One of the most significant steps taken to guide the evolution of the EHR following the beginnings of Health Informatics Standards activities in the mid 1980s was the study by the Institute of Medicine (IOM) of the National Academy of Sciences which began in 1989 and completed its initial report in 1991 titled “The Computer-based Patient Record: An Essential Technology for Healthcare” (Ref A3);  it was subsequently updated in 1997 (see http://www.nap.edu). This study tapped a wide range of expertise, included the major developmental projects that are described in the Developmental Models Section of this Segment of the Web site and involved individuals active in a wide range of professional specialty disciplines. This document has become the statement of the "Vision", the global target capabilities toward which the various activities, products and services must point, if a truly interoperable, comprehensive EHR environment is to emerge. This report has had a major influence on the creation of the Health Insurance Portability and Accountability Act - HIPAA (PL 104-191) that was enacted in September 1996 and which clearly stated that this Act was a first step toward an EHR environment.