among the key players revising an international classification system that has potential benefits for practitioners, consumers and the health-care system worldwide.

APA's Practice Directorate has contributed to revising the World Health Organization's (WHO) classification system since 1995, when WHO began the document's revision process. Known as the International Classification of Impairments, Disabilities and Handicaps or ICIDH, the system is a companion document to the better-known International Classification of Diseases or ICD­10, the WHO document that classifies diseases and enables the reporting of international mortality rates.

The ICIDH differs from the ICD in that it emphasizes human functioning rather than disease descriptions. In creating the current revision, WHO is seeking to make the document more user friendly, more health-oriented and less discriminatory in the language it uses to describe those it serves. Its name has been changed to reflect its increased emphasis on functioning and health rather than on disability per se, those involved in the revision process say. The revision, now called the International Classification of Functioning, Disability and Health or ICIDH­2, is the first since the ICIDH was released in 1980.

APA's involvement in the revision has grown exponentially as it has increasingly come to view the system--with its emphasis on client functioning as opposed to disease--as a promising alternative to other classification systems, says Russ Newman, PhD, JD, APA's executive director for professional practice.

Strong involvement, support

In light of this growing interest, the APA Practice Directorate has been strongly involved on two fronts. For one, the association has independently conceptualized and started the initial phase of an interdisciplinary manual to guide health-care professionals and other users in implementing ICIDH­2. For another, APA has been a key contributor to international field trials to test the system's validity and reliability.

Those efforts are meeting with objective success. APA's growing role was particularly visible at a November WHO meeting in Madrid, Spain, which addressed the ICIDH revision. As one mark of APA's stature, the association was one of only three non-governmental organizations--and the only one based in the United States--invited to the meeting, which included 95 government health officials representing 64 of WHO's 191 member states.

In addition, when APA presented a prototype and gave a presentation of its plan for producing the interdisciplinary Procedural Manual and Guide for a Standardized Application of the ICIDH­2 (Manual), WHO officials and conference attendees alike expressed strong interest in obtaining more information and possibly making it an international project, says Jayne Lux, director of board operations in APA's Practice Directorate.

"We received significant support, and this puts us in a strong position to move to the next phase of the project," Lux says. "Specifically, we need to garner interdisciplinary professional support for creating the manual."

The road toward that end is still long and by no means clear, Lux and others emphasize. Issues to confront include funding and whether APA should be involved on the international and cross-cultural front or strictly at the North American level. In either scenario, says Lux, the project is an enormous one, potentially taking several years to complete.

Why APA is interested

The potential benefits of getting involved in developing such a manual are great, however, those involved say.

"If we succeed in building partnerships to help create this manual, then we have created the opportunity for it to become the resource document for health professionals," believes John D. Corrigan, PhD, the Committee for the Advancement of Professional Practice (CAPP) liaison to the APA work group involved in the ICIDH revision.

That group, directed by APA's Board of Professional Affairs and CAPP, includes task force chair Stanley Berent, PhD, of the University of Michigan; J.G. Benedict, PhD, an independent practitioner in Denver; Linus Bieliauskas, PhD, of the Veterans Affairs Medical Center in Ann Arbor, Mich.; John Jacobson, PhD, of OMRDD Planning and Service Design in Albany, N.Y.; Donald Kewman, PhD, of the University of Michigan; Peter Nathan, PhD, of the University of Iowa; and Christine Trask, PhD, of Neurobehavioral Resources in Ann Arbor, Mich. Over the past several years, APA's collaboration with WHO has been nurtured and guided by Geoffrey M. Reed, PhD, assistant executive director for professional development, along with Chris McLaughlin, director of professional development demonstration projects. Reed and McLaughlin were recently joined on the APA staff by Lux, who was formerly senior technical officer with WHO, where she was senior project officer for the ICIDH revision effort.

"The manual potentially has a lot of utility," adds Kewman, immediate past president of Div. 22 (Rehabilitation) and clinical professor in the University of Michigan's department of physical medicine and rehabilitation. "It's an investment that could pay off in a big way down the road."

The manual would serve as the practical arm of the ICIDH­2, allowing practitioners to effectively apply the information with clients, explains Reed.

"The ICIDH gives you a laundry list of codes that are very difficult to apply without some sort of guidance," he says. "Practitioners are currently looking at a book that's 200 pages long that will be very difficult to use unless there's a manual that explains how to do that."

