Electronic Health Record Running Head: HISTORY OF THE ELECTRONIC HEALTH RECORD

The History of the Electronic Health Record MAJ Darrin M.Vicsik Army-Baylor 2010

Electronic Health Record Background The United States invasion of Iraq in 2003 re-emphasized the need for an electronic health

record that would follow armed services personnel into battle. Americas previous foray into the Persian Gulf area of operations in 1990-91 left many veterans incapacitated with what became known as Gulf War Illness. However, research into the cause of Gulf War Illness was hampered by a lack of medical records from the theater. In 1997, President Clinton directed the Department of Defense and Veterans Affairs to create a new Force Health Protection program. Included in this program was the goal that every Soldier, Sailor, Airman, and Marine would have a comprehensive, life long record of all illnesses and injuries they suffered while on Active Duty as well as medical care received, inoculations, and exposure to environmental hazards. The vision of a comprehensive, life long medical record, however, is not new; this vision has been touted since the advent of the digital computer in the late 1950s and early 1960s. Computerbased electronic medical records in both the civilian and military settings have evolved with technology and are now on the cusp of meeting the visions of the first systems developed in the early 60s. The Department of Defense has one of the largest electronic health record systems in the world and has continuously updated its system since it was first implemented in its worldwide medical treatment facilities. The Department of Defense Electronic Health Record began in 1988 utilizing the Veterans Administrations Decentralized Hospital Computer System as a base. The Earliest Systems In 1958, physicians at the Tulane University Medical School recognized that the increasing amount of medical data made it difficult to classify, search, and store medical records. Utilizing medium-sized electronic digital computers, distributed to universities by the National

Electronic Health Record Institutes of Health, they evaluated their use and determined them to have great potential in clinical and investigative medicine (Schenthal, 1960). In 1964, Physicians and Researchers at University Hospitals of Cleveland and Western Reserve University utilized Public Health Service grants from the National Institute of General Medical Sciences to study the use of computers to provide optimal medical records at minimum cost. They recognized computers could improve the quality, consistency, and legibility of patients records as well as allow faster research and automatic quality control reports. They concluded such a system could be adapted to any large ambulatory clinic with a reasonable economic cost (Levy, 1964). Both the Tulane University Medical School and Western Reserve University studies utilized pre-printed forms that were filled out and entered into the mainframe computers via punch cards. University of Wisconsin researchers noted that taking a patients history consumed a large amount of a physicians time and the resultant records were often not standardized, were incomplete, or

illegible. In 1966, they utilized what is recognized today as the worlds first personal computer: a Laboratory Instrument Computer (LINC), developed at MIT, to take patients histories. The main difference of this system was that patients were on-line and directly interacted with the computer utilizing a keyboard and cathode ray tube. While the study was limited only to a medical history of allergies, it was determined that the computers patient acquired history was more thorough than the physicians (Slack, 1966). Automated Medical History (AMH) was further researched by the Mayo Clinic, where it was hoped an AMH would act as a force multiplier and relieve physicians from routine, time consuming activities. Again, the study found better annotation of past illness/surgery from the AMH than from physician recorded medical histories. Of note in this study, was the inability to determine whether or not the AMH affected the patient-physician relationship (Mayne, 1968). Another breakthrough for electronic health

Electronic Health Record records occurred at the Permanente Research Group in California in 1968. Researchers there realized the limitations of the previous fixed length and fixed format computerized medical

records and, in conjunction with IBM, organized the medical record into a tree-structure divided and sub-divided into the patients history, physical findings & diagnosis, and laboratory and other test results. In addition, their system utilized automated report generators and information retrieval compilers (Davis, 1968). The Harvard Medical Schools Laboratory of Computer Science at the Massachusetts General Hospital (MGH) began work on one of the most developed electronic health record systems. This system also recognized the increased growing complexity of medical care resulting in fragments of information from a variety of sources. Their studies indicated that as much as 25% of their operating budget was spent on information processing and saw computerization as a means to alleviate scarcity of staff. Their initial design was an on line computer facility for the systematized input of radiology reports. This system utilized a Digital Electronics Corporation (DEC) Personal Data Processor (PDP) model 7, an evolution of the LINC computer developed at MIT and distributed commercially by DEC. Data was entered utilizing an imposed structured phrases that the user linked by touching conductive cross lines on the cathode ray tube. Free text could be entered at the end of the report via a keyboard but the use of structured text allowed quality control as well as later retrieval and analysis of the data (Pendergrass, 1969). MGH continued to expand the use of computers for medical information with the implementation of a Clinical Data Management System for chemistry data reporting, the taking of patients histories, and physician entered narrative information. Evaluation of the AMH with respect to patient and physician attitudes indicated patient attitudes towards the system were positive while physician attitudes were mixed (Grossman, 1971). Like the Permanente Group, physicians and researchers

