History of electronic medical records

In the 1960s, a physician named Lawrence L. Weed first described the concept of computerized or electronic medical records. Weed described a system to automate and reorganize patients’ medical records to improve their utilization and thus lead to better patient care.

Weed’s work formed the basis of the PROMIS project at the University of Vermont, a collaborative effort between physicians and information technology experts that began in 1967 to develop an automated electronic medical record system. The goals of the project were to develop a system that would provide timely and sequential patient data to the physician, and enable rapid data collection for epidemiological studies, medical audits, and business audits. The group’s efforts led to the development of the problem-oriented medical record, or POMR. Also, in the 1960s, the Mayo Clinic began developing electronic medical record systems.

In 1970, the POMR was used for the first time in a medical room at the Medical Center Hospital of Vermont. By this time, touch screen technology had been incorporated into data entry procedures. In subsequent years, drug information elements were added to the core program, allowing physicians to check drug actions, dosages, side effects, allergies, and interactions. At the same time, diagnosis and treatment plans were designed for more than 600 common medical problems.

During the 1970s and 1980s, several academic and research institutions developed and refined various electronic medical record systems. The Technicon system was based on hospitals and the Harvard COSTAR system had ambulatory care records. Duke’s HELP system and ‘The Medical Record’ are examples of early hospital care systems. Indiana’s Regenstrief registry was one of the first combined inpatient and outpatient systems.

With advances in diagnostic and computer applications during the 1990s, electronic medical record systems became increasingly complex and widely used by practices. In the 21st century, more and more practices are implementing electronic medical records.