Up-and-coming device lets health care organizations keep paper yet reap benefits of automation. By Bill Briggs, Senior Editor
(September 2004) At Cherokee Indian Hospital Authority, everything old is new again for coding patient encounter forms. The Cherokee, N.C.-based Native American health service has discovered a way to marry traditional paper-based forms and new digital pen technology to save $1.50 per insurance coding transaction.
Without any training expense, doctors and nurses are using digital pens to write on patient encounter forms, which yields paper and electronic copies. The electronic version is based on a digital image of the inked information that is stored temporarily in the pen and downloaded later to the organization's billing system via a docking station.
At roughly 127,000 forms annually, saving $1.50 per is a pretty good reason to implement the technology, says Jim Eller, computer analyst at the health service, which provides care for a Native American population of about 12,500 members of the Eastern band of Cherokee Indians."Our cost to manually code a patient visit is more than $2 per transaction," Eller says. "With digital pen technology, we can upload and code forms for around 50 cents per transaction."
The hospital authority is among the first health care organizations to test digital pen technology. Many are finding it relatively inexpensive to purchase; and when it comes to training, all a user need know is how to write.
Digital pen technology is based on tiny infrared cameras and digital memory, along with an ink cartridge, all contained in a device that looks like an ink pen on steroids. At less than two ounces, the pens pack a battery and enough memory to hold 40 or more pages of documents until they must be placed in a PDA-like docking station that downloads the writing to an application that uses or stores the data.
The camera photographs the pen's ink strokes as the writer fills in information on a paper form. The form's data fields are covered with nearly invisible dot patterns, which enable the pen's camera to convert the ink lines into image files.
The paper can be purchased in pre-packaged tablets, notebooks or appointment books in the consumer world. Hospitals can buy pre-printed forms from paper and digital pen technology vendors. And they can use plain paper if using technology from Palo Alto, Calif.-based Hewlett-Packard Co., which features software capable of printing the dot patterns via certain models of its printers.
In addition to HP, other digital pen technology vendors include: Logitech, Fremont, Calif.; Nokia Americas, Irving, Texas; Maxell Corp. of America, Fair Lawn, N.J.; and Standard Register, Dayton, Ohio. Much of the underlying digital pen technology is licensed from Anoto Inc., Waltham, Mass., part of Anoto AB, Stockholm, Sweden.
Prices run from about $120 to $200 for basic digital pens and include a docking station and some type of software that converts images to text.
HP's Forms Automation System with 1,000 digital pen "seats," conversion software and integration with existing information systems, can range from $100,000 to $250,000, says Don Palmer, director of business development for the vendor's digital paper and pen unit. The HP system automatically stores the handwritten information as an image file and converts it into digital data that can be used to populate other information systems.
As in Cherokee Indian Hospital Authority's case, the return on investment potential is significant. "There are tremendous cost savings in getting paper-based information into a database," Palmer says.
The Hewlett-Packard system also is available via a lease program offered by an HP business partner, Pace Business Solutions, Whitehouse Station, N.J. Under the program, Pace will install the infratructure and software and hardware components of the system and lease the technology on a monthly or annual basis.
An additional advantage of digital pen technology in general is that it can enable physicians to write with symbols rather than alphabetic characters, thus saving time on the front end. "This whole technology lends itself to moving from character writing to icon writing," Palmer says. "It not only allows users to get handwritten information into a database, but also simplifies it through the use of icons."
Such capabilities can be particularly useful for orthopedic surgeons, says Sandra Nutten, R.N., a senior management consultant at The Chi Group of Superior Consultant Co., Ann Arbor, Mich. "Most surgeons will sit down with a patient and, in explaining a procedure, draw a rough sketch. But how do you type that into a computer?"
Digital pen technology can capture handcrafted words and pictures and transfer the digital images into a database. That enables an orthopedic surgeon, for example, to call up a drawing after a procedure.
Nutten uses a digital pen from Logitech in her daily writing and note-taking activities as a consultant. She cautions that some software can have a difficult time reading medical shorthand, and a user's handwriting can contribute to some confusion if the software can't distinguish, for example, between the letter "i" and the letter "j."
Most vendors claim accuracy rates in the 90th percentile, an estimate confirmed by Cherokee Indian Hospital Authority's Eller. The organization has worked with HP and Mi-Co., a Research Triangle Park, N.C.-based vendor of digital writing software, to help develop and deploy the system.
The hospital authority has introduced a step into the process where a coder reviews all data entered so any questions can be answered before approving the data for posting to other databases, such as billing, Eller explains. "The majority of the data is pretty smooth," he says. "I'd estimate the data is 90% accurate."
His organization began piloting 20 pens in April, the result of a process that began in mid-2003. Eller hopes to have about 40 digital pens in place enterprisewide by the end of 2004.
The organization also tested Tablet PCs from HP, which many clinicians also liked. The tablets can resolve a common problem with the digital pen-based forms: missing data. "With a tablet you can make form fields required," he says. "You can't with the pen. But the pen is less expensive and easier to use."
Ease of use was a factor when Anthem Blue Cross and Blue Shield's Midwest Region in Indianapolis began to explore digital pen technology. Anthem Midwest was looking for ways to make it easier for providers to do business with the health plan, part of an organization with 12.6 million covered lives.
Wasting no time
Within 30 days of hearing about the technology from the New York-based consulting firm Accenture, Anthem Midwest had a digital pen technology pilot rolling out in July to 20 rural physician offices, says Jane Niederberger, vice president and general manager.
The health plan sought participants from among several hundred rural physician practices. Those who volunteered quickly began offering suggestions, such as pre-populating information on patient encounter forms to save them steps, Niederberger says.
Implementation was painless, because the digital pens are "not upsetting their workflow process. It's just automating what they are already doing."
The physicians get feedback quickly, by computer, about any incomplete claims data. That cuts out the traditional mailing process. "Their claims get into our payment system faster and practices get paid more quickly," she explains. "The bonus for us is if they mail a paper claim it costs $2.50 to process. If they use the pens the cost drops to 49 cents."
Accenture Technology Labs, the consulting firm's research and development division, developed Anthem Midwest's test program. It is using digital pen technology from Standard Register. Phase two of the program will test wirelessly transmitting digital pen data by mobile phone.