Applying the ICF in Health Policies and Administration

Original Editor - Ewa Jaraczewska based on the course by Patricia Saleeby

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

The International Classification of Functioning, Disability, and Health (ICF) is a tool used in clinical practice, research, and policy development to understand functioning and disability.[1] Many countries have adopted the ICF as the reference framework when developing health and social policies and legislation on disabilities and related areas.[2] The ICF has a broad application at the population and health and social service levels.[3] This article will discuss how the ICF can be applied when developing health policies and health administration locally and globally.

ICF and Health Policy[edit | edit source]

Healthcare providers use the ICF framework to assess a client's health and disability. However, the ICF can also capture data at the population level.[4] For example, information from the International Classification of Diseases (ICD) about mortality combined with health-related outcomes provided by the ICF, offers an in-depth measure of population health and provides key information needed to develop new health policies or to monitor existing policies and practices.[4]

The following are the examples of the ICF framework used at the population level:

Population level:

  • Health and disability data collection for the surveys of general and specific populations. The ICF "provides the conceptual framework and item pool."[3] Examples:
    • Global Study on Ageing - SAGE[5]
    • National surveys (First National Study of Disability in Chile)[3]
    • World Health Organization (WHO) Multi-Country Survey Study[6]
    • World Health Survey (2002-2004)[6]
  • Data compilation and analysis. Examples:
    • Measurement of Health and Disability in Europe (MHADIE).[7] The ICF was utilised to analyse population health and disability data.
    • Australian Health Data Dictionary. The ICF is used to "facilitate the harmonisation and comparability of data sets"[3]
  • Modules and questions set development for international and regional disability surveys. Examples:
    • The EUROSTAT Survey Module on “Disability and Social Integration".[8] The ICF is used for:
      • designing questions which reflect the interactive nature of the ICF definition of disability
      • designing a questionnaire based on ICF classification
      • obtaining reliable information on barriers and facilitators
  • Policy development and monitoring, and setting targets and indicators for national health and social policies.[9] Examples:
    • United Nations Convention on the Rights of Persons with Disabilities (CRPD) "promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity".[10]

The following are examples of how the ICF is used at the health and social service level:

Health and social service level:

  • National legislation: health and disability-related legislations use the ICF model and definition of disability as a reference. Examples:
    • Germany's 9th Basic Social Law (SGB IX). The ICF helps to regulate entitlements and service provision for people with chronic diseases and disabilities.[11]
    • Spain's law for the promotion of personal autonomy and care for persons with dependency (LPAD). This law "regulates the basic conditions for the promotion of personal autonomy and care for people in a situation of dependence".[12]
    • In Sweden, the ICF documents the social services management process for the older adult population.[4][13]
    • Italy's labour policy. An ICF-based checklist evaluates the functioning profile of individuals with a disability seeking employment.[14]
  • Service provision: the ICF helps document the assessment of "patient needs, planning health and social care and measuring the changes brought by interventions across many dimensions".[3] Example:
    • WHO Disability Assessment Schedule (WHODAS 2.0)
  • Disability certification: the assessment of the disability status using the ICF helps to determine the individual's eligibility for health, social, or educational services.[15] Example:
    • Mexico's Person with Disability Card was developed to create an administrative record of the disability population for the health sector and identify issues of concern regarding prevention and intervention.[4][16]
    • Italy used the ICF as a reference framework for the process of disability certification.[4]
    • Irish National Disability Survey. An ICF-informed survey was used to identify persons with disability not captured in the general census.[17]
  • Eligibility procedure for education: the ICF-CY model and classification can assist in developing a continuum of services for children with disabilities.[18]

ICF and Health Administration[edit | edit source]

Healthcare administrators are involved in planning, directing, and managing medical services. The ICF can be useful for health administrators as it provides data on functioning. This data, in turn, helps to predict service needs, length of hospitalisation, or functional outcomes.[4]

Examples of the ICF framework used and proposed to be used by health administrators:

  • The National Committee on Vital and Health Statistics (an advisory body to the Department of Health and Human Services in the USA) recommended using the ICF to collect functional status information to "enable health care providers to report their findings consistently across the continuum of care for both clinical and administrative purposes."[4]
  • Evaluation of long-term clinical outcomes in coronavirus outbreaks. A study by Patel et al.[19] recommends using the ICF framework for outcome measures in the follow-up studies of COVID-19 survivors.
  • Van Leeuwen et al.[20] investigated the development of an ICF-based e-intake tool used in clinical otology and audiology practice to assist with referrals and treatment decision trees.
  • Using the ICF framework jointly with the capability approach ("theoretical framework based on the normative assumption that people should have the freedom to live a life they value"[21]) via e-health application to foster holistic, patient-centred care.

