History of Electronic Health Records — Early Prototypes and RMRS (Lecture a)

Terminology and Definitions

  • Names associated with EHRs (as listed in the material): Medical Information Systems; Computer-based Patient Record; Electronic Medical Records; Electronic Health Records; Personal Health Records. Source references: Collen (1986); Dick et al. (1991).

  • Electronic Medical Record (EMR) definition:

    • An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization. \text{Source: The National Alliance for Health Information Technology, 2008}

  • Electronic Health Record (EHR) definition:

    • An electronic record of health-related information on an individual that conforms to nationally-recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. \text{Source: The National Alliance for Health Information Technology, 2008}

  • Personal Health Record (PHR) definition:

    • An electronic record of health-related information on an individual that conforms to nationally-recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual. \text{Source: The National Alliance for Health Information Technology, 2008}

  • Relationship to meaningful use: The attributes identified for a computer-based patient record in the 1991 Institute of Medicine (IOM) Report relate to the concept of meaningful use (MU) in later policy discussions. In short, early IOM recommendations foreshadow the capabilities sought in MU, including interoperability, data sharing, decision support, and patient engagement.

  • Timeline note: The evolution of terminology reflects shifts from single-organization record-keeping to interoperable, multi-organization records and ultimately to patient-controlled data in some models.

Early Names for EHRs

  • Terms listed as historically associated with electronic health information systems: Medical Information Systems; Computer-based Patient Record; Electronic Medical Records; Electronic Health Records; Personal Health Records. (Sources: Collen, 1986; Dick et al., 1991).

  • These names illustrate the evolving scope from intra-organizational records to cross-organization interoperability and patient-centered data.

Early Problems with Paper Records (1960s–1990s)

  • Core problems with paper records:

    • Inaccessible/unavailable when needed

    • Illegible handwriting

    • Incomplete information

  • Early prototypes and directions included:

    • EMRs (electronic medical records)

    • Multimedia EMR

    • Portable PHRs

  • Timeframe reference: 1960s–1990s.

  • Sources: Collen (1995); Smith et al. (2005).

COMPUTER-STORED Ambulatory Record (COSTAR)

  • Development context:

    • Began in the 1960s at Massachusetts General Hospital

    • Led by G. Octo Barnett and colleagues

    • Utilized the MUMPS computer language

  • Design goals:

    • Accessibility for clinicians

    • Support for administrative and financial needs

    • User queries

    • Quality assurance

  • Source: Barnett et al., 1982.

  • Significance: COSTAR foreshadowed integration of clinical data with administrative/data management capabilities and laid groundwork for modular, queryable ambulatory records.

The Medical Record (Duke) — 1970s

  • Development:

    • Duke University, 1970s

    • Leaders: W. Edward Hammond, William Stead, and colleagues

  • Origin and expansion:

    • Started as an obstetric history-taking program

    • Expanded to other departments and functions

  • Source: Hammond (2001).

The Medical Record (TMR)

  • Full name: The Medical Record (TMR)

  • Features:

    • Modular design

    • Data definition dictionaries

    • Problem-oriented and time-oriented formats

    • Multiple input modes: computer, paper, dictation

    • User configuration and choice of data collection content/methods

  • Source: Hammond (2001).

Regenstrief Medical Record System (RMRS) — Beginnings and Goals

  • Development:

    • Began in the 1970s at the Regenstrief Medical Institute

    • Pioneers: Clement McDonald, William Tierney, and colleagues

    • Initial site: Regenstrief Diabetes Clinic; later expanded to other outpatient and inpatient units

  • Core goals:

    • Data capture

    • Automated reminders

    • Clinical decision support

  • Source: McDonald et al., 1992.

RMRS Features

  • Data capture methods:

    • Electronic interfaces with devices when possible

    • Dictation/manual coding and entry

    • Structured forms/manual coding and entry

    • Direct computer entry

  • Clinical decision support:

    • Hundreds of rules to generate reminders and alerts

    • Support available since 1974

    • Studies exist on impact to costs and patient health outcomes

  • Administrative and financial integration:

    • Integrated administrative and financial functions

    • RMRS remains in use today and has expanded to multiple inpatient and outpatient facilities

  • Significance: Demonstrates long-standing integration of clinical data with decision support and operational functions, influencing modern EHR design principles.

