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The Problem-Oriented Record (POR) has had a profound effect upon the medical community. Since its introduction not quite ten years ago, POR has gained remarkable acceptance. A short review of the relatively brief history of POR is given and various facets of its use are outlined as guidelines for more critical reappraisal of its merits. The fact, however, that POR is currently taught in a majority of medical schools and used in ever increasing numbers of hospitals is highly indicative of eventual conversion of all medical recoreds to POR format.

An ad hoc committee of the North American Primary Care Research Group (NAPCRG) was appointed to develop a classification system for procedures in primary care. The committee developed and field tested a completely hierarchical four digit process code for primary care. It is hoped that with wide-spread use and further testing, the code will become a nucleus for an international companion volume to ICHPPC-2 (International Classification of Health Problems in Primary care, second edition). This first version is being made available to interested potential users at this time.

The importance of an encounter form for recording ambulatory patient information is stressed. Certain problems surrounding appropriate definition of the minimum basic data set (MBDS) are discussed as is the potential development of a uniform encounter form which would cover diagnostic information as well as items necessary for insurance companies and internal practice management.

ICHPPC-2 is an international classification developed for use by primary care physicians. It is an official modification of ICD-9 and consists of only 362 diagnostic titles, which are directly comparable to arbitrarily selected ICD-9 rubrics. In the United States, third party reimbursement requires physicians to provide coded diagnostic information. These authors have arbitrarily assigned those code numbers from ICD-9-CM that are most likely representative of the type of health problems encountered by family physicians and therefore most appropriate for billing purposes where an ICD-9-CM code is required.

An ad hoc committee of the North American Primary Care Research Group (NAPCRG) was appointed to adapt the diagnosis clusters instrument for use with the International Classification of Diseases (ICD-9-CM) and the International Classification of Health Problems in Primary Care (ICHPPC-2). This article describes the development and testing of the final roster of 110 diagnosis clusters for family physicians. Almost 90 percent of all diagnoses recorded by family physicians in a variety of settings were included in the clusters. The diagnosis clusters can be used in the analysis of large databases and facilitate comparisons between different providers and practices.

Outreach can be accomplished by the primary-care physician if he institutes data systems that permit identification of cohorts of his patients by age, sex, diagnoses, and area of residence. These systems were used by the Rochester Family Medical Program to identify and invite patients at risk to receive prophylactic influenza immunization, participate in an obesity treatment group, and receive screening tests for lead intoxication.

The spectrum of otitis media includes acute and chronic forms, each of which can be either suppurative of nonsuppurative. In the usual clinical setting distinctions between these several forms can be difficult. Determination of accurate incidence figures is impeded by the unavailability of universally accepted diagnostic criteria. Risk factors include season of the year, genetic factors, race, preceding respiratory tract infections, cleft palate, and others. The effect of household size and allergy are uncertain. The most common infecting organisms are Streptococcus pneumoniae and Hemophilus influenzae, although in a significant number of cases either the fluid is nonpathogenic or no organisms can be isolated. The effects of several therapies are reviewed, including antibiotics, myringotomy, steroids, and middle-ear ventilating tubes.

Faculty members from four family medicine training programs participated in the production of a definitive conversion of the Royal College of General Practitioners Classification of Diseases as modified for use with problem-oriented medical records (RCGP) to the International Classification of Health Problems for Primary Care (ICHPPC). The method used to produce the conversion and the several problems encountered are described. A detailed translation with the appropriate ICHPPC equivalent for each RCGP diagnostic title and code number is provided.

To investigate how family/household problems could be classified 186 problems recorded in 55 families by 14 Israeli family physicians were studied. Four major categories were used which included health problems in one family member affecting others in the household, relationship problems, social problems and health problems in more than one family member. Over half of the 186 problems were psychological or physical problems in the individual which affected other household members. Specific diagnostic titles from the International Classification of Health Problems in Primary Care (ICHPPC-2-Defined) were suitable to classify virtually all identified family/household problems. More problems were identified in mothers than in fathers or children and mothers were perceived as being affected most by social and relationship problems. Additional studies are suggested.

The Ambulatory Sentinel Practice Network (ASPN) is a network of primary health care practices across the United States and Canada offering (1) a laboratory for the study of populations under the care of primary care providers, and (2) surveillance of primary care problems and services. This paper reports the methods and policies developed and used by ASPN to conduct studies and describes the initial sentinel practices.