The manual would take the information from the ICIDH­2 and "operationalize" it--that is, provide standard definitions for what is meant by particular codes and how to approach coding issues, including suggestions about standardized assessment tools. APA also intends to develop the manual in an interactive format that allows practitioners to apply the system to classify patient functioning using an Internet- or a CD-ROM-based program, potentially in real time while interviewing the patient.

Such a program--which could end up being the main ICIDH tool used by practitioners--would include decision logic so that when a patient answered a question a certain way, the program would automatically proceed to another set of questions. On completion of the coding protocol, the program would provide a set of codes related to the person's condition and level of functioning, Reed explains.

Adding strength to the system

The manual adds to what APA sees as the potential strengths of the ICIDH­2 over other diagnostic and classification schemes, says Newman.

Instead of outlining disease categories as do the ICD or the DSM­IV, for example, the ICIDH is rather an encyclopedia of categories about the body's functioning and about how a person functions in his or her world. For example, it details a person's ability to communicate, move around, solve problems or work.

"The appeal for APA of the ICIDH­2 is that we support the concept of human functioning as it relates to treatment planning, measuringoutcomes and conducting research," Newman says. "The classificationis much better suited than other systems to the way psychologists approach practice, education, research and policy."

If done properly, such a scheme would assist in advocacy efforts to secure reimbursement for psychologists who provide services to a broader range of patients, particularly patients with nonpsychiatric health conditions, adds Reed.

"A person with a cardiovascular condition, for example, may have functional limitations," he says. "Given that many of those functional states have to do with behavioral and psychological processes, it becomes difficult to argue that psychologists shouldn't be able to provide or be reimbursed for treatment aimed at improving patient functioning."

In an era where many health conditions are chronic ones such as heart disease and diabetes, that focus is especially important, he adds.

Psychologists involved also believe a solid ICIDH­2 revision and a well-developed manual have rich research potential, especially for outcomes research.

"An international scheme gives us the ability to do cross-cultural research and makes it easier to conduct international research," Kewman notes. "Being able to use a rich classification that focuses on functioning would really enhance our understanding of rehabilitation and human functioning worldwide."

Field trials produce positive results

According to results of the field trials in which APA has participated, it looks as if the ICIDH­2 is well on its way to becoming a better instrument than its predecessor, those involved say. The revised system goes to the World Health Assembly for a vote in May 2001.

"WHO's field trial findings indicate that the reliability of the system when applied using a standard checklist was very high," says Reed.

APA's involvement in the trials is one more measure of its prominence, Reed adds: It had the largest number of participants of any of the U.S. field trials to test the system. APA field trials were conducted at 22 sites across the country. Some 40 countries participated in the field trials in all.

Kewman, who participated in trials at the University of Michigan, says his participation offered him the chance to become more familiar with the strengths and weaknesses of the system, knowledge he believes will be useful for future work on the manual and the ICIDH.

What's next?

The Madrid meeting was a landmark for APA that involved a major effort to compile the manual prototype and share the results of the field trials, those involved say. While it would be nice to breathe a sigh of relief now that a major part of the revision effort is complete, APA must keep up its momentum, they say.

Once the ICIDH­2 is roughly finalized, APA plans to hold "stakeholders" meetings for U.S. parties with potential future interest in the manual, including policy-makers, data systems professionals, third-party payers, interdisciplinary health professionals and employers, says Lux.

It's vitally important that the effort be a collaborative one, she emphasizes.

"This isn't a psychology-only project," adds Reed. "It's interdisciplinary. To simply create a splinter system that only a few psychologists use wouldn't make much of a dent. There needs to be a large, orchestrated effort involving players from all areas of the health-care system."

Reed envisions a three-year process to get the manual up and running--if enough people express interest and if APA can secure enough funding.

"We could hit the wall without either of these things," he says. Those involved, however, think the effort has been worth it, no matter what the outcome.

"Even if nothing comes of the manual, APA and its membership will profit from our involvement in a number of ways," believes work group chair Berent. Positive outcomes include new ways of thinking about human functioning and forging alliances with other health professions, cultures and nations, he says.

Kewman believes that APA's strong participation from the beginning stands it in excellent stead for future input.

"If we didn't get involved early on, we couldn't have credibly helped to shape the process later on," he says. "We want to see the ICIDH­2 remain an international and interdisciplinary tool, but one that we're heavily involved in contributing to so it will be useful to psychologists in their efforts to advance our knowledge of human functioning and our care of people with disabilities and health conditions."

Tori DeAngelis is a writer in Syracuse, N.Y.

Further Reading

Tori DeAngelis is a writer in Syracuse, N.Y.