ICF and Electronic Medical Record (EMR)/Electronic Health Record (EHR)[edit | edit source]

Electronic Medical Records (EMR)[edit | edit source]

Electronic Medical Records (EMR) are digital versions of the paper documents used in clinical offices.[4] EMRs allow providers to monitor and track health data over time. They guide clinical decisions, and improve the quality of care.[4] Several countries have put forward initiatives toward implementing the ICF in EMRs. Maritz et al.[22] indicate that the ICF has predominately been implemented in documentation used in rehabilitation settings. Using the ICF in EMRs can be accomplished in various ways. The following examples demonstrate the integration of the ICF and EMRs.

Documentation Template[edit | edit source]

Documentation templates can improve the consistency and comprehensiveness of therapy documentation. In addition, the ICF-based template could help focus on the biopsychosocial model of health,[23] which focuses on the interaction between biological, psychological and socio-environmental factors. Integration of the ICF and EMRs can occur by:[23]

  • using the ICF Core Sets to describe functional status and activity level
  • using the ICF condition-specific Core Sets
  • using elements of patient management from the Guide to Physical Therapist Practice

This integration could potentially have the following benefits for rehabilitation:[23]

  • WHO conceptual framework will be implemented
  • outcome measures will be standardised
  • ICF condition-specific Core Sets offer greater flexibility in client assessments
  • any data gathered can be compared across practice settings and countries for clinical and research purposes

Digital Medical Records for Physiotherapists[edit | edit source]

Finezjo is one example of a digital medical record that all rehabilitation team members can use. Polish physiotherapists have used it since January 2020. The system has "a built-in intelligent ICF dictionary, a database of over 70 activity tests based on ICF, and [...] the WHODAS 2.0 questionnaire."[24]

Electronic Health Records (EHR)[edit | edit source]

Electronic Health Records (EHR) focus on the overall health and well-being of the patient as they move from one clinical setting to another.[4] EHRs are used to:

  • share clinical information among healthcare providers
  • facilitate improved and shared communication
  • allow more timely decision-making on behalf of the patient

To enable data and information sharing, standardised clinical terminology must be used to make the EHR system accurate and consistent.[25] This terminology must represent all diagnostic statements across all professional groups using the system. It must also rely upon national and international data standards, including coding terminologies.

Clinical Terminology[edit | edit source]

The following are examples of clinical terminology linked with the ICF:

  • SNOMED-CT - U.S. standard for electronic health information exchange[26]
  • International Classification of Nursing Practise (ICNP)[27]
  • Nutrition Care Process Terminology (NCPT)[28]
  • Natural language processing (NLP) technologies[29]

ICF Classification Taxonomy[edit | edit source]

Taxonomy is "naming and classifying things such as animals and plants into groups within a larger system, according to their similarities and differences."[30] The ICF groups "domains" into functioning and disability, and contextual factors.

"The ICF taxonomy is considered the worldwide standard for reporting on functioning and disability and offers a comprehensive spectrum of categories for documenting all framework components".[31]

ICF classification taxonomy groups chapters into an organised, hierarchical system. Thus, the ICF lends itself to multiple uses at different levels.[4] Example for grouping of chapters:

  • 1st Level Chapter 2 SENSORY FUNCTIONS AND PAIN
  • 2nd Level – b280-b289 Pain
  • 3rd Level – b2801 Pain in the body part
  • 4th Level – b28010 Pain in head and neck or b28013 Pain in back

Resources[edit | edit source]

References[edit | edit source]