The genogram is presented as a technique to record both genetic and interpersonal family-household data. Working with model patients, and using standard instructions and symbols, family medicine residents elicited and recorded an average of 83 percent of available information items during interviews that lasted an average of 16 minutes. Interpretation of data derived from genograms written by other physicians was achieved with a high degree of accuracy (91 to 96 percent correct answers to 25 questions on each of three family-households). The genogram appears to be a practical instrument to record and retrieve family-household data, but its wide application will require standardization of both the technique of recording and the symbols employed.

The red blood cell (RBC) content of urine specimens was determined both by direct counts by a hemocytometer and by the number of RBCs per high-power field (HPF) in the sediment by routine urine analysis. The sensitivity of a finding of 1 to 3 and 2 to 4 RBCs/HPF in detecting greater than or equal to 2,000 RBCs/ml unspun urine was 63% (73/116) and 54% (63/116), respectively. There was a wide range of values of RBCs/ml determined by direct counts for each degree of microscopic hematuria as defined by the HPF method. We conclude that examination of the urinary sediment by the HPF method is not sufficiently sensitive to be used as a screening test for the detection of microhematuria in asymptomatic subjects.

Manual and computer versions of the diagnostic of the index-E-Book are described. Methods for establisment and maintenance of both indexes are given and the relative merits of each are delineated. Uses of diagnostic indexes are presented which are appropriate to solo and group practices. The role of the diagnostic index in curriculum development within a family practice training setting is also illustrated.

This issue of 'Selections' focuses on studies of cholesterol reduction in asymptomatic adults. Treatment of persons with coronary heart disease involves other issues and the need to consider additional evidence from other studies. Elevated blood cholesterol levels are associated with increased coronary heart disease in young adults. The real question is whether or not lowering cholesterol levels with diet and drugs is possible and if possible, whether it reduces the risk of morbidity and mortality. Even if the relative risk can be reduced it is necessary to consider the absolute risk reduction. Reduction of the risk of fatal myocardial infarction from 2.0% to 1.6% over a seven year period while at the same time increasing the risk for gallbladder surgery from 1.3% to 1.9% may not be an attractive gamble. There is little evidence that elevated cholesterol levels are a risk factor in adults over the age of 60 years. Intervention trials have not been conducted in women or in the aged, and overall mortality has not been reduced in any of the studies. The Department of Health and Human Services of the United States recommends an approach that if implemented could have initial costs that exceed 10 billion dollars. Yearly costs are likely to exceed the initial cost. In a recent editorial Professor Joseph Herman expresses concern that the Israel Society for Research on Atherosclerosis and the European Atherosclerosis Society have adopted similar recommendations to those recently announced in the United States. He also points to large variations reported from 5000 laboratories given standard samples to be tested for total cholesterol. Currently blood cholesterol levels are available to shoppers at a supermarket in Florida (New York Times 1989, January 3). The end of this controversy is not yet in sight.

This is the first of series of articles which describes an integrated system for recording medical data. The age-sex register is described in detail. Uses of the register include enhanced capabilities for office management, assessment of postgraduate educational needs, outreach, audit, and research. The problems encountered with definition of the practice size are discussed. Subsequent articles will describe a classification of health problems, a diagnostic index, family folders, filing patients records by geographic location, problem-oriented medical records, encounter forms, and various record forms.

Blood lead level tests, by the finger-prick micromethod, were given to 333 children in a primary care practice. On initial testing, 18.6 percent of children had lead levels between 30 and 39 microng/100 ml and ten percent had lead levels of 40 microng/100 ml or greater. In the latter group, only 2.7 percent had levels in that range when retested with venous blood samples. Socioeconomic status, as determined by census tract residence, correlated with evidence of undue lead absorption. Of the children tested from socioeconomic Group I (I is highest), 3.4 percent were affected, as opposed to 60.0 percent of the children residing in Group V census tracts.

A practice profile is a compilation of information allowing definition and evaluation of any of several parameters of health-care delivery. Prerequisites for development of profiles presented in this report include: suitable classification of health problems; patient demographic data; identification of individual and groups of health-care providers; and definition of the practice or study population. Details are given for two profiles: the assigned patient and the diagnostic workload profiles. Single profiles are purely descriptive but, when evaluated by appropriate peer comparison, may form the basis for a more dynamic process--that of improvement and change. Possible applications of practice profiles are discussed.