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April 14, 2008

Quill Power — Is the Digital Pen Mightier?
By Mary Anne Gates
For The Record
Vol. 20 No.8 P. 22

Digital pen and paper technology integrates the familiarity of traditional information-gathering methods with the latest cyberspace technology.

In the healthcare industry, technology comes in many forms, some of it being quite complicated and some of it being as simple as ... well, a pen and paper. Digital pens function like ordinary pens but are enhanced with electronics that can store time-stamped content. Paper used with the digital pen has an irregular pattern of very faint dots comparable to map coordinates. The dot configuration tells the pen what form is being used, what is being written on the form, where on the form the writing is, and when the writing occurred.1

Each pen has its own identifier for added security and enables the recorded information to be traced back to it. Data stored in the pen are transmitted through a “synching inkwell or Bluetooth mobile phone” to a central server that can store, analyze, process, or transmit the information.1

Using the Digital Pen
“In clinical workflow, I see numerous places for it,” says Stephen R. Levinson, MD, author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care. “One, which I think people don’t commonly think of, is gathering information from patients prior to the visit. We are all familiar with going to the doctor’s office and sitting down with a pen and paper and filling out forms.”

Many in the healthcare industry have been projecting that there will be tablet PCs or kiosks in waiting rooms where people can enter pertinent personal information. That technology is just emerging, and there are a number of drawbacks, including cost. Also, many patients aren’t comfortable inputting information on such devices, according to Levinson.

Further, personnel must take the time to help patients learn how to use the technology so they can successfully enter their data. This scenario is neither productive nor cost-effective, Levinson says.

The pen and paper method gives patients an opportunity to provide their own demographic, clerical, and other pertinent information in a more familiar way. The form is then uploaded and available to physicians when they arrive in the exam room. Also, when an established patient makes a subsequent visit, a nurse or medical assistant can update the medical history to include any changes to the patient’s health.

Besides creating good forms that provide accurate, handwritten capture of word-by-word and number-by-number information, the digital pen can record drawings or sketches.2

Additionally, different digital pens have different memory or performance capabilities as do other electronic devices. A study evaluating an io2 Digital Writing System by Logitech found the pen had 856 kilobytes of memory, or the equivalent of 40 written pages, and a battery life of up to three hours, or 25 written pages.2

The benefits of a digital pen include the following:

• Information is processed more quickly.

• Written information is automatically sent electronically to a central database.

• There is automatic backup.

• It creates an identical virtual record.

• It is expected to help with compliance and reporting issues.

• It can be easy to use.

• There is accountability and traceability.

• There are unique identifiers embedded in the pen that keep track of signatories.

• It is a familiar device for data capture.

• It maximizes storage space.1

An automatic backup creates a virtual second copy that can be accessed by authorized personnel within a facility or by authorized external personnel, while specific identifiers indicate which pen was used and the time the information was written.

Programming Good Forms
“The critical piece is correctly programming good forms,” says Levinson. In other words, there are two sides to the digital pen. The one that you see is the data capture element of writing with a pen that also has a memory chip and a camera. The other side is the software that allows forms to be loaded and printed. Barely visible microdots identify the form, the patient, and the date while maximizing storage potential because it doesn’t need to store the entire image.

“You store the digital data and when you need to see the data, it matches it up with the underlying form. It’s highly efficient,” says Levinson. The use of high-quality forms can promote efficiency, usability, compliance, and data integrity, says Levinson, and working in a predominately paper environment at the bedside, the forms also need to be matched in the software they populate.

Levinson says the digital pen’s memory capabilities make it unnecessary to download information after each patient encounter.

Revolutionizing Medical Records
“The electronic medical record [EMR] has the potential for vastly improving the capture of medical data with the promise of improving the quality and safety of patient care,” says Robert J. Rothstein, MD, director of the department of emergency medicine at Suburban Hospital in Bethesda, Md., and a cofounder of BartCharts, an electronic documentation system. “However, available systems, as currently configured, may very well be an impediment to quality and safety in the emergency department [ED]. In the fast-paced, high-pressure environment of the ED, efficiency is essential for quality and safety, but most if not all of the marketed and so-called integrated EMRs are anything but efficient. Every minute that the clinician is away from direct patient care is a minute of opportunity for error. When it takes longer to document the care than to deliver it, there is a problem.”

A digital pen and paper system keeps the clinician’s focus on the patient instead of a monitor and a keyboard, trying to get the correct information entered quickly. Other advantages are more accurate patient information and the ability for qualified personnel to access the most current information to provide the best treatment.

