Digital Pen and Paper: A Review of the Technology
and its Potential Application in Healthcare
By: Martin Schiavenato RN, BSN, MS
Doctoral Student in Nursing at the University of Central Florida

Citation:
Schiavenato, M. (February, 2006). Technology Brief: Digital Pen and Paper: A review of the technology and its potential application in healthcare. Online Journal of Nursing Informatics (OJNI), 10, (1) [Online]. Available at http://ojni.org/10_1/schiavenato.htm

 

Abstract

Electronic medical records (EMR) are a priority in the landscape of US healthcare.  Digital pen and paper systems offer an expedient and innovative way of adapting the familiar handwriting medium into the EMR.  The technology of the digital pen and paper and its components is reviewed and critically evaluated as to its potential advantages, disadvantages, and implications to patient care.  In addition, field testing of a commercial digital pen and paper system was carried out in an informal educational setting by a panel of expert clinicians and educators.  Potential nursing and healthcare applications and implications are listed and discussed.  

Keywords

Digital Pen, EMR, Clinical Documentation, Handwriting, Field Testing

The need for accurate documentation is self-evident in clinical practice and it is an integral part of delivering quality healthcare.  Under the leadership of President Bush (The White House, 2004), the Health Information Technology Plan attempts to lay out a strategy to bring healthcare in the United States into the 21st Century.  A major component of this strategy, now endorsed by the Department of Human Services (US Department of Health and Human Services, n.d.), is the creation and maintenance of electronic medical records (EMR), or electronic health records (EHR).  This paper discusses the technological application of the digital pen and paper as a possible element in the development and maintenance of EMRs.System Components

The digital pen and paper technology promises to capture electronically handwritten and form documentation in the familiar context of writing with pen and ink.  This comes with the added bonus of an almost instant conversion or download unto the digital environment of a computer and other electronic media.  Digital pen and paper technology promises to expedite the capturing, saving and dissemination of clinical data i.e. produce and facilitate EMRs.  Three components make up this system: Pen, paper and software. This discussion, unless otherwise stated, is based on the evaluation of the IO2 Digital Writing System by Logitech (Logitech, n.d.).

The Pen

Aside from its mundane duty of writing in ink, the digital pen is able to record every pen stroke through a built in camera.  Recorded pen strokes include drawings and sketches in addition to alphanumeric input. This information is then stored onto the pen memory.  The memory on this model was 856 kb stroke memory, or the equivalent of 40 written pages.  Memory use, as well as battery life, is displayed with light indicators on the pen.  The battery itself is a lithium ion battery with up to 3 hours or 25 written pages of life. The pen is recharged in a cradle that hooks up to a personal computer via USB.  This cradle also automatically acts as the download point for recorded pen strokes.  Other models, not reviewed, have interface capabilities via Bluetooth with mobile phones (Maxell, n.d.; Nokia, n.d.).     

The Paper

To properly use the digital function of the pen, writing has to occur on specially prepared paper.  The paper consists of dots barely visible to the naked eye which form a grid and act as map coordinates to direct and pinpoint the exact location of every pen stroke on the paper (Anato, n.d.).  Paper is available from leading paper product providers in various styles and sizes.  In addition, applications for in-house forms and documents can be obtained from software providers that enable the layout and production of custom forms and documents (Digipen, n.d.; Dotforms, n.d.; Expedata, n.d.; Mi-Co, n.d.).  Hewlett Packard also markets a system that incorporates the digital pen and custom form-making software to print the digital grid on standard paper using standard HP printers (Hewlett Packard, n.d.).   

The Software

Besides the custom applications for form and paper production discussed above, the digital pen system comes with its own standard software that facilitates download of data from pen, and common document handling utilities such as editing, filing and searching.  After downloading a document unto a PC, the document can be modified, stored, or even automatically emailed. Text conversion can also be accomplished.  This feature enables your written notes to be converted unto a text file with the promise of 90% accuracy.  In other words, your handwriting can be translated into a common word processing document simply at the click of a button.

Healthcare Applications

Digital pen and paper technology enable the collection and digitalization of written notes, as forms or as free text, including sketches, which can easily be incorporated into the EMR.  Traditional paper handling activities such as scanning, transcribing and other storage and processing can be significantly minimized.  Potential applications include clinical documentation (i.e. progress notes, assessment and intake forms, surgery drawings etc.) as well as billing and “back office” utilities such as record archiving and access.  Communication applications include email, and cellular phone messaging.  In Sweden, a hospital based home care clinic implemented a system that utilized digital pen technology and a mobile internet technology to assess pain in patients at their home (Lind & Karlsson, 2004).  A panel of six expert clinicians and educators field tested the IO2 (Logitech, n.d.) in an informal educational setting and their findings and suggestions for applications are summarized in Table 1.  Additionally, it is worth mentioning that because of the common digital format, these forms and documents can be secured using standard security protocols such as system passwords and encryption.   

Advantages

Advantages of a digital pen and paper system include ease of use and low need for training: The pen and paper format is intuitive and in common use.  Contrast this to a light pen, PDA or even a keyboard, all which require some degree of training or familiarization.  Although custom form-making software and institutional applications can be pricey, a standard IO2 system as reviewed retails, as of writing, for under $300.  Considering other technologies and electronic applications, this is relatively inexpensive.  This cost includes the pen, cradle and file software including text conversion software; a160 page 8 ½ by 11 inch spiral digital paper notebook retails for under $9.00. 

