The Integrated Taxonomy of Health Care: Classifying Both Complementary and Biomedical Practices Using a Uniform Classification Protocol

Antony Porcino, BSc,1 Colleen MacDougall2
1CAMEO Project, BC Cancer Agency and University of British Columbia, Vancouver, BC, Canada; 2Executive Director and Registrar, Natural Health Practitioners of Canada, Edmonton, AB, Canada.


Background: Since the late 1980s, several taxonomies have been developed to help map and describe the interrelationships of complementary and alternative medicine (CAM) modalities. In these taxonomies, several issues are often incompletely addressed:

Results: A full vertical taxonomy was developed that includes and clearly differentiates between techniques, modalities, domains (clusters of similar modalities), systems of health care (coordinated care system involving multiple modalities), and integrative health care.

Domains are the classical primary focus of taxonomies. The ITHC has eleven domains: chemical/substance-based work, device-based work, soft tissue–focused manipulation, skeletal manipulation, fitness/movement instruction, mind–body integration/classical somatics work, mental/emotional–based work, bio-energy work based on physical manipulation, bio-energy modulation, spiritual-based work, unique assessments. Modalities are assigned to the domains based on the primary mode of interaction with the client, according the literature of the practitioners.

Conclusions: The ITHC has several strengths: little interpretation is used while successfully assigning modalities to single domains; the issue of taxonomic verticality is fully resolved; and the design fully integrates the complementary health care fields of biomedicine and CAM.

KEYWORDS: Complementary therapies, classification; complementary therapies, methods; delivery of health care, integrated; delivery of health care, classification; organizational models interdisciplinary communication



One of the first reviews to discuss health care schemata by medical anthropologists and sociomedical scientists that incorporated complementary and alternative medicine (CAM) was published in 1986. The authors, Levin and Coreil, were focusing on practices of “new age healing.”(1) The reason for developing taxonomies then seems just as pertinent now: to systematically define components of health care. The application of that systematic definition has many relevant uses, from understanding “sociocultural significance and policy implications,”(1) to recognizing how the similarities, differences, and limits of practice relate to each other for practical scenarios such as risk management and clinical decision-making.

Each of the several taxonomies now published is trying to solve a particular need of the developer, usually through a lens shaped by the paradigm of the developer’s approach. For example, Tataryn(2) looks at paradigms of body interaction; Jones(3), at modes of therapeutic action; Grossinger,(4) at historical relationships from an anthropological perspective; and several others from a point of contrast to biomedicine. The need for and development of CAM taxonomies has been dealt with well in other articles; the introduction to the subject by Tataryn(2) is highly recommended. Jones(3) outlines well how a taxonomy is also important to facilitate the communication that is necessary for integrative medicine.

Of the many taxonomies available, the taxonomy of the National Center for Complementary and Alternative Medicine (NCCAM) is the most well known (Appendix 1), in part because it provides a quick overview of the general CAM therapy concepts and how CAM therapies generally relate.(5) However, the categories are so broad that many therapies could be classified under more than one category, yet the process or reasoning of assigning a therapy that fits multiple categories to only one category is not explained. For example, reflexology is often placed under Manipulative and Body-based Practices, while acupressure is placed under Energy Medicine: Biofield Therapies, even though the two are similar in that they both are creating change by manipulation of points on the body to create physical change in other parts of the body (practitioners ascribe different theoretic bases to the two therapies). And while both chiropractic and nuad bo rarn (Thai massage) fall under Manipulative and Body-based Practices, that classification tells little about their actual similarities and differences. No taxonomy system to date has a categorization that fully resolves this issue. Another difficulty exemplified within the NCCAM taxonomy is the lack of verticality, when one category (Whole Medical Systems) is placed at the same conceptual level (horizontally) as other categories that may fall within this supra-category.(6,7) Although a number of taxonomies, such as those by Tatayrn(2) and Jones,(3) were developed to provide more detail about the therapies, none reviewed fully resolved the verticality issue.