Electronic Health Record creating the MGH system realized the need for higher level programming languages in order to structure their Electronic Health Record. They developed the MGH Utility Multi-Programming System (MUMPS), a language still in use today and utilized by the Veteran Administrations Decentralized Hospital Computer Program (DHCP) and its successor, the Veterans Health Information Systems and Technology Architecture (VistA). Their use of MUMPS was cited as an advantage over other electronic health records that had been designed around general use computers with complex operating systems (Pappalardo, 1969). Providers utilizing the MGH system in the hypertension clinic were able to decrease the time to enter their structured notes

from twenty minutes to five minutes over a period of 25 patient visits and free text dictation was limited to 12% of the patients record. The structured input again minimized the time required to review the record and lowered the administrative costs of handling the records (Greenes, 1970). Yet another iteration of electronic health record developed at MGH was the Automated Medical Record System (AMRS). While MGHs other electronic record systems had been designed to help a limited number of patients in a specialty clinic or disease entity, the AMRS was designed to create a large database that was adequate for patient care, management, and evaluation. AMRS was implemented in the Harvard Community Health Plan group practice and, by 1972, had over 80,000 electronic records on 20,000 patients. Apart from the size of this system, another departure from the other MGH electronic health record systems was its use of physician encounter forms that were uploaded into the system by the medical record clerks instead of direct, physician entered narration. These encounter forms were individualized for each of the specialty clinics and the physician also had the option of recording additional information using a telephone transcription service. For quality control, the final electronic record was printed off and signed by the physician. The AMRS benefited managers and administrators by creating

Electronic Health Record reports with statistics such as tests ordered and medications prescribed, as well as physician utilization, and even assisted in contacting patients whose medication had been recalled by the FDA. A fully utilized electronic health record like the AMRS provides a continuous patient health record that simultaneously serves the needs of day to day healthcare, administration, and review of care but must have the participation of its users in its design and implementation to be accepted (Grossman, 1973). Other Early Electronic Health Records

Research in electronic health records was not only limited to the United States. In the 1960s, the University of Glasgow in Scotland implemented a study of case histories utilizing the System of Western Infirmary for the Total computerization of Case Histories (SWITCH). SWITCH utilized an English Electric KDF9 computer to digitize the patient encounters. In this system, forms were once again utilized and the information transferred to the computer. Systems in the United States strove for structured entry of patient information to facilitate later research. The SWITCH researchers recognized that specialty clinics were okay for the use of structured forms but allowed the general clinics to utilize free comment with the detriment that the data, although stored electronically, was not suitable for any future analysis (Kennedy, 1968). An even more ambitious project was Swedens Medical Information System for Danderyd Hospital (MIDAS) begun in 1969. The purpose of this system was to provide real-time medical information of the 1.5 million inhabitants in the Stockholm region. The contract for the system was awarded to Univac with goals of following morbidity, controlling utilization of medical resources, and providing medical updates on an existing central population registry. Items added to the existing population registry included blood type, history of illness or injury classified by World Health Organization codes, allergies, vaccinations, and history of inpatient and outpatient