Cherokee Indian Hospital reports savings in their insurance processing transactions using a digital pen and paper system on a per form basis from $2.00 to $0.50 (Briggs, 2004).  While obviously significant, this savings also came with the added benefits of expediting billing and accounts receivables.  The promise to expedite and simplify the paper process carries with it the potential for cost savings and better resource management.  It is this promise that continues to forward the EMR movement.   

Disadvantages

Although the digital pen reviewed was a bit bulkier than a standard writing instrument, I did not find it difficult to handle or particularly tiring on the hand.  I found download times to the PC a bit long, as compared to, say, PDA synchronization.  A limiting factor inherit in this system is the necessity for specialized paper.  This adds the inconvenience of “standard” digital papers that may or may not be suited to a particular documentation task, or the potential costs associated with customized software and/or pre-printed digital forms.  Also, a large institution with hundreds of forms to adapt to the new system should keep in my mind costs associated with that process (i.e. technical expertise and time).  This and all potential costs should be weighted against the potential savings and benefits of expediting and enhancing documentation and billing processes.

The process to “train” the text recognition software to recognize my handwriting was a bit involved and took me about one hour.  But the main current disadvantage of this system is its text recognition accuracy, which although it appears quite impressive at 90% it of course, implies a 10% error rate; quite high for a clinical application –imagine nurse’s notes in which every 10th word was inaccurate, or about 7 wrong words in this paragraph.  

Discussion and Conclusion

The impetus for EMR in the US is a reality well into progress.  The digital pen and paper is a potential and promising element in the evolving pursuit of the application of technology in healthcare.  This system can transform the familiar process of pen and forms, into an expedient and effective way to document and process clinical, research, and financial/administrative data.  Given the current text recognition accuracy rate, free handwriting input in clinically relevant areas requiring conversion into text form should be limited or avoided.  Forms mostly driven by boxes and check marks may be least vulnerable to errors in conversion to text.  On the other hand, capturing the form or written record on paper, without conversion (that is maintaining the free handwriting input as an image), would completely eliminate the potential for this error in text conversion.  If conversion from free handwriting to text is a must, than a transcription review would be necessary to ensure integrity in the text.       

Finally, although cost savings and better resource management are incentives for individuals and institutions to adopt EMR technologies such as the digital pen and paper, there is a need for current research noting the effects of this technology on patient care and quality outcomes.  For example, do clinical digital pen and paper systems allow for more patient time and or, better provider/patient interaction?  Are savings accrued from these new technologies used to improve patient resources such as better facilities and more staff?  These and many other questions related to the effect of technology on the healthcare consumer still loom ahead.         

Table 1.

Documentation and archiving applications: clinical, administrative, and research

 

  • Prescription writing and recording.
  • Patient journals (i.e. symptom journals).
  • Surveys: Forms and open-ended questions.
  • Field notes and transcription (i.e. in qualitative studies).
  • Graphic documentation (i.e. pressure sores and skin lesions, fundal height, anatomical position, tumor staging, etc.)
  • Rapid, emergent documentation (i.e. “codes” and resuscitation flow sheet).
  • As an intermediary technology to a “paperless” system, or as digital adaptation of “paper must” processes.
  • Instances where patient’s handwriting/signature is required (i.e. informed consents, living wills etc.).

 

References

Anoto. (n.d.).  Anoto functionality.  Retrieved June 30, 2005, from http://www.anotofunctionality.com/
Briggs, B. (2004). Digital technology puts pen to computer. Health Data Management, 12(10), 94, 96
Digipen. (n.d.).  Bendit innovative interfaces.  Retrieved June 30, 2005, from http://www.digipen.de/
Dotforms. (n.d.) Diagramm Halbach dotforms.  Retrieved June 30, 2005, from http://www.halbach.com/dotforms/index_en.html
Expedata. (n.d.). Digital solutions.  Retrieved June 30, 2005, from http://www.expedata.net/  
Hewlett Packard. (n.d.).  HP Forms Automation System.  Retrieved July 1, 2005, from            http://h30046.www3.hp.com/ipgformsautomationcomponents.php?topiccode=IPGFORMSAUTOMATIONCOMPONENTS&regioncode=NA&langcode=USENG Lind, L., & Karlsson, D. (2004). A system for symptom assessment in advanced palliative home healthcare using digital pens. Medical Informatics and the Internet in Medicine, 29(3-4), 199-210.
Logitech. (n.d.). Logitech digital writing system.  Retrieved June 30, 2005, from http://www.logitech.com  
Maxell. (n.d.).  Digital pen.  Retrieved June 30, 2005, from http://www.maxell.co.jp/e/products/industrial/digitalpen/index.html
Mi-Co. (n.d.).  Putting handwriting to work.  Retrieved June 30, 2005, from http://www.mi-corporation.com/page.php?pageid=13
Nokia. (n.d.).  Nokia digital pen.  Retrieved June 30, 2005, from http://www.nokia.com/nokia/0,5184,5787,00.html
US Department of Health and Human Services. (n.d.). The decade of health information technology: Delivering consumer-centric and information-rich health care.  Retrieved June 29, 2005, from http://www.hhs.gov/news/press/2004pres/20040721.html
The White House. (2004). Health information technology plan.  Retrieved June 30, 2005, from http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html

Author Bio

Martin Schiavenato RN, BSN, MS

Doctoral Student in Nursing at the University of Central Florida

Martin Schiavenato is a PhD student in Nursing at the University of Central Florida.  His research interests are in pediatric pain assessment and pain management, and in the applications of technologies in nursing education and clinical practice.