Duke University’s system began in 1969 in an obstetric clinic setting (Ref A9) but later was expanded to inpatient settings. They used an in-house proprietary system (named GEMISCH for GEneralized MIS for Community Health) for managing the persistent data which over the years evolved into a high level programming language. The system was referred to in later years as “The Medical Record” - TMR. The system performed administrative as well as care data management functions. By 1971 it was used to administer questionnaires for patient health histories. A major clinical focus was representing patient management.