Friday, April 8, 2011

Cool Technology of the Week

Structured electronic clinical documentation is the next frontier in EHR implementation.  It's particularly challenging in Emergency Medicine which is a fast paced, sometimes chaotic environment.   Documentation can be time consuming and is the most frequently interrupted task.  How can we balance the need for structured data capture with ED workflow?

There is no single right answer - we've used iPads with web applications, voice recognition, and disease specific templates.

We now have a new tool in our quiver, the Digital Pen from Anoto as implemented by Forerun Systems for ED charting.    Forerun is a technology spin out of BIDMC and I have no financial relationship to it.

The digital pen is NOT a handheld scanner, capturing graphics or PDFs.   It's a means to capture discrete patient data to support clinical documentation, quality reporting, and regulatory requirements.  It captures data at the bedside with a granularity that dictation cannot.

Here's how it works.

Forms are printed with a special background matrix that identifies the unique form, patient, clinician, and data elements.  Think of it as a page of  2D barcodes.   Forms can be printed as needed at various points in the ED workflow either manually or automatically.

The pen "knows" exactly which patient form is being used and what fields are being entered.   You can write on multiple forms in parallel without confusing it.    Checking a box generates structured data indicating that a sign or symptom is present.   Writing through a word generates structured data indicating that a sign or symptom is absent.   When free text is entered, both the original text and an optical character recognition interpretation are available.

As the pen is inserted in a USB dock, the structured data is uploaded into the EHR.

Here's an example

The form as entered by the user

The discrete data displayed in a web application (including handwriting recognition in red for editing).

The final output with all discrete data converted to structured documentation for clinical use.

Although we hope to use iPads for clinical documentation throughout the institution, there are workflows in which digital pens are faster, easier, and less intrusive to the caregiver/patient interaction.

A pen for patient specific structured electronic clinical documentation.   That's cool!


Anonymous said...

One Word. WOW.
Linda Stotsky

Anonymous said...

wow indeed - this needs to get picked up!

The Medical Quack said...

That is just very cool and thanks for sharing! I have been a tablet person since day one and input and making it easy and simple through software is huge and I have tried and used many input programs. I don't care which one it is as long as it works and is easy to use and this certainly looks to meet the grade there!

One other item I would like to comment on here too is I know you have used it and put it to the test, much appreciated as we are hearing the real thing here, unlike many others who are not "hands on" folks, and that makes all the difference in the world and gives the information you take time out to add so valuable.

I love those 2D bar codes and what they can do too and noticed that reference in there, and maybe one day they will be taken more seriously too for finding FDA recalls.

Kudos and thanks again for sharing!

ER Doc said...

This demo is similar to T-System's DigitalShare product. T-System is the company behind T-Sheets used in 50% of emergency departments. Check out the live demo:

Jonathan Merrill said...

I'd be interested to read how your organization is handling iPads in IT. How are you encrypting iPads? Are you controlling PHI, such as generated by this application, from remaining on the iPad? Have you guys thought through theft?


W C Hitt said...

Just saw the recent news segment. Great work! Wish we had the will to create/adapt an ipad friendly emr.

Anonymous said...

Anoto's tech is very cool and well tested/mature -- they've actually been around for quite some time, with their first product launching in the late '90's. Nice to see it integrated into a medical application.

Anonymous said...

How is this better than structured document capture from a tablet at the point of care?

Cameron Tully-Smith said...

How is this better than tablet point of care data capture?

Chris Corbit said...

I have had the opportunity to use this system and I find the workflow with the digital pen works very well. The overall process with capturing data at the bedside on a paper template coupled with the ability at add natural language into the chart takes advantage of the strengths of each type of documentation -- digital pen for the info that is easily templated, natural language processing to capture the encounter with a free text, and finishing it up on a computer workstation to edit or add any additional information (lab and radiology feeds for diagnostic results, etc.).

I have seen the Digital Share system at HIMSS and the T-System implementation of this technology at a couple of trade shows, and the workflow of this product is fundamentally different. The final output of the T-system Digital Share system is still a templated sheet, and the data points that are captured are limited to specific areas. Also, there is no use of NLP to add narrative text to the encounter.

For the statement about "How is this better than tablet point of care data capture?" -- let me respond to this one also. I have fortunately (unfortunately) been through 4 EDIS implementations so far, and each time it was touted that tablets will be the 'holy grail' of documenting at the bedside -- directly into the EMR. In each instance, the tablets gathered dust and were not used. Why? Try carrying a tablet with you around on a shift, moving from room to room. It is awkward and difficult to carry. Also, there is always a speed issue. Try going through a chart quickly on an EMR template -- there is always a lag in the system response. However, a digital pen is much smaller and the paper template is with the rest of the paper chart, or easily carried in your pocket, and there is no lag in response from the system.


Jordan Davis said...

We here at Emergisoft have been working with Anoto and deployed this same technology 4 years ago. A few extra features we provide is complete sentence output formatted in a narrative layout as opposed to single word or phrase. We also have this capability via the cloud with our EDAnywhere solution.

logicalink said...

@Chris - it is interesting that you mention speed as a deterent for using the tablet and that "the rest of the chart is paper". Using a mix of paper and electronic documentation would be a non-starter in my opinion and destined for failure. Let's all agree that replacing paper is very difficult. Especially in the ED. This solution is great for improving documentation but you don't eliminate paper. If you aren't using tablet-friendly documentation software, no tablet (including the iPad) is going to help. We're a big believer in the pen/paper metaphor and believe it is the most practical path to electronic medical records. And we put it into practice on the iPad and other tablets. Data entry on the iPad is tedious out of the box if you want to be beside. We've hightlighted some differences between digital pen and tablet on our web site if you are interested.

Ed Larkin said...

I am going to date myself with this comment but in 1990 Wang Labs introduced the first tablet and a stylus for written annotation of any file that could be displayed on a PC. I remember when this product was presented to our company. The only problem was that Dr. Wang should have gone with IBM rather than UNIX for his new PC platform....