Out-patient Medical Record (OMR)
The OMR was first developed due to the relocation of approximately 20% of clinical staff to a location physically disconnected from the main hospital.  Due to the remoteness of the new location, it was difficult to transport the patient's paper medical record from the main hospital for use in patient care.
To facilitate communication between the clinicians at this new location and those at the main hospital, computer terminals were installed in every office. These terminals allowed clinicians to enter, edit, and display patient data such as "problem lists, medication lists, health promotion and disease prevention screening sheets, flow sheets, and progress notes" as well as influenza vaccination reminders.  Any patient problems were entered by the clinicians into a problem list and were categorized as either active or inactive. Medications were recorded separately on lists as well as patient vital signs and any progress notes. Utilizing the OMR clinicians were able to index, sort and view patient information by date and time. 
The Beth Israel Hospital clinical computing system, developed by the Center for Clinical Computing, is a heavily used hospital information system . In 1991, 20 staff physicians, 5 fellows, 64 residents, and 11 nurse practitioners had entered 15,121 active problems and 1,996 inactive problems for approximately 3500 patients. Over the years modules for referral letters and rapid physical exam findings entry were added to the OMR system . By 1994, clinicians were using the system more than 50,000 times a week from any of 2,000 terminals located throughout the hospital and outpatient facilities . Tasks performed by clinicians using the computing system included:
- look up laboratory results
- review diagnostic reports
- obtain medication and discharge information on hospitalized patients
- perform literature searches 
During this time period, 1993-1995, alerts and early decision support features were introduced. They were designed to offer reminders for flu vaccines and track laboratory data and interventions of anticoagulation patients. The staff at Beth Israel were able to conclude “that routinely collected data contained in an electronic patient record (EPR) can be a rich resource for describing and evaluating clinical practice”. This made the OMR more valuable than initally thought. “Identifying and decreasing clinical practice variation in anticoagulation has implications for cost, utilization of services, and patient satisfaction.” 
As of 2001, over 1,000 staff physicians, nurses, residents, and psychiatric social workers made 1,278,484 progress notes, entered 391, 897 medical problems, and written 1,367,450 online prescriptions for at least 53,000 patients. It is important to note that psychiatric notes are stored online, demonstrating clinicians’ confidence in the established security measures.
In 2009, Beth Israel reported a seven-fold increase in the number of notes/addenda per day for a staff of five-hundred clinicians at the site of the Harvard Medical School as a result of a nine month implementation of a new EMR .
Today, the Out-Patient Medical Record at Beth Israel Deaconess Medical Center has been renamed to the Online Medical Record (Web OMR). Web OMR is used in both inpatient and outpatient settings for applications ranging from inpatient progress notes, to inpatient stays. BIDMC laud Web OMR for its ease of use as it allows all relevant patient information to be viewed in one place. In addition, BIDMC claims Web OMR reduces error and facilitates communication between outpatient providers, inpatient providers, and the patient’s pharmacy . January 24, 2011 Beth Israel Deaconess Medical Center was certified as a complete EHR under the Certification Commission for Health Information Technology (CCHIT) EHR Alternative Certification for Hospitals (EACH) program. BIDMC also credits its success with Web OMR as a major contribution to being distinguished by US News and World Reports as a Most Wired Hospital in 2007 .
The goals of the OMR are to facilitate workflow, support collaborative practice models, provide clinical practice guidelines available, and create a paperless ambulatory office environment. 
The OMR was designed around three guiding principles, which were:
- There should be frequent clinician interaction with the system
- Paper forms should not be used to transcribe to the OMR
- Data entry should be minimal and records should be shared universally between physicians, staff and even the patients themselves
“The OMR is organized around a central, integrated patient registry that contains information on more than 1 million patients that is the core of the Center for Clinical Computing system” .
Like many electronic health record systems physicians and nurses have access to the patients chart and have the ability to order prescriptions electronically from the OMR. Physicians are not limited by a controlled vocabulary for entry of information, but an included dictionary/thesaurus is used to facilitate searching and research . This aspect in design reflects the preference of the physicians who are given more control over input by this method.
