In with the old: "writing" is the newest form of technology, thanks to digital pens and paper

Health Management Technology, April, 2004 by Nick van Terheyden

As a tech-savvy physician, I have longed for a way to capture clinical data that would make it instantly available to my colleagues. Unfortunately, most of my colleagues still rely on pen and paper. While these colleagues might be intrigued with the newest electronic devices to access information and support them in their personal and professional lives, their reticence still prevails when it comes to electronic documentation. The underlying fear is that any technical innovation will cost more time away from their primary role: the delivery of care to patients.

My colleagues accept the value derived from clinical information stored on computers. However, to review this information, it must get into the computer, and therein lies the problem: asking physicians to capture data. Recent advances in technology such as automated template-based solutions, speech recognition and scanning have spurred some success, though minimal, and the transcription industry remains a healthy $6 billion to $18 billion one. The fact remains, most clinicians still are more comfortable with pen and paper then anything electronic in nature.

Writing as Data

A new advance in digitized paper and pen (DPP) allows anyone, not just clinicians, to continue to write information on paper, which is then transferred into the computer as data. This advance represents patented technology from Anoto, a Swedish company.

The key to this technology is the pairing of paper and pen. The digital pen writes on ordinary paper that is printed with a unique pattern almost invisible to the naked eye. The Anoto pattern consists of small dots approximately 0.3 mm (0.01 inch) apart. The placement of these dots relative to a grid allows the pen to ascertain its exact position and motion relative to that form. When writing with a digital pen and Anoto-enabled paper, digital snapshots of the pattern are taken at a rate of more than 50 per second. The "intelligence" in the paper derived from the pattern makes it possible to capture the content digitally and extract data from these forms.

Physicians can write using the same strokes they have used for years and transfer this to a computer as data--with no voice recognition, no time-consuming data entry by a clerk and no scanning. With the ability to identify the location of pen strokes, it is now possible to effectively digitize paper and convert the written word into data.

As a side benefit, physicians can retain much tighter controls and tracking of who entered that information and when, since the pen keeps a date and time log tied to the data it captures. This is important with the latest regulatory requirements associated with the Health Insurance Portability and Accountability Act of 1996.

Applicability

Look around any hospital or clinical practice and count the forms and paper in place. How many of these get filed away or lost, with no hope of providing useful information to the clinician, because it is impossible to extract data from these forms without a manual review of each one?

There are already applications built on this technology to capture data on handwritten forms such as a prescription blanks and convert this into true clinical data. Here in the U.S., some companies supply paper-based forms on digitized paper to use with the digital pen.

Imagine the possibilities. A health risk assessment (HRA form in this new format can be used by a patient in a doctor's waiting room. The patient can complete an HRA form while he waits to see the doctor. The patient's responses would be digitized and converted into data values that trigger alerts, guidance and notes generated for the physician when he sees the patient. This could help the physician to focus on critical healthcare issues during the visit and also could be an important timesaver for the physician, who is already time-pressured to complete the consultation.

Right now, because so much data is locked in single-access and poorly organized paper files, physicians repeatedly end up asking for the same data--and get it. That new information also is stored in multiple locations, never checked for consistency and provides minimal value to the clinical care of patients. Patients endure repetitive questioning because they have come to expect it as part of healthcare delivery. In its simplest form, DPP captures all this data in electronic form, which means it can be stored, shared and retrieved more efficiently and by more people.

The value proposition doesn't stop there. Most physicians remember a small percentage of the known medical facts--typically, the well-established, common facts and not necessarily the latest and greatest treatments. If a patient falls into the "typical" group, then the physician's typical questions have covered the potential issues and questioning will benefit the patient.

But what if the patient's condition or disease fails outside the typical boundary? This combination of events may set the physician on his way to a medical error. What if the physician could capture his clinical interaction as clinical data and, based upon this, the computer could provide him with context-sensitive, current clinical research that helps in professional decision-making and delivery of patient care? Does anyone lose in this equation?