The Medical Record (TMR)
The Medical Record (TMR) was a comprehensive medical information system developed at Duke University Medical Center in Durham, North Carolina by William Stead, M.D. and Edward Hammond, Ph.D. Known as GEMISCH (based on the Generalized MIS for Community Health programming language) up until the 1980's, the original goal of the TMR was to replace the paper chart with a computer-based record that would serve the needs of a practicing physician. TMR incorporated administrative functions for economic feasibility. By 1974, 15,000 mark-sense patient histories had been processed and interactive questionnaires were available for patients covering a variety of symptoms.
The TMR development effort began in 1969 and was funded by Duke University, Robert Wood Johnson Foundation (RWJF) and the National Institutes of Health (NIH). It initially began with 19-page, mark-sense screening medical history entered into a large mainframe system by clerks (Hammond 2001). Shortly after, a real-time interactive questionnaire was developed by Dr. William Stead and completed by patients directly on the minicomputer which was newly available technology. Some of the early functions of the TMR system were to record any data that could be found in a traditional ambulatory record or inpatient chart.
By 1974 the TMR system could process 1,000 patients a week and as time went by it was enhanced with a dictionary, administrative features and a variety of characteristics that allowed it to be used in a variety of clinical settings (Hammond 2001).
The TMR went through tremendous growth during the 80s. Minicomputers were being used, which expanded the implementation of the TMR at multiple sites in a variety of clinical settings including inpatient and outpatient. By January of 1981 TMR allowed large practices to do scheduling, accounting and medical records. In April of 1983 TMR was used at the Kenneth Norris Cancer Research Center, with the expectation that it would maintain computerized record and support information needs of ambulatory and clinical care. (Stead and Hammond 1983). Programs in the TMR were constructed for specific purposes. These purposes include:
• Input • Frames • Message • Print • Retrieve • Store
Over its lifecycle, TMR was implemented in over 40 sites and 14 different specialties. The smallest application was a solo practitioner, and the largest site supported more than 350 providers. The maximum number of patients supported by TMR in one system was approximately 750,000. The Medical Record provides an integrated clinical and accounting functionality. At its peak, it was operational in 15 different sites. The system was used at Duke until 2002. 
In the last thirty years, there has been a shift from single family physicians providing almost all of an individual's medical care to teams of health care professionals in outpatient clinics and HMOs sharing the responsibility. Because of this shift, the need for ambulatory care records that contain notes written by different health care providers, large numbers of laboratory test results, and a diverse set of other data, including X-ray examinations and pathology reports became a necessity. TMR, along with COSTAR, Regenstrief Medical Record System (RMRS), and STOR were among the first systems that focused on ambulatory care (Tang & McDonald, 2006, p. 452).
Although TMR was created for ambulatory care, it has grown to include inpatient care, including the Labor and Delivery Unit and Surgical Intensive Care Unit at Duke. A recent project connected inpatient and outpatient computer-based patient records for the Bone Marrow Transplant Unit. Medical informatics trainees work in the TMR Laboratory, giving them hands-on experience. One of the reasons why TMR was a major step forward in the history of electronic medical records is because it was one of the first widely used systems that utilized hierarchical data structure with variable-length text. It also incorporated an advanced data dictionary that included an extensive medical vocabulary, algorithms, decision making rules and user passwords (8). The user passwords were used to protect clinicians and patients. Patient records always have to be concealed for HIPPA purposes. That is why TMR IS revolutionary because it had the data dictionary with the security to protect it. In 2003, the American College of Medical Informatics (ACMI) presented the Morris F. Collen Award to Edward Hammond in recognition of his significant contributions to medical informatics. The Collen award is the ACMI's highest award, for lifetime achievement and contributions to the discipline of medical informatics.
Examples of information captured
Admission Data Display.
Information such as date of admission, room, time, physician, patient category, service, case number and admiting diagnosis are passed to the workstation by the Hospital Information System. Other critical medical information is entered into the workstation on the Unit by the nurse. http://img203.imageshack.us/img203/1717/tmr1.png
Summary Physiological Data.
A filtered average of the data from the monitor is recorded in the patient's longitudinal record each hour. The summarydata permits rapid display of data for multiple days.
Detailed Physiological Monitoring Data.
The workstation samples the physiologic bedside monitor for data every five minutes. The detailed monitor data is kept in a separate record linked to the patient's longitudinal computer-based record.
Data such as height, weight, heart rate, cardiacoutput, the various pressures, and blood gas information are obtained from the record and all other parameters are calculated in a spreadsheet fashion.
Laboratory Flow Sheet.
Data is transferred from the transaction-oriented Hospital Information System and converted into time-oriented storage for clinical review.
1. Hammond WE, Stead WW. The Evolution of GEMISCH and TMR. In: Orthner HF, Blun BI, editors. Implementing Health Care Information Systems. Springer-Verlag, New York, 1989;33-66.
2. Hammond, W. Ed How the Past Teaches the Future: ACMI Distinguished Lecuture
3. Stead, WW, Hammond, EW. TMR - The Medical Record Spanning the Spectrum of Patient Care.
4. Tang, P.C., & McDonald, C.J. (2006). Electronic health record systems. In E.H. Shortliffe & J.J. Cimino (Eds.), Biomedical informatics: Computer applications in health care & biomedicine. (pp. 447-475). New York, NY: Springer.
5. William W. Stead and William E. Hammond. Functions Required to Allow TMR to Support the Information Requirements of a Hospital. Proc Annu Symp Comput Appl Med Care. 1983 October 26; 106–109. 
6. William W. Stead, MD. Presentation of the Morris F. Collen Award to William Edward Hammond II, PhD. J Med Inform Assoc. 2004 May–Jun; 11(3): 221–224. 
7. http://www.openehr.org/downloads/presentations/Edv2BerlinEHR.ppt#1 8. Sittig, Dean. Week 1 – History of EMR v2. UT Houston School of Health Information Sciences