The Medical Record (TMR)

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The Medical Record (TMR), is a comprehensive medical information system developed at Duke University Medical Center by William Stead, M.D. and Edward Hammond, Ph.D. TMR is based on the GEMISCH (Generalized MIS for Community Health) programming language and was know as GEMISCH 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. Initially, patient data entry was done using mark sense and key-to-disc system.

Development started in 1969, The development effort was funded by the Duke University, Robert Wood Johnson Foundation and NIH. By 1974 the TMR system could process 1,000 patients a week and 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 maintain computerized record and support information needs of ambulatory and clinical care. (Stead and Hammond 1983)

Over its existence, TMR has been implemented in over 40 different sites. It has been implemented in 14 different medical specialties. It has operated in outpatient settings, inpatient settings, intensive care settings, and combinations of these settings. 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. At present, TMR is operational in four sites. It is still a character-based system, uses DEC's VMS operating system, and runs on the Alpha computer (Hammond, 2001).

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).

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. It could also maintain a complete list of diagnoses, procedures, and time-oriented records containing subjective and physical findings, laboratory data, and therapeutic interventions. As the system evolved, more features were added such as administrative management functions.

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.

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. http://img72.imageshack.us/img72/6307/tmr2.png
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. http://img4.imageshack.us/img4/4707/tmr3.png
Hemodynamic/Metabolic Calculations. 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. http://img710.imageshack.us/img710/1162/tmr4.png
Laboratory Flow Sheet. Data is transferred from the transaction-oriented Hospital Information System and converted into time-oriented storage for clinical review. http://img535.imageshack.us/img535/3490/tmr5.png

References

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. [1]

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. [2]

7. http://www.openehr.org/downloads/presentations/Edv2BerlinEHR.ppt#1