Lessons Learned from Early EHR Implementations

  • Incremental build strategy:

    • Modular approach

    • Start with easily captured data

  • Configure for varied settings and user needs

  • Support multiple data entry methods (computer, paper, dictation, etc.)

  • Use coded data for storage and retrieval

  • Maintain a data dictionary

  • Establish standards for sharing information

  • Source: Hammond (2001)

Lessons Learned 2: Clinician and Operational Considerations

  • Integrate administrative and clinical functions, especially in outpatient settings

  • Data entry challenges for direct physician entry:

    • Structured orders are easier for physicians

    • Clinical documentation can be more challenging

  • Importance of user training and ongoing support

Barriers to Use (From Early EHR Experience)

  • Major obstacles:

    • Cost of hardware and software

    • Inability to accommodate all data types (notably unstructured data)

    • Design issues (user interface, cognition support for physicians)

    • Data entry difficulties

    • Lack of physician acceptance/interest

  • Source: Collen (1995).

Goals of EHRs (as articulated in early work)

  • Objectives:

    • Accessibility of patient data

    • Increase efficiency and reduce costs

    • Improve quality of patient care

    • Facilitate health services research

    • Facilitate claims processing

  • Source: Collen (1995).

HITECH Vision (2009)

  • Vision statements (as cited by Blumenthal, 2010):

    • Improved individual and population health outcomes

    • Increased transparency and efficiency

    • Improved ability to study healthcare

    • Improved care delivery

  • Source: Blumenthal (2010).

  • Implication: Policy-driven push toward interoperable EHRs and the broader goals of health information technology adoption.

History of Electronic Health Records — Summary (Lecture a)

  • Core takeaways:

    • EHR terminology has evolved over time

    • There are early, concrete examples of EHRs and prototypes

    • There was a persistent struggle to define the requirements and scope of EHR systems

History of Electronic Health Records — References (Lecture a)

  • COSTAR: Barnett GO, Zielstorff RD, Piggins J, et al. COSTAR: a comprehensive medical information system for ambulatory care. Proc Annu Symp Comput Appl Med Care. 1982;8–18.

  • Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382-5.

  • Collen M. A history of medical informatics in the United States, 1950-1990. Washington, DC: American Medical Informatics Association; 1995.

  • Collen MF. Origins of medical informatics. Med Inform. West J Med. 1986;145:778-85.

  • Dick RS, Steen EB, Detmer DE. The computer-based patient record: an essential technology for healthcare. Washington, DC: National Academy Press; 1991.

  • Hammond WE. How the past teaches the future: ACMI distinguished lecture. J Am Med Inform Assoc. 2001;8(3):222-34.

  • McDonald CJ, Tierney WM, Overhage JM, Martin DK, Wilson GA. The Regenstrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Comput. 1992;9(4):206-17.

  • The National Alliance for Health Information Technology. Report to the Office of the National Coordinator for Health Information Technology on defining key health information technology terms. 2008; p. 6.

  • Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293(5):565-71.

Acknowledgements

  • This material was developed by the University of Alabama at Birmingham and funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, under Award Number 90WT0007.

  • License: Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

  • Acknowledgement reference: Page 23 content reiterates the study and licensing terms.

Connections to the Institute of Medicine and Meaningful Use

  • The 1991 IOM report defined attributes of the computer-based patient record.

  • Those attributes align with later MU criteria, including:

    • Interoperability and standards-based data exchange

    • Comprehensive data capture across settings

    • Decision support capabilities

    • Data accessibility for multiple actors while maintaining appropriate access controls

  • These early definitions informed later policy directions and the MU framework used in the HITECH Act.

Links to Foundational Principles and Real-World Relevance

  • Incremental, modular development mirrors modern agile EHR implementation strategies.

  • The balance between data capture, usability, and clinician workload remains central to successful adoption.

  • Integration of administrative, financial, and clinical data remains a foundational design principle for scalable health IT systems.