Electronic Health Record treatment. The system utilized a UNIVAC 494 and utilized a FORTRAN like language. One concept still in use today was the use of a local hospital computer connected to clinic video terminals. These local computers would pull patients files from the central registry computer,

update the file, and then return the updated file to the central registry thus limiting the amount of communication required between the central registry and the individual video terminals utilized in the clinics that covered the population as a whole (Abrahamsson, 1971). Another electronic health record utilized in the 1970s was the United Kingdoms Exeter Project that provided a single record of healthcare for a general hospital, an orthopedic hospital, two health clinics and five group practices in the city of Exeter. In 1982, the entire system was updated to a MUMPS-based system utilizing DEC PDP model 11s. Some key requirements from this upgrade exist in many modern electronic health records to include unique passwords for individual users, record access based on job/position, an audit trail of who accessed what and when, and business aids to include payroll, accounting, and word processing. The Maturation of Electronic Health Record The advent of microcomputers (desktops), optical storage of data (CD-ROM), and advanced networking furthered the concept of the electronic health record. By the 1980s, three different, robust systems had been developed and are considered the basis of current EHR systems used in both ambulatory and hospital-based systems used today. They are the Computer-Stored Ambulatory Record (COSTAR) developed from MGHs initial projects of the 1960s, The Medical Record (TMR), and the Regenstrief Medical Record System (RMRS) (Carter, 2008). COSTAR was developed at MGH incrementally between 1968 and 1978 and fulfilled the need for a common medical record utilizing a variety of sources. By 1984, the vision of a move from paper encounter forms, filled out by providers and typed in by clerks, to direct provider

Electronic Health Record input was established. However, physicians were reluctant to use direct data entry via a computer. The primary dilemma in the use of a computer-based medical-record system is how to reconcile the physicians custom of recording free-form narrative on a blank page with the computers need for structure and a pre-defined vocabulary (Barnett, 1984). TMR, developed at Duke University in the 1970s, combined AMH, physical exam findings, pre-natal care, ambulatory care, and clinical research into a single system. It utilized a DEC VAX computer utilizing a Virtual Memory System (VMS) operating system and IBM DOS clients. The IBM DOS clients allowed for physician direct entry of information but the system also offered the option of paper encounter worksheets for those not wanting to use the workstations. It was considered a chartless, not paperless, system as all patient encounters and discharges were printed out and maintained for legal traditional reasons (Stead, 1988). The RMRS, developed at the Regenstrief Institute at Indiana University Medical Center, combined lab, imaging studies, diagnoses, and treatments for outpatient, emergency room, and hospital encounters. It utilized a DEC 8550 server linked to Zenith microcomputer workstations for the general medicine clinic and paper generated encounter forms for later clerical entry for other clinics. By 1988, the system already had over 24 million records on 250,000 patients spanning a time of 16 years of utilization. Unlike the MGH COSTAR system, providers were encouraged to use video terminals (as well as microcomputer clients) to enter data directly into the system. Data structure was controlled at entry but providers were given a free text entry that was stored as a separate file from the main record. Like the Duke TMR system, it complemented but did not replace the paper medical record (McDonald, 1988). The United States Government and Electronic Health Record

Electronic Health Record Many of the earliest universities found part or all of their support towards creating an

electronic health record from the federal government through the National Institute of Health, the Public Health Services, or other government grants. The governments Health Care Technology Division, part of the U.S. Public Health Service (PHS), studied many of the early attempts at a medical information system. After presenting their findings, a systems technology strategy was formulated to address the software-infrastructure issues the studies had found. In 1975, the design and technical specifications were directed for a successful proof of concept system. Due to the closure of PHS hospitals, the implementation was moved to Veterans Administration. In 1978, the initial modules were deployed to twenty VA Hospitals and by 1981 the program was renamed the Decentralized Hospital Computer Program (DHCP) (WorldVistA.org, 2008). In 1982, the Indian Health Services followed the VAs implementation of the PHS electronic record system with the Department of Defense (DoD) joining in 1988 (WorldVistA.org, 2008). The Department of Defense awarded Science Applications International Corp (SAIC) a $1.6 Billion contract to implement the renamed Composite Health Care System (CHCS) (Hassig, 1992). Conclusion With each advancement of technology, EHR is sold as a panacea for the woes created by gaps in patient health care records, a means to control utilization, or follow health trends in a population. However, the utopian vision of automation acting as a force multiplier and relieving physicians of routine, time consuming tasks while producing perfect records for later retrieval and analysis of data, quality of care, and consistency, remains a dream. The creation of Electronic Health Records by physicians and administrators stemmed from the desire to have a comprehensive, life-long medical record. Through forty years of history,

Electronic Health Record physicians and researchers sought a means of organizing the complex data associated with modern healthcare and its advancements. From the beginning, government support, whether

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direct or through university grants and funding, was key in the development of electronic health record and will continue to play a large part in its future.