Rothstein turned to digital pen technology at Suburban Hospital when the facility began looking for a simple approach to quickly and efficiently gathering patient information. The facility was searching for something at a reasonable cost that would cause minimal disruption to staff and patients. Officials at Suburban realized that the system must adapt to the way clinicians work and fit with already-established patient and clinician interactions. Combining digital pen technology from the Swedish company Anoto with what the hospital calls the electronic BartChart (eBC) allows clinicians to document in the time-tested manner of pen on paper, says Rothstein.

“Printed on the paper is a chief complaint template that allows a shorthand documentation of the patient’s history, physical examination, ancillary tests, treatment, diagnosis, and disposition. The clinician takes the paper on a clipboard with the computer pen to the bedside. What may take 20 to 30 minutes to document on many of the EMRs takes two to three minutes on eBC,” he says.

“The system for documentation must be in concert with the work habits of the clinician and in sync with the patient flow,” he adds. “It must be easy to learn, easy to use, and cost-effective.”

After implementing the digital pen and the eBC, Suburban Hospital has become more efficient and productive, according to Rothstein. “That does not count the fact that the learning curve on an EMR may take days to months, with efficiency falling to dangerous levels at times and never returning to baseline, let alone to the promise of improved productivity,” he says. “Within 10 minutes of sitting down with eBC, the clinician is nearly at full efficiency. Moreover, the embedded logic in the BartChart software makes for a higher degree of efficiency and productivity than the user experienced before. This logic allows for real-time feedback to the clinician regarding completeness of documentation and suggestions for entertaining evidence-based best practices.”

Costs and Other Concerns
Rothstein says the cost of implementing digital pen and paper technology in concert with eBC in the ED—which receives 42,000 annual visits—was under $10,000. The concern with the new method of data capture was that it had to be compatible with the existing computer system. A secure link to a patient medical record lets the clinician bring up any past ED visits. “From an access standpoint, this is really all that is necessary, and it did not require any significant effort from our IT department or the computer system vendor,” says Rothstein.

Any concerns the IT department had about maintaining the system disappeared with the realization that maintenance includes changing pen cartridges, filling the paper tray in the printer, and replacing toner cartridges.

Making the transition from paper to electronic documentation can be a challenge. Because of physician familiarity with pen and paper, the implementation of a similar digital technology could make the transition to an EMR easier. Additionally, because the technology essentially works in the background, little training is required. This means users can perform their duties as they always have while the new technology upgrades are put in place.

The familiarity with the technology helps healthcare organizations better deal with physicians who resist wholesale workflow changes. Because digital pen and paper technology has the ability to create an instant virtual record, it also has a significant impact on HIM departments. Today, a virtual record can be integrated into the patient’s medical record and be easily accessed by authorized personnel.

“While the system seems too good to be true, simplicity has won over our doctors and now a second group of physicians at our newest installation in a Houston hospital,” says Rothstein. “As more of our colleagues visit our ED, they begin to realize that efficiency and safety can actually be used in the same sentence as EMR.”

Acceptance of the new system also got a big boost at Suburban Hospital when its effect on the bottom line was realized. “One skeptic watched his reimbursement improve by 10% compared to his prior productivity using paper charts,” says Rothstein.

Study Results
While Suburban Hospital has enjoyed success with its implementation, the American Medical Informatics Association (AMIA) has raised several concerns about the usability of digital pens. In a recent AMIA study, 21 labor and delivery nurses compared the digital pen to its more traditional counterpart.3 The results demonstrated that nurses had an overall positive attitude toward using pen and paper technology and felt the system had merit but did not like its current design because the pen was bulky. Most nurses, the study found, used the first available pen when they were busy. However, making the digital pen readily available by putting it in a front shirt pocket, as most nurses or healthcare professionals do with a conventional pen, was not practical because the size and weight allowed the pen to fall out during tasks that required nurses to stoop, bend, or lean over.

While this usability study was the first of its kind for a digital pen, researchers also noted other issues that must be evaluated before widespread use of the pen occurs, including “integrity of data transfer, system robustness during downtimes, and the quality of character recognition.”3

Mary Anne Gates is a medical writer based in the Chicago area.

1. Accenture. Points of view: Digital pen and paper. Available at: http://www.accenture.com/Global/Services/Accenture_Technology

2. Schiavenato M. Digital pen and paper: A review of the technology and its potential application in healthcare. Available at: http://www.eaa-knowledge.com/ojni/ni/10_1/schiavenato.htm

3. Yen PY, Gorman P. Usability testing of digital pen and paper system in nursing documentation. AMIA Annu Symp Proc. 2005:844-848.