  1. Ustün TB, Chatterji S, Bickenbach J, Kostanjsek N, Schneider M. The International Classification of Functioning, Disability and Health: a new tool for understanding disability and health. Disabil Rehabil. 2003 Jun 3-17;25(11-12):565-71.
  2. Salvador-Carulla L, Garcia-Gutierrez C. The WHO construct of health-related functioning (HrF) and its implications for health policy. BMC Public Health. 2011 Dec;11(4):1-0.
  3. 3.0 3.1 3.2 3.3 3.4 Kostanjsek N. Use of The International Classification of Functioning, Disability and Health (ICF) as a conceptual framework and common language for disability statistics and health information systems. InBMC public health 2011 Dec (Vol. 11, No. 4, pp. 1-6). BioMed Central.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Saleeby P. International Classification of Functioning, Disability and Health(ICF) , Administration and Policy. Plus Course 2023
  5. World Health Organization: WHO Study on Global Ageing and Adult Health (SAGE). Wave 1 Individual Questionnaire - Set A. 2009. Available from [last access 9.01.2023]
  6. 6.0 6.1 WHO Multi-Country Studies Data Archive. Available from [last access 11.01.2023]
  7. Functioning and disability in Europe MHADIE project results. Available from [last access 9/01/2022]
  8. Module on "Disability and Social Integration" - CDC. Available from [last access 9.01.2023]
  9. Griffo G, Leonardi M, Martinuzzi A, Francescutti C, Raggi A, Kosic V, Barbieri PV. Moving towards ICF use for monitoring the UN Convention on the rights of persons with disabilities: the Italian experience. Disabil Rehabil. 2009;31 Suppl 1:S74-7.
  10. United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Available from [last access 10.01.2023]
  11. Welti F. Das SGB IX in der Entwicklung des Sozialrechts1 [The SGB IX, book 9 of the German social code, in the development of social security law]. Rehabilitation (Stuttg). 2002 Aug;41(4):268-73. German.
  12. Law 39/2006, Of 14 December, Promotion Of Personal Autonomy And Care For People In A Situation Of Dependence. Available from [last access 10.01.2023]
  13. Almborg AH, Welmer AK. Use of the International Classification of Functioning, Disability and Health (ICF) in social services for the elderly in Sweden. Disabil Rehabil. 2012;34(11):959-64.
  14. Francescutti C, Martinuzzi A, Leonardi M, Kostanjsek NF. Eight years of ICF in Italy: principles, results and future perspectives. Disabil Rehabil. 2009;31 Suppl 1:S4-7.
  15. Francescutti C, Frattura L, Troiano R, Gongolo F, Martinuzzi A, Sala M, Meucci P, Raggi A, Russo E, Buffoni M, Gorini G, Conclave M, Petrangeli A, Solipaca A, Leonardi M. Towards a common disability assessment framework: theoretical and methodological issues for providing public services and benefits using ICF. Disabil Rehabil. 2009;31 Suppl 1:S8-15.
  16. Implementation of ICF in Mexico. Available from [last access 11.01.2023]
  17. Good A. Using the ICF in Ireland. BMC Public Health. 2011 May 31;11 Suppl 4(Suppl 4):S5.
  18. Hollenweger J. Development of an ICF-based eligibility procedure for education in Switzerland. InBMC public health 2011 Dec (Vol. 11, No. 4, pp. 1-8). BioMed Central.
  19. Patel K, Straudi S, Yee Sien N, Fayed N, Melvin JL, Sivan M. Applying the WHO ICF framework to the outcome measures used in the evaluation of long-term clinical outcomes in coronavirus outbreaks. International Journal of Environmental Research and Public Health. 2020 Sep;17(18):6476.
  20. van Leeuwen LM, Pronk M, Merkus P, Goverts ST, Anema JR, Kramer SE. Developing an intervention to implement an ICF-based e-intake tool in clinical otology and audiology practice. International Journal of Audiology. 2020 Apr 2;59(4):282-300.
  21. van der Veen S, Evans N, Huisman M, Welch Saleeby P, Widdershoven G. Toward a paradigm shift in healthcare: Using the International Classification of Functioning, Disability and Health (ICF) and the capability approach (CA) jointly in theory and practice. Disability and Rehabilitation. 2022 Jun 21:1-8.
  22. Maritz R, Aronsky D, Prodinger B. The International Classification of Functioning, Disability and Health (ICF) in electronic health records. Applied clinical informatics. 2017 Jul;8(03):964-80.
  23. 23.0 23.1 23.2 Escorpizo R, Stucki G, Cieza A, Davis K, Stumbo T, Riddle DL. Creating an interface between the International Classification of Functioning, Disability and Health and physical therapist practice. Phys Ther. 2010 Jul;90(7):1053-63.
  24. Finezjo- innovative, based on ICF. Available from [last access 12.01.2023]
  25. Florin J, Strandberg E, Jansson I, Ehrenberg A, Björvell C. A comparison between the ICNP and the ICF for expressing nursing content in the electronic health record. Int J Med Inform. 2021 Oct;154:104544.
  26. Maritz R, Aronsky D, Prodinger B. The International Classification of Functioning, Disability and Health (ICF) in Electronic Health Records. A Systematic Literature Review. Appl Clin Inform. 2017 Dec 20;8(3):964-980.
  27. Florin J, Strandberg E, Jansson I, Ehrenberg A, Björvell C. A comparison between the ICNP and the ICF for expressing nursing content in the electronic health record. Int J Med Inform. 2021 Oct;154:104544.
  28. Gäbler G, Coenen M, Lycett D, Stamm T. Towards a standardized nutrition and dietetics terminology for the clinical practice: An Austrian multicenter clinical documentation analysis based on the International Classification of Functioning, Disability and Health (ICF)-Dietetics. Clin Nutr. 2019 Apr;38(2):791-799.
  29. Newman-Griffis D, Fosler-Lussier E. Automated coding of under-studied medical concept domains: linking physical activity reports to the International Classification of Functioning, Disability, and Health. Frontiers in digital health. 2021 Mar 10;3:620828.
  30. Definition of 'taxonomy'. Available from [last access 13.01.2023]
  31. Schwegler U, Anner J, Glässel A, Brach M, De Boer W, Cieza A, Trezzini B. Towards comprehensive and transparent reporting: context-specific additions to the ICF taxonomy for medical evaluations of work capacity involving claimants with chronic widespread pain and low back pain. BMC health services research. 2014 Dec;14(1):1-3.