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References Abrahamsson, S., Bergstrom, S,, Larsson, K., & Tillman, S., (1970). Danderyd Hospital Computer System II. Total Regional System for Medical Care. Computers and Biomedical Research, 3(1), 30-46. Barnett, G. Octo (1984). The Application of Computer-Based Medical Record Systems in Ambulatory Practice. The New England Journal of Medicine, 310(25), 1643-50. Carter,Jerome H. (2008). Electronic Health Records Second Edition: A Guide for Clinicians and Administrators, Philadelphia: American College of Physicians Press. Clarke, David (1982). The Evolution and Features of a MUMPS-based Primary Care System. Medical Informatics, 7(2), 127-40. Davis, Lou S., Collen, Morris F., Rubin, Leonard, & Van Brunt, Edmund E. (1968) ComputerStored Medical Record, Computers and Biomedical Research, 1(5), 452-469. Greenes, Robert A., Barnett, G. Octo, Klein, Stuart W., Robbins, Anthony, & Pryor, Roderick E. (1970). Recording, Retrieval and Review of Medical Data by Physician-Computer Interaction. The New England Journal of Medicine, 282(6), 307-15. Greenes, R. A., Pappalardo, A. N., Marble, C. W., & Barnett, G. Octo (1969). Design and Implementation of a Clinical Data Management System. Computers and Biomedical Research, 2(5), 469-85. Grossman, Jerome H., Barnett, Octo G,. McGuire, Michael T., & Swedlow, David B. (1971). Evaluation of Computer-Acquired Patient Histories. Journal of the American Medical Association, 215(8), 1286-91.

Electronic Health Record Grossman, Jerome H., Barnett, Octo G., Koepsell, Thomas D., Nesson, H. Richard, Dorsey, Joseph L., and Phillips, Rosalie R. (1973). An Automated Medical Record System. Journal of the American Medical Association, 224(12), 1616-21. Hassig, Jim (1992). $1.6 Billion CHCS Project Flayed by Experts. Healthcare Informatics, 9(11), 72-76. Kennedy, F., Cleary, J., Roy, A., and Kay, A. (1968). SWITCH: A System Producing a Full Hospital Case-History on Computer. The Lancet, 2(7580), 1230-33 Levy, Richard P., Cammarn, Maxine R,. and Smith, Michael J. (1964). Computer Handling of Ambulatory Clinical Records. Journal of the American Medical Association, 190(12), 1033-37. Mayne, John G., Weksel, William, & Sholtz, Paul N. (1968). Toward Automating the Medical History. Mayo Clinic Proceedings, 43(1), 1-25 McDonald, Clement J., Blevins, Lonnie, Tierney, William M., and Martin, Douglas K. (1988). The Regenstrief Medical Records. M.D. Computing: Computers in Medical Practice, 5(5), 34-47.

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Pendergrass, Henry P., Greenes, Robert A., Barnett, G. Octo, Poitras, James W., Pappalardo, A. Neil, & Marble, Curtis W. (1969) An On-Line Computer Facility for Systematized Input of Radiology Reports, Radiology, 92(4), 709-13. Schenthal, Joseph E., Sweeney, James W., & Wilson Jr., Nettleton (1960). Clinical Application of Large-Scale Electronic Data Processing Apparatus: New Concepts in Clinical Use of the Electronic Digital Computer. Journal of the American Medical Association, 173(1), 90-95.

Electronic Health Record Slack, Warner V., Hicks, G. Phillip, Reed, Charles E. & Van Cura, Lawrence J. (1966). A Computer Based Medical-History System. The New England Journal of Medicine, 274(4), 194-98.

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Stead, W. W., Hammond, W. E. (1988). Computer-Based Medical Records: The Centerpiece of TMR. MD Computing, 5(5), 48-62. World VistA. History. Retrieved September 8, 2008 from http://worldvista.org/AboutVistA/VistA_History