Regardless of these shortcomings, taxonomies can be used to solve practical problems. In 2001, the Natural Health Practitioners of Canada (NHPC) had need of a taxonomy for several related purposes:

In addition, the NHPC recognized that a well-conceived taxonomic structure can also give guidance for research because it delineates commonalities among health care approaches. Understanding the common and dissimilar aspects of therapies is important because differing underlying issues within a health care service may have differing research design needs and solutions. For example, a randomized controlled trial works for pharmaceuticals and standardized herbal extracts without much modification, but a randomized controlled trial of reflexology cannot be run in the same way because manual therapies present unique trial research challenges.(8) Reflexology and Swedish massage are both manual therapies, but their underlying concepts of therapeutic action (energy reflex versus physical tissue manipulation) may require different solutions in a research trial, such as different controls or sham treatment. In contrast, research methods for Swedish massage and trigger point therapy can be similar because of the close similarities in the modalities.

None of the taxonomies available provided the needed structure or understanding to resolve the foregoing issues. The primary issues encountered in other taxonomies were these:

A lack of consistent use of language, a lack of verticality, and in many cases, a lack of consideration of how CAM relates to biomedicine all limit the use of the available taxonomies. The NHPC therefore undertook the development of a theory-based taxonomy, grounded in a clear developmental process, that could be used daily for the association’s credentialing and education work and communication with members, businesses, organizations, and governments. The process took five years and involved three stages. The first stage involved the development of a consistent vocabulary; the second, an analysis of various taxonomies detailing the strengths and opportunities; and the third, steps of developing and refining the taxonomy system including consultation with NHPC members.



Stage 1

Development of a vocabulary involved analyzing current language and terminology used by several sources. We reviewed how the CAM community described itself in practitioner writing (magazines, journals, websites) and in discussions with NHPC members and with other CAM organizations. We also reviewed written and verbal sources within the stakeholder community, especially those of governments, researchers, other nonprofit organizations such as the Prince’s Trust and the World Health Organization, and insurance companies. Language choices and definitions were then refined through a consensus process, first by the Credentials Committee of the NHPC, then by the its Board of Directors. Based on issues arising in stage 3, definitions were sometimes refined or altered.

Stage 2

The authors did not have full access to published journals at the time, and so the research process was not fully systematic, but was based on what was available. The references studied provided good coverage of the CAM taxonomies available:

The taxonomic structure was completed and has been used by the NHPC in its current structure since early 2005.

Three additional taxonomies were reviewed as they became available:

During this same period, a number of books undertook the task of describing CAM modalities—from a few to many(11–18). However, these books either used general groupings similar to the NCCAM ideas, groupings by symptoms treated, alphabetic groupings, or no particular pattern. Although they increased public awareness of the many CAM modalities available, these books did not, in our opinion, develop or support a rigorous universal taxonomic approach to understanding CAM services or their relationship with standard health care.

Stage 3

Individual modalities (therapies) were analyzed for distinguishing features and categorized into clusters using the latest version of the classification protocol until conflicts or failure to definitively classify one or more modalities into a single category occurred. The glossary language would be consulted, sometimes refined, and then the classification protocol and developing category definitions would be adjusted and the modalities re-classified in an iterative process. The domains therefore evolved out of the functional clusters that developed.

The process often began with simple yet fundamental questions that arose in the daily work of the NHPC. For example: Is doula work physically or mentally based? Can aerobic workouts at exercise franchise “X” be classified as CAM? Are the classical somatics modalities physically or mentally focused, given their mind–body paradigm of perception?

