This document evaluates the use of digital pen and paper (DPP) technology in an acute public hospital. DPP allows for both a paper copy and electronic copy of patient records to be created simultaneously. Several studies found that DPP improved access to patient files and productivity by allowing multiple users to view records at once. However, nurses preferred conventional pens. Overall, DPP shows promise as a transition to electronic medical records while maintaining paper records. Further research is needed to evaluate DPP for different tasks.

1. Evaluation of digital pen and paper
(DPP) technology within an acute
public hospital
Nikki Littlewood
ISYS90060

2. Imagine a nurses station in a hospital ward
(except less smiles, more mess and patient files everywhere except where
they’re meant to be kept)

3. The missing patient file is a problem
• Of course, it isn’t really missing.
• It’s either being used by one of the many health
professionals assisting with the care of the patient.
• Or it hasn’t been returned to its rightful place.
• Or it’s with the patient at x-ray, theatre or anywhere
else that the patient is and their notes are required.

4. Which wastes time
and energy and results in...

5. Is there a solution to the ongoing search
for a patient file?
Yes.
• Electronic medical
records (EMR) are already
available, however the
nature of work on wards
has not yet allowed real-
time information transfer
using this system.
• Digital pen and paper
(DPP) technology is one
solution to bridge this gap http://farm3.staticflickr.com/2473/35
32795871_2d81ce74ed_s.jpg

6. What are its features?
• A regular ballpoint pen
• With an integrated digital
camera
• Using specially printed paper
with nearly invisible uniquely
sequenced dots to accurately
duplicate exact location of
writing on paper
• Incorporated memory for up to
50 sheets of A4 paper
• The pen wirelessly connects to a
smartphone or tablet via
bluetooth. Or alternatively can
be docked via USB to PChttp://www.inphoactive.com/capture-
data/digital-pen/#!prettyPhoto

7. How does it work?
Anoto Functionality © Anoto Group AB
http://projects.oucs.ox.ac.uk/vre/ibvre/index.xml?ID=digitalpaper

8. • If the surface being written on is
printed with the anoto dot
sequence then the pen has the
ability to read it.
• This can include LCD screens,
whiteboards and transparent glass.
• Pre-existing forms can be modified
using a forms package software.
• A small tick box exists in the bottom
corner of each piece of digitalised
paper that when ticked will
automatically allow data to be
transferred when docked or
immediately via bluetooth
http://www.emeraldinsight.com/content_im
ages/fig/0490340604007.png

9. Additional information
• The data stored on the pen is encrypted.
• The pen can record the time, date and name
of the person who has used the pen.
• The digital paper can continued to be used as
a paper copy of the document.

10. What are the benefits to use in a
hospital ward?
• There will be a paper copy available as usual
• There will be a real-time electronic copy available too
which has been updated via DPP technology.
• More than one person will be able to view the file at
one time
• Less time will be spent looking for the patient file
which will lead to increased productivity
• Health professionals will be happier because they
won’t be frustrated from being unable to locate
notes.

12. Usability of DPP amongst nurses
• Usability of DPP was assessed by 21 nurses in a
labour ward, who volunteered to trial using the
DPP and regular pen for 4 weeks each over an 8
week period to complete the labour admission
database form.
• They found that despite a positive attitude from
nurses towards DPP that post study preference
was for conventional pen.
• Reasons given were a conventional pen was less
bulky and simply reaching for what was closest at
the time.
Yen and Gorman (2005)

13. Integration of DPP into an existing
clinical information system (CIS)
• A further study in Switzerland assessed the feasibility
of integrating and using DPP in a pre-existing CIS within
primary, secondary and tertiary healthcare systems.
• Concluded that the quality of the DPP was as good as
using a professional scanner and that the mobility of
DPP was an advantage over scanning.
• Satisfaction surveys demonstrated DPP to be well -
accepted amongst users.
• DPP was able to be successfully integrated with pre-
existing CIS using JAVA and web-services.
• The requirement of colour laser-printers to produce
the forms was inconvenient.
Despont-Gros et al. (2005)

14. Feasibility of DPP technology to record vital
signs in acute care
• A six week prospective study was conducted on surgical and inpatient
medical units using DPP to document vital sign data and accuracy of data was
compared with the original working paper-copy. Random generator selected
25% vital sign values to review.
• Data collected by DPP was found to be 92% accurate in comparison to paper-
copy.
• Error in accuracy was related to inaccurate recognition of handwriting or
missing data.
• User satisfaction survey demonstrated greater satisfaction in vital sign data
recording post DPP but this was not statistically significant.
• Concluded that DPP is a promising transition from paper-based systems to
EMR
Dykes et al. (2006)

15. Advantages and Disadvantages
• Enables real-time transfer
of data whilst allowing
traditional paper-copy to be
maintained
• Generally well-accepted
amongst users
• Easy to implement
alongside pre-existing CIS
• Digital copies consistent
with scanned versions
• Cost-effective in long-term
• Colour laser printer
required which is more
costly than black and white
• Early versions of pen are
bulky
• Increased training may be
necessary to encourage use
• Expensive in short-term

16. Recommendations
• Further studies into the use of DPP are required.
• Limitation of Yen and Gorman (2005) feasibility study on
labour ward was that it only involved one task which did
not encourage full-active use of DPP to provide more
accurate evaluation.
• Further studies on quality of handwriting and capture of
vital sign data would be helpful in deciding use in acute
care settings as majority of information is not captured in
forms.
• Further usability studies should be conducted for DPP. The
requirement for printed surfaces has not changed but the
digital pen has been redesigned by a number of different
companies.

17. Conclusion
• DPP technology is a cost-effective and user-
friendly transition of healthcare systems from
paper-based patient files to EMR.
DPP “From handwriting to computer...in real-
time”
Anoto Group AB (2013)

18. References
• Yen, Po-Yin., & Gorman, Paul. (2005). Usability testing of digital pen and paper
system in nursing documentation. AMIA ... Annual Symposium Proceedings / AMIA
Symposium. AMIA Symposium, 844-848.
• Despont-Gros, Christelle., Bœuf, Christophe., Geissbuhler, Antoine., & Lovis,
Christian. (2005). The digital pen and paper technology: implementation and use
in an existing clinical information system. Studies in Health Technology and
Informatics, 116, 328-333.
• Dykes, Patricia C., Benoit, Angela., Chang, Frank., Gallagher, Joan., Li, Qi., Spurr,
Cindy., . . . Prater, Marita. (2006). The feasibility of digital pen and paper
technology for vital sign data capture in acute care settings. AMIA ... Annual
Symposium Proceedings / AMIA Symposium. AMIA Symposium, 229-233.
• Anoto Group AB. (2013). from
http://www.anoto.com/lng/en/pageTag/page:home/