ICE guidelines for assessing the residual functionality of workers to be reintegrated into the work process in an appropriate manner

G. Ceccarelli | Rete ferroviaria Italiana Spa, Gruppo Ferrovie dello Stato Italiane SpA, Direzione Sanità-SO Medicina del Lavoro e Tutela Ambientale

Introduction. The term “codify” derives from the Latin Codex (contract) and Càudex (stump, pedal, tree, probably referring to the wooden tablets covered with wax on which people wrote using a stylus; over time, the term changed meaning to refer to a book, account, or collection of laws).
De Mauro, in defining its meaning, refers, among other things, to “translating, transcribing using the rules and symbols of a conventional code: codifying information, a message, an order.” The term ‘classify’ is given the meaning of “divide, order by class.” In essence, codifying and classifying means defining rules for mutual understanding. The aim is to define the same object of practical interest in a uniform and shared way, in order to avoid misunderstandings; the means is represented by the “grammar” and “syntax” that are used, the classification systems and those for coding the classified objects.
Classification practices have a special place in the history of science. Starting with Aristotle (384-322 BC), who, in his “De Anima,” classified animals based on their mode of locomotion and the environment in which they moved (air, land, water). Incredibly, Aristotle's zoological theories, more or less revised and corrected over time, but without any really substantial changes, lasted for about 2000 years. It was not until the Renaissance that an innovative movement was viewed in this field with authors such as Aldrovandi, Moutet, Ray, and others after them, but it was only with the contribution of Carl von Linné (Latinized as Carolus Linnaeus; 1707-1778) through the various successive editions of his “Systema Naturae” that the systematics on which the modern theory of classification of the animal world is still based was achieved.
The world of medicine was no stranger to the processes of classification and codification, which focused immediately on diseases and their consequences. The first known attempts at systematic classification of diseases date back to 1600-1700, although at the time they were considered of little practical use. In the 1800s, however, the subject gradually became increasingly indispensable, and in 1893, the International Statistical Institute issued the first international classification of diseases, based on the “Bertillon Classification of Causes of Death” (Jacques Bertillon, French statistician and demographer, 1851-1922). In 1898, the American Public Health Association recommended the adoption of the international classification in the US, Canada, and Mexico, establishing a requirement for a ten-year review of the classification itself. Bertillon's classification gradually became known as the ICD (International Classification of Diseases), and in 1948 the WHO assumed responsibility for publishing the ICD and initiating the international collection of data for epidemiological surveillance and health management. ICD, now (since 1992) in its 10th version (the 11th, already released, has not yet come into force globally), is at the heart of the family of international classifications (WHO-FIC), which also includes the International Classification of Functioning, Disability and Health (ICF) [3].

International Classification of Functioning, Disability and Health (ICF). Approved for international use by the 54th World Health Assembly on May 22, 2001 (resolution WHA54.21), it represents the evolution of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), first published in 1980. The ICF provides both a unified and standard language and a conceptual reference model for describing health and health-related states, and is the appropriate tool for implementing international mandates for the protection of human rights and national regulations. The WHO recommends the joint use of ICD-10/ICD-11 to code health conditions and ICF to describe a person's functioning. The ICF was designed to be updatable, and a web platform for updates has been operational since 2011. The latest updated version translated into Italian dates back to 2018 [4] and is available on the Italian Health Classification Portal [5].
The fundamental aims of the ICF are: to provide a scientific basis for understanding and studying health as an interaction between the individual and their environment; to establish a common language for describing health and related conditions, with the aim of improving communication between healthcare professionals, researchers, planners, public administrators, and the population, including people with disabilities; to enable comparison between data collected in different countries, health disciplines, services, and times; to provide a systematic way of coding information in health information systems.
The ICF can be used in all systems related to health, such as social security, employment, education, insurance, economics, legislation, and those dealing with environmental changes.
The Italian Health Classification Portal itself recognizes that it is necessary to define protocols for the use of the ICF as a language and as a model for describing health status. These protocols must be customized appropriately according to the context in which the classification is applied.
In our country, with the publication of Legislative Decree No. 62 of May 3, 2024, the use of the ICF and ICD has become mandatory in the process of taking charge of persons with disabilities, both for basic and multidimensional assessment, and consequently in the development of their “life plan” [2].
Fundamentals of the ICF classification system. The ICF is organized into two parts: 1) Components of Functioning and Disability, divided into the two Components Body (which includes Body Structures and Body System Functions) and Activity and Participation; 2) Components of Contextual Factors, divided into the two Components Environmental Factors and Personal Factors (unclassified but classifiable). The following table summarises the various aspects of the classification system.

For each classification item used, at least one qualifier must be used, which, in numerical form (from 0 to 4, plus 8 and 9 for ‘not specified’ and ‘not applicable’ respectively), where it is useful to define this qualifying element as well. The qualifier essentially provides the possibility of defining in summary terms the magnitude of the element under consideration (impairment, activity and participation limitation, relevance of barriers/obstacles, validity of facilitating elements, etc.).
Conclusions. International health classification systems (in particular ICD and ICF) now form the basis for defining disability status. The “life plan” provided for in Legislative Decree 62/2024 for each disabled person also includes aspects concerning inclusion in work activities. Therefore, even at the stage of hiring a disabled person, the competent doctors will have to begin to familiarize themselves with the classifications. If we then extend our gaze to workers with an already established employment relationship and with intercurrent disabilities, even if not assessed under Legislative Decree 62/2024, it is clear that the use of classification systems in the process of reintegration into the workplace should be based on the use of ICD and ICF, with the undoubted advantage of operating in a codified context, with shared criteria, both with other company representatives responsible for decisions concerning the full employability of the worker and with any stakeholders outside the company. However, tools, including those aided by information technology, and management protocols must be defined through which the steps of assessment, epicritical evaluation, and, finally, the choice of the correct job classification for workers can be carried out in a traceable and sustainable manner. It is desirable that similar models and protocols can also be applied to the management of aspects that conventionally concern the competent doctor in the field of health surveillance aimed at safeguarding health and safety at work, through the adoption of “personalized work plans” [1]. The personalized work plan tool, in fact, could, if properly managed in a multidimensional and multidisciplinary context and with the involvement of all relevant company stakeholders, become the way to formally express reasonable accommodation for the comprehensive management of both states of disability (and the way in which these conditions interact with workplaces and organizational contexts, with the related barriers to be eliminated or reduced and the related facilitators to be put in place) and the relationship between health and occupational risks.