Digital Ink's Mark on Medicine

International Journal of Medical Informatics

The Ancient Indians were the first to use pens around 5000 BCE. While these writing implements were primitive, typically consisting of hollowed out reeds that could hold a small amount of ink, which was generally soot in water with a plant gum binder, they were used for thousands of years and are still used today in certain parts of Pakistan. Around 500 BCE, pens started to be constructed from the wing feathers of larger birds, such as geese or swans. These pens, known as quill pens, were widely used until steel-nib pens were developed in the 1800s. Today, the most commonly used pen is the retractable ballpoint pen, the type often distributed by exhibitors at medical conventions or by local businesses. Being so widely available, and often free, pens are largely considered dispensable these days. While it is hard to imagine pens evolving much further, tech companies have envisioned pens with digital capabilities for decades. This year has been particularly exciting for the digital-pen tech sector, with many touting unique advancements yet reasonable price tags, making them more appealing to consumers; however, pens are already finding a place in healthcare and are poised to leave their mark on medicine.Examining Digital PensThere are two types of digital pens: those that come with tablet PCs and function as an input device and the stand-alone digital pen, which has been around since the late 1990s when Anoto, a Swedish company, pioneered a paper that would allow a pen with a built-in camera to track itself. Stand-alone digital pens have come a long way since then, and they are being used in several ways by medical professionals. As they become more commonplace, their function will likely increase as healthcare providers discover new uses for them.Digital Ink in MedicineMedicine is moving into a digital age, with a great push toward replacing paper records with electronic health records (EHRs). Digital pens may eventually serve as an integral component of EHRs, and several companies are offering digital pens as EHR components or as a workflow solution that can be integrated with an existing EHR or practice management system. Digital pens are also being used in certain medical settings and can be useful to both physicians and patients to monitor and record side effects, assess side effects, and facilitate communication of information between healthcare providers and patients, as well as between various healthcare practitioners. EHRs and Workflow SolutionAlthough healthcare is increasingly becoming digitized, many key processes remain ideally suited to paper. Several companies, such as Assist Med, Digital Pen Systems, and Satori Labs, offer digital-pen services that allow physicians to continue to use paper forms, but also enable these forms to integrate instantly and seamlessly into existing EHR software. This allows healthcare professionals to populate these systems with timely data, which has been a challenge for many. Because using a digital pen is just like using a standard pen, there is no new technology for users to get used to. The time it takes to transfer clinical and other patient data to the EHR is also greatly reduced, and the risk of incorporating any errors is minimized. It is estimated that data re-entry alone can add 2 or 3 hours to the workload daily, reducing time that could be better spent with patients.Tracking Patient Health and Well-beingDigital pens have largely been applied clinically in Europe. During MEDICA 2009, which took place in Düsseldorf, Germany, from November 18 to 21, a new telemedicine solution called DiabCareOnline from Germany’s Ontaris was highlighted. This solution used a blood glucose meter, patient diary, Anoto digital pen, and a mobile phone to enable faster communication of patient data. Patients monitored their blood glucose levels as before and recorded them in their diaries using the Anoto digital pen. The data were then transmitted via a mobile phone to the patient’s EHR and compared with the patient’s specific blood glucose targets. Anoto officials noted that this method allowed health issues to be addressed much more quickly and lowered the cost of care because much of the data analysis was handled remotely, which also allowed patients to spend more time away from the doctor’s office.Digital pens have also been used to assess pain. In 2008, an article by Swedish researchers published in the (www.ncbi.nlm.nih.gov/pubmed/17363323) reported on the use of a pain diary, digital pen, and mobile Internet technology to assess pain in 12 palliative home care patients between December 2002 and September 2003. On a Visual Analogue Scale (VAS) for pain, patients reported an initial pain level of 35 mm or greater on a scale of 0 to 100 mm. Patients were instructed to record their pain intensity and the number of consumed extra doses of analgesics three times daily. Additional data were collected from interviews with patients and their families, questionnaires, medical records, and the system log. Overall, patients found the pain diary and digital pen easy to use for pain assessment, and the researchers noted that contact between patients and their caregivers improved, leading to an increased sense of security among patients. In addition, an assessment of the patients’ medical records showed a quick response to variations in their health status by means of changes in medical treatment.Clinical TrialsIt is not difficult to envision digital pens eventually being used to monitor side effects experienced by patients enrolled in clinical trials or to assess pain or side effects in those receiving cancer treatments. In many cases, side effects are the reason for discontinuing treatment. If clinicians become aware of side effects earlier, strategies to minimize or eliminate them can be implemented sooner, which may allow patients to continue to receive treatment. While no trials in patients with cancer are currently applying digital-pen technology, one observational study being conducted in the United States is assessing the use of this technology to develop individual education plans (IEPs) for people with autism spectrum disorders (http://tinyurl.com/yarypsm). The researchers plan to use the pens to collect behavior data, chart progress, create forms, and facilitate communication within the IEP team. The investigators hypothesize that a digital pen-based system will facilitate educating children on the spectrum, while enhancing communication between schools and families and saving time and money in the process by eliminating cumbersome paper-and-pencil methods of developing IEPs.Facilitating Communication of Test ResultsIn France, digital pen technology has been used to reduce the amount of time it takes for patients to receive mammogram results, which has also cut down on the time other women must wait to receive breast cancer screenings. Although women who had mammograms that were positive for breast cancer received notice quickly, those with negative results had to wait 3 or 4 weeks to receive notification because French law requires negative screenings to undergo a second expert review. By using digital-pen technology, the expert reviewers had access to the examining radiologist’s notes while assessing the mammograms, and facilities were able to process the results of the examinations more quickly. Through the use of digital-pen technology, screening centers in France have been able to meet the legal requirement of sending out results of breast examinations within 2 weeks.The Future of Digital InkThe healthcare sector is especially well-suited to making use of digital pens, especially as incentives are offered to migrate to EHRs. While populating EHRs may be cumbersome and time-consuming, requiring considerable data entry, digital pens may help bridge the gap between paper and electronic records by converting paper documentation into digital information. Patients may eventually complete their medical history and other forms using a digital pen, and healthcare providers may use digital pens to make notes in patient records, record encounter data, write prescriptions, and more.Digital pens have also shown promise in improving patient care. European studies have shown that digital-pen technology may help treatment by making healthcare providers aware of important patient information in a timely fashion, such as blood glucose levels or pain levels, allowing them to act on this information more quickly. While no studies have been conducted assessing the use of digital pens to improve the care of patients with cancer, it is reasonable to conclude that this technology could have a positive impact in this population as well. Technology will continue to progress, and as it does, this platform’s mark is bound to become more pronounced.