Wednesday, October 29, 2014

Standardized Languages: ICF and IDNT -- Different, Similar, or Compatible??

At FNCE there was an excellent session on international issues in implementing the Nutrition Care Process.   Daniel Buchholz and Rubina Hakeem discussed Middle Eastern and European implementation of the Nutrition Care Process (NCP) and standardized languages.  For more than 5 years we have been thinking about how the International Classification of Functioning (ICF) and International Dietetics and Nutrition Terminology (IDNT) relate to each other.

We have noted previously that the ICF dietetics extension developed by the Dutch has a more robust assessment of the some areas of nutrition assessment (particularly descriptions of taste and appetite).  But it wasn't until I heard Daniel and saw the phrase on one of his slides that the light-bulb really came on.

His slide said something to the effect that the ICF-Dietetics was intended to describe the functions of the patient.  At this moment the pieces clicked into place in my mind!!

The two languages have different purposes.  The ICF is describing the patient, and the IDNT describes the care that dietitians provide to the patient.  As a necessity parts of the IDNT also describes the patient (Nutrition Assessment, Nutrition Diagnosis, and Monitoring and Evaluation) since the care provided by the dietitian is based on their assessment of the patients condition and changes in the patient condition reflect whether the care was successful or not.

So the major way of thinking about how the two languages intersected was in contemplating the PURPOSE of the language...

And according to the Page 5 in theWorld Health Organization Family of International Classifications: definition, scope and purpose" the ICF is ONE of several sets of  standardized languages that are intended to be used together.  The other languages are the International Classification of Diseases and Conditions (for diagnoses) and new sets being developed to describe health interventions, the International Classification of Health Interventions (ICHI).

I began playing with how to lay this out in a way that was easy to understand so we could have a more productive conversations.  I am more familiar with the IDNT and welcome comments from those more familiar with the ICF.  Below are some initial thoughts:

Nutrition Care Process Steps
ICF Terminology
IDNT Terminology
Focus of terminology
Describe patient
Describe care provided by dietitian
Nutrition Assessment
Information from WHO Website:  Functioning and disability are classified separately in the International Classification of Functioning, Disability and Health (ICF)

Terms describe patient’s functioning using ICF domains.  The WHO generic ICF evaluation checklist captures the following sections: 
-Impairment of body functions
-Impairment of body structures
-Activity Limitations and Participation Restrictions
-Environmental Factors
-Other Contextual Information
It includes scoring terms and guidance for each section tailored to the items that are being assessed.
The proposed dietetics extension includes specific nutrition functioning.  Specific nutrition assessment data may or may not be included (e.g. gms of carbohydrate intake)
Terms in Nutrition Assessment are intended to reflect the individual nutrition assessment data/factors evaluated by the dietitian in the following domains:
-Food and Nutrition History
-Anthropometric measurements
-Biochemical Data, Medical Tests and Procedures
-Nutrition focused physical findings
-Client History
Dietitians choose how to capture data relative to the assessment data identified (record actual Gms, Servings, gm/dl, weight, etc).  Standard scoring not provided.

Nutrition Diagnosis
Terms blur together with both assessment of body functions, activity limitations, participation restrictions, and environmental factors that could be framed either as assessment of the situation or as the “problem” to be addressed. 

Information from WHO website:  Diseases and other related health problems, such as symptoms and injury, are classified in the
International Classification of Diseases, now in its 10th revision (ICD-10) 
-Diagnosis terms are higher level with combinations of the nutrition assessment data used to determine which problem exists and it is intended to be used to reflect the care being provided in this episode/visit, not overall functioning
Nutrition Intervention
At present interventions can only be reflected by indicating a desired “change” in status, e.g. change in knowledge, or change in functioning, referred to as the individuals ability to "manage" intake. 
Information from WHO website
A third reference classification, the International Classification of Health Interventions (ICHI), is under development.
The individual health experience in general can be described using the dimensions of the ICD and ICF. The needs of the user will determine the number of dimensions, and the level of specificity used. Other classifications needed to describe other aspects of the health experience and the health system have been
adopted as related classifications (e.g. ATC/DDD3 classifies therapeutic chemicals). 
Terms reflect the nutrition prescription to be pursued and the method used by the dietitian to pursue that optimal nutrition prescription.  Dietitian focused terms:  provide food, nutrition education, nutrition counselling, collaboration with other health care providers
Nutrition Monitoring and Evaluation
Changes in scores associated with selected terms used to describe the patient’s functioning can be used to monitor and evaluate impact of intervention
Changes in selected nutrition assessment terms can be used to monitor and evaluate impact of intervention.

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