Beyond Diagnosis: Leveraging ICF Summary Data for Disease-Specific Patient Profiling to Advance Integrated Care

Background: The International Classification of Diseases (ICD) is a common language in healthcare, and the global adoption of ICD-11, effective since 2022, is underway. ICD-11 emphasizes the inseparability of disease and functioning by incorporating its sister classification, the International Classification of Functioning, Disability and Health (ICF), as a supplementary section (Section V). However, the systematic application of ICF in clinical practice remains a major challenge. In collaboration with an acute care hospital in the Kansai region of Japan, we developed an information-sharing tool, the 'ICF Summary,' following a pilot study and tool validation in FY2020.

 

The collaborating hospital has integrated and been operating the tool within its EHR system since the following year. This initiative is now actively used for admission/discharge support and is gaining national attention in Japan. This presentation demonstrates how this proven model enables cross-disease patient profiling, offering a pioneering solution for advancing integrated care.

 

Approach: An anonymized dataset was constructed from the EHR-integrated "ICF Summaries." This tool is based on the ICF Generic-30 Set and was co-designed with practitioners to extract essential information for care transitions. It comprises a 20-item functional assessment score and qualitative text data capturing notes from medical, nursing, and pharmaceutical perspectives, as well as environmental factors like the patient's and family's goals. Using this dataset, we conducted descriptive statistics of the functional assessment and qualitative analysis of the text information on specific patient cohorts (e.g., stroke, heart failure) to visualize characteristic patterns of functional challenges—creating detailed patient profiles—that are invisible when relying on diagnostic information alone.

 

Results: The analysis revealed highly diverse patterns of functioning even among patients sharing the same ICD diagnosis. Cerebrovascular disease patients, in particular, showed significant "heterogeneity of functional impairment." A divergence between physical and cognitive/communication functions was observed; for example, some patients with preserved physical function had severe memory impairment, while others with clear cognition had severe hemiplegia. Qualitative analysis also revealed that environmental factors, such as family support and living environment, strongly influenced the impact of sequelae. This evidence demonstrates that ICF-based profiling can enable more precise, personalized care planning for rehabilitation and discharge support.

 

Furthermore, this data-driven approach has the potential to optimize resource allocation based on a more accurate assessment of care needs, a finding supported by systematic reviews showing that adding functioning information improves the predictive accuracy of casemix systems for resource utilization.

 

Implications: This project offers a concrete methodology for transforming the ICF from an abstract framework into a practical clinical data asset. Patient profiling via the ICF Summary serves as a common language for multidisciplinary teams, facilitating person-centered care planning. This initiative has drawn national interest. As the global health community adopts ICD-11, our practice provides a proven, replicable and scalable prototype for a next-generation clinical information infrastructure that integrates both "disease" and "life functioning" data, offering powerful lessons for the international integrated care community.