Such questions were answered through long discussions, usually involving applying various solutions to these questions and testing the effects on other modality classifications. Simultaneously, and in a similar manner, issues of vertical classification were refined. Development predominantly used CAM examples; biomedical examples were used to critique developing answers. Initial classifications and theoretical development were carried out by the authors in collaboration with the NHPC Credentials Committee. The final classification protocol used the primary mode of interaction (primary application or approach) with the client–patient, based on that primary interaction as described in published writings and texts by practitioners acknowledged by other practitioners to be authorities or experts within their discipline.



Taxonomy-Relevant Definitions

Assessment: The process of reviewing and evaluating competencies and qualifications. Assessment may also be the initial determination of needs of treatment during a modality session.

Competency component: A specific set of knowledge and skills, and training in applying them.

Complementary and alternative medicine (complementary and alternative health care): A broad range of healing resources that encompass all health systems, modalities, and practices ... other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period.(19)

Device: Any non-human object used in treatment, ranging from simple technique-assisting objects to machines or electrical stimulators.

Discipline: A discipline level of training includes every competency component needed to safely and appropriately apply the modality on the public.

Domain: Broad-based categories that encompass one or more modalities through the recognition of the primary mode of interaction with the individual

Integrative medicine (integrative health care): any approach that uses a partnering of both biomedicine (Western medicine) and complementary and alternative medicine.

Method: The manner of applying techniques or a way of doing something.

Modality: A modality is a named scope of practice with defined standards of practice.

Named: Having a distinct and unique moniker allowing a modality to be recognized and distinguished from other modalities (for example, Reiki, Feldenkrais Method, massage therapy).

Occupational standards: Skills, knowledge, and abilities required for an occupation as established by a recognized body or through which the qualifications of an individual are assessed.

Primary mode of interaction: While many modalities function, are applied, or can be perceived on more than one level (physical, mental, emotional, spiritual or energetic), there is usually one aspect that defines the overarching approach of practitioners with their patients.

Scope of practice: The scope of practice for an occupation refers to the range of activities that a qualified practitioner of an occupation may practice. It establishes the boundaries of an occupation, especially in relation to other occupations where similar activities may be performed. The scope of practice for an occupation may be established through governing legislation or through internal regulations adopted by a regulatory body.

Specialist:An expert in a special branch of a subject.

Specialization: A specialization level of training requires an appropriate, previously learnt discipline to provide one or more competency components in order to safely and appropriately apply the modality on the public.

Standard for practice: Having a required certification for a given modality, or having recognition or membership with the regulatory body recognized as needed for a given modality.

System: A specified grouping of a number of distinct health care modalities (for example, traditional Chinese medicine, nursing).

Technique: A specific action to achieve a particular outcome (for example, gliding, percussion).

Therapy: A generalized term referring to a specific remedial outcome desired through the application of a modality. When used as part of names, it represents a desire to have the modality considered therapeutic by medical professionals with a Western-medicine paradigm.

Model: Taxonomy of Health Care

The taxonomy of health care (Fig. 1) is a hierarchical structure in which each higher category of health care encompasses the previous level. Thus, domains are groupings of modalities, and modalities (disciplines and specializations) comprise techniques. The most overarching structure is health care, which encompasses any system, modality, or technique that is used as a healing resource. Within this structure, at any given level, all healing resources—biomedicine and CAM— are complementary to each other rather than as compared with biomedicine.

Fig 1. Taxonomy overview.


Systems of Health Care

Systems comprise multiple modalities that are consistently taught and used together. For example, physicians and naturopathic doctors both learn multiple ways of approaching health care treatments (prescribing pharmaceuticals or herbs, applying physical manipulations, and using counseling techniques, among others) through training programs that teach to minimum competencies that are fairly uniform throughout North America. “Natural health practitioner” programs train participants in a conglomeration of modalities that can be used together, but, because there is no consistency in the modalities taught in the various programs, that would not be considered a system.

Domains of Health Care

The domain level of the taxonomy of health care is the primary focus of most taxonomies. Here, we summarize the domains and their subdomain categories (Fig. 2 shows examples of modalities for each domain and subdomain):