One of the first organizations to begin the definition and use of an EHR capability was The Laboratory of Computer Science (Dr. Octo Barnett, Director) at MGH in Boston in 1966 (see Refs A1 and A5). In order to deal with the complexity of patient information, this model development began design of a programming language that enabled manipulation of data defined as strings of characters but with manipulation of characters in both persistent and process-transient data structures in both a unified way and using limited computer memory. This programming language Ref B1) later became both an ANSI and an ISO standard and ran, both then as well as now, on a wide variety of hardware platforms. It provided capabilities essential to the exploration of the functional capabilities of an EHR. Pilot capabilities were developed for a number of clinical settings at MGH that were interactive using the teletypes that were the prevalent access ports of that time whereas most other administrative data input still used the punch card formats that were widely used in business data processing. This interactive data entry capability provided both the speed of input at point-of-care and the ability for the immediate responses which enabled prompts and reminders to be conveyed to practitioners during patient care. This behavior had never before been demonstrated in health care settings. Because of the sequential nature of the user-input-followed-by-system-response sequence, a scrolling style of dialog resulted that held until Graphic User Interfaces (GUI) arrived; with that arrival, event driven dialog then became possible which was supported by various "middleware" platform components of the communication architecture. But, beginning in 1975, this Model development site embarked on the development of a package for ambulatory care called "Computer-Stored Ambulatory Record (COSTAR)" that could be widely used; it was delivered in 1977 and it became widely available, being supported by both vendors and a Users Group.

The programming language that was developed for these efforts and supported by federal funds, was named "Massachusetts General Hospital Utility Multi-Programming System (MUMPS later named M)" and it quickly spawned several dialects such that application systems running in one language variant could not be ported to another environment with a different variant. Individuals in both the Depts. of Health and Welfare (DHEW at that time) and Commerce (National Bureau of Standards - NBS - now National Institute of Science and Technology - NIST) who had been supporting the language development recognized that unless something was quickly done the investment in EHR system capabilities would never benefit healthcare until a common (standard) version existed that all could use as a common data management environment among which applications could be moved. A 2 year joint standards project was set up, jointly managed by NBS of DOC and the National Center for Health Services Research an Development (NCHSRD now Agency for Healthcare Quality and Research - AHRQ) of DHEW. It began in Sept 1973 and it completed with an approved Standard Language Specification in September 1975. This language specification was submitted to the ANSI Canvass process as X11 and was approved in 1977 as the first ANSI MUMPS Language Specification. It was later submitted to ISO which subsequently also approved it as IS 11176. In the mid 1980s the alternate name "M" was adopted by the X11 Standards Body. It was this standard which subsequently triggered the VA Model development effort but in 1967 it was those language capabilities that were first implemented in the initial MGH dialect that allowed demonstration of the EHR capabilities and stimulated the separate US Navy Medical Dept. Model Development that, together with the MGH experience also eventually helped stimulate both the VA and the DOD Model development projects that fully validated the capabilities that the MGH project originally set out to demonstrate. The M standard language remains today in 2000 as a fully competitive technology with high performance and scalability properties and with commercial as well as Openware suppliers. This seminal Model Development project was recognized in 1990 by the IOM report on the CPR( Ref A3).

In examining this Model development, it should be noted that in addition to the work at MGH at this time, several allied major hospitals and healthcare systems utilized the programming language technologic catalyst developed at MGH to craft separate EHR capabilities that were later recognized in their own right. For example, The Robert Brigham hospital joined Women’s Hospital and produced the Brigham and Women’s MRS. Brigham and Women’s later joined MGH to form Partner’s Healthcare System. At Beth Israel the system arose. They all drew on the same data management technologic innovation to implement similar basic patient care informational management functions (Ref A3).