Title: Digital writing for data capture (digital pen) Title (721) 2012 VHA Employee Innovation Competition Title: Digital writing for data capture (digital pen) Title (721) Facility: Tampa VAMC, station 776, VISN 8 Initial Idea Submitted by: Jorge A. Ferrer M.D., M.B.A.

Problem Statement Clinical documentation has evolved from its original objective of recording what actually was going on with a patient, and what the clinician was actually thinking, to sterile boilerplate documents. We need to make it simple for the clinician to interact with the record without loosing the richness of the clinical narrative; data entry must be almost as easy as writing. Perhaps the single greatest challenge that has consistently confronted most clinical system developers is how to engage clinicians in direct data entry in a way that does not disrupt clinician-patient communications.

Description of Idea Our idea is to develop a method for clinical documentation using the most natural, efficient and clinically intuitive methods, with the most comfortable point of care input device. Allow clinicians to use their preferred method of documentation, to include: writing with digital pens, dictation, voice recognition, and transcription, incorporating Natural Language Processing and Clinical Language Understanding to analyze the data. The digital & audio ink is converted to text and tagged for analysis. No longer would typing after the fact into CPRS be the only option. All information entered would be accompanied by tags (XML) that would allow the data to be used for other purposes.

Strategic Goals Impacts Veterans, Clinicians & Staff Clinical data entry that is easy to learn and desirable by clinicians. Improves Patient Care & Quality Improvement in acceptability, thoroughness of documentation, ease of documentation and naturalness of technology feel. Improves Patient Safety Improve accuracy of clinical data entry Improves Efficiency Faster more accurate documentation, improved clinical workflow, improved timely distribution of data/information. Improve green initiatives Reduced scanning, faxing, copying and processing of paper forms Improves unmet need Can capture coded narrative notes for clinical care & research

Success Metrics Functional Prototype Success Metric Clinicians will be able to view semantically coded text-based new progress notes in desired format, including hand written drawings with content captured by digital pens in a test environment. Clinicians can be mobile and gather any data they choose, using their own pre-existing forms. We will evaluate the application’s usability and ability to support accurate documentation via a set of sample forms of variable complexity. Expected Results Reduce the time to document a new progress note by entering data once, not re-entering data after the encounter from ordinary paper to CPRS. Avoid duplicative work such as taking notes while the clinician is with the patients and then transferring by hand to CPRS. Eliminate the need to have documents manually scanned in CPRS. Improve accuracy and completeness of data entry

Impacts Veterans Will have improved clinical documentation “telling their story” Will experience better communication with their clinicians VA Clinicians & Staff Will spend less time documenting clinical care Will be mobile while documenting clinical care Will be able to treat more patients as a result of reduced data capture & re-entry of data Will be able to capture their clinical thoughts intuitively Additional support needed Coordination with OIT to ensure digital pens and connectivity can support clinical documentation requirements

Approach Our approach involves data capture, creating user-designed progress note forms for the digital pen to access the Computer Patient Record System (CPRS) & VistA Imaging We will test a data integration and data transformation & message broker that will receive the unstructured data using medical terminology and ontology services. Once the data has been structured into the correct HL7 format it will be routed to a VistA integration service. The VistA integration service will consume the HL7 message data and integrate the data via web services or VistA remote procedure calls. Data security will be accomplished by using VA standard VPN clients for the chosen platform. Authentication and single sign on capabilities will be extended from current VistA.

Team and Environment We have created a strong team with VHA and Tampa VAMC.: Dr. Ferrer, physician informaticist for this project, has led a similar prototype innovation project titled Positive Impact of Multiple Input Devices for EHR Adoption. This project was selected by the Office of the National Coordinator to be showcase in the HIMSS 2011 interoperability kiosk. Prior to his current position with the VHA he was a Medical Officer at the Centers for Medicare & Medicaid Services (CMS), leading a similar project that led to the creation of VistA-Office EHR. He is an Assistant Professor in the Division of Health Sciences Informatics at the Johns Hopkins University School of Medicine. He is an Editor of Aspects of Electronic Health Record Systems, Health Informatics Series, Springer, Second Edition, 2006. Our environment is supportive, capable and with a proven track record. The Tampa VAMC innovation team is lead by: Edward P. Cutolo M.D., Chief of Staff, Robert D. Shapiro, Associate Chief of Staff for Clinical Informatics, Alexander I. Reiss M.D., Hospitalist, Lynn J. Martinez, Staff Assistant.  

Implementation Requirements will be gathered from VA clinicians & staff Workflow analysis of the progress note clinical documentation process will be completed User testing will occur with a volunteer group of clinicians and staff Digital writing with pens will be rolled out to the volunteer group of providers and the performance of the point of care clinical documentation digital pens will be assessed

Timeline Definition of Above Steps: Step 1: Acquisitions process Step 2: Development of digital writing pen interface Step 3: Development of GUI application Step 4: Integration VistA applications Step 5: Live testing and integration with VHA OHI Innovation Sandbox Cloud systems of the “Digital Pen,” functional prototype.

Budget Narrative The main cost of implementing a pilot of the “Digital writing pen-smartforms clinical data capture progress note” at a VA Medical Center: The IT services cost of developing and deploying the digital writing pen-smartforms software to support the progress note generation $700,000 The hardware cost of the digital writing pens smartforms platforms $300,000

Budget Proposal - Optional Expenses FY12 FY13 Software Development Costs $700,000 Roll Over unobligated FY12 funding Digital pens $300,000 Totals $1,000,000

Challenges & Risks Risk: If the innovation proceeds beyond proof of concept to use in actual patient care, Veterans’ personally identifiable information (PII) will need to be HIPAA compliant when the digital writing pen-smartforms is used. Solution: Use only digital writing pen-smartforms technology defined as an EHR Modules that have been tested and certified under the Certification Program maintained by the Office of the National Coordinator for Health IT (ONC). Challenge: Clinicians may not embrace the digital pen technology Solution: Educate clinicians on the ease of use of digital writing pen- smartforms creation and use of the digital writing pen solution.

Digital pen & smartforms processing Form Processing Analysis & mapping Handwriting recognition Interpretation Natural Language Processing Verification & correction Data Capture Data Transmission CPRS Information Integration Application integration Display/reporting Storage

What Do You Really think? The clinical narrative must never be lost. If the full clinical narrative never comes into existence, the knowledge discovery cycle is broken and the discoveries of medicine are threatened. The strong team of informatics and Tampa VAMC are well poised to succeed with a proven track record of current innovations. We will be successful when clinicians can document their thoughts freely and we provide the tools necessary to improve their performance. “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” (William Osler MD) “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” (William Osler MD)