In addition to an ambulatory environment, other health care institutions such as MD Anderson Cancer Center in Houston, TX use the OMR to provide a sequential record of documentation of medications, nursing plans of care, and interventions related to medications  . Three months after introducing the system to the rest of the clinics at the hospital in July 1990, a study noted a discrepancy in the number of patients with updated medication and problem lists between the clinics at the hospital and the outside clinics. Almost three fourths of the patients taken care of at the hospital clinics were without any problem lists or medication lists unlike the distant clinics, where 70% of the patients had updated problem and medication lists .
Even though it took more time to type the notes than to write them, clinicians typed twice as many words as they wrote in every note. Using problem lists generated by the system, providers were prompted to review, edit, and update clinical records. This shows that clinicians considered the notes that they typed in the out-patient medical record more valuable and effective. 
Beth Israel informaticians and clinicians never foresaw some of the fundamental changes that were to be brought on medical practice by the implementation of the electronic medical record. It demonstrated the ability to improve the quality of care, decrease medication errors, save time for physicians and nurses, improve clinical precepting for residents and medical students, and supported collaboration in complex organizations. Currently, the five major components of the system are:
- the On-Line Medical Record (Web OMR)
- Physician Order Entry
- the Emergency Department "dashboard,"
- the Performance Manager.
A graph of the data from January, 2008, to January, 2009 illustrates the dramatic results. Such results bode well for the increasing adoption rate of EMR in healthcare.  Among the lessons learned reported by Beth Israel: face-to-face discussions with all disciplines involved was key to keeping the project on track, and including ancillary services helped the team achieve the goals of this project. Recommended next steps, including audit documentation, recommendations for additions to the database, and format template notes for other services, testifies to the incremental and iterative nature of EMR evolution.
- Beth Israel Deaconess Medical Center (BIDMC) http://www.bidmc.harvard.edu/
- Safran C, Rury C, Rind DM, Taylor WC. Outpatient medical records for a teaching hospital: beginning the physician-computer dialogue. Proc Annu Symp Comput Appl Med Care 1991 http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1807568
- Einbinder J, Safran C,Rury C. Outcomes Research Using the Electronic Patient Record: Beth Israel Hospital's Experience with Anticoagulation http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579208/pdf/procascamc00009-0848.pdf
- Cintron A, Phillips R, Hamel MB. The effect of a web-based, patient-directed intervention on knowledge, discussion, and completion of a health care proxy. J Palliat Med 2006 Dec;9(6):1320-8. http://www.ncbi.nlm.nih.gov/pubmed/17187540
- Bohmer R, McFarlan FW. Information Technology and Clinical Operations at Beth Israel Deaconess Medical Center. Harv Bus Rev 2007 Jun 4 http://harvardbusiness.org/product/information-technology-and-clinical-operations-at-beth-israel-deaconess-medical-center/an/607150-PDF-ENG
- Beth Israel Deaconess Medical Center – “What Sets Us Apart” http://www.bidmc.org/MedicalEducation/Departments/Medicine/ResidencyinInternalMedicine/WhyBIDMC/WhatSetsUsApart.aspx
- US News and World Reports – “Most Wired Hospitals 2007” http://health.usnews.com/usnews/health/articles/070718/18mostwired.all.htm
- MD Anderson OMR Policy http://www2.mdanderson.org/app/ir/SACSHTML/DocumentAppendix/Appendix%20G/CLN0645.pdf
- Wilcox, A. A Physicians Use of Outpatient Electronic Health Records to Improve Care. AMIA Annu Symp Proc 2008;809-813. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655996/
- http://www.bidmc.org/QualityandSafety/QualityandSafetyImprovementsatWork/~/media/Files/QualityandSafety/2009%20Silverman%20Symposium/Patient%20Safety/Implementation_ofNew_Elect_Doc_System.ashx Beth Israel New Electronic Documentation System