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Digital pen technology

Stuart Cooper
Head of IMT Strategy,
Royal Wolverhampton, 
Hospitals NHS Trust
Chris Ragdale
Senior Project Manager,
Royal Wolverhampton, 
Hospitals NHS Trust
At the end of 2010 we began the process of rolling out digital pen technology to the six hundred plus clinicians across our Trust. The objective was to record over 45,000 community contacts per month on digital patient activity records, and transmit this data automatically into iPM.
We had already presented a business case and carried out a pilot programme, but it was difficult to estimate how well users and patients would accept digital pen technology until it went live. Eight months on, however, we can truly say that it has made a dramatic difference to the amount of time that our clinicians have available to spend with patients – on average, three or four hours per clinician per week. And, at the same time, the technology has enabled us to reduce our costs as well as improve the accuracy and quality of our data.
Paper diaries
Previously a clinician may have seen up to twenty patients per day and recorded approximately ten key pieces of information for each patient on a diary sheet. They would then have to either re-enter all data onto iPM or delegate to administrative staff. Either way, it was a long-winded manual process that reduced clinical time and increased the risk of mistakes as information, was recorded twice. 
It was clear that we needed to look for a solution that would minimise the strain on admin and free up more clinical time for front line patient care. We also needed to produce accurate, reliable statistics to report to commissioners and provider management teams for costing, activity management and clinical governance. 
Initially, we considered laptops as an obvious method to speed things up, but in fact we hit no end of problems, such as patchy and inconsistent 3G coverage, slow boot-up owing to security requirements, the barrier laptops formed with patients as well as associated costs and support. What we actually discovered was that laptops were eroding consultation time rather than saving it.
Digital pen technology
We first came across digital pen technology at an NHS IT trade fair in Birmingham. Straightaway we appreciated that the technology was simple to operate, which was essential for those clinicians used to using pen and paper. So, we started to assess providers and performed a competitive review of what was available in the market. We also talked to Derbyshire Mental Health Trust (now Derbyshire Healthcare NHS Foundation Trust), which was successfully using the same technology, providing us with a valuable benchmark.
Our choice of digital pen technology, supplied by destiny®, followed a year-long process that included practical research and testing to ensure that we would be able to fully realise the benefits we envisaged. One of the key deciding factors was the partnership arrangement between destiny® and Computer Science Corporation (CSC), and the gateways that this opened up to the national iPM electronic patient record system.
After reviewing all the diary sheets used by different services across the Trust, we created a single diary sheet, which destiny® converted into a digital format. The new form design used tick boxes and coded fields to make the process faster and more accurate. It also used coded fields that could be plugged straight into iPM.
The pilot
We initially piloted the new system within our anti-coagulation service, which was selected because it typically manages between eighteen and twenty contacts per day. After a successful experience here, we rolled it out across all the many service areas of the Trust including community (INR, matrons, continence, district nursing, hospital at home and out of hours nursing), AHPs (physiotherapy, SLT and OT elderly care), children and family (children’s nursing, health visiting and school nursing) and CICT rehab. By the second quarter of 2011, digital pen technology was being used by all of our 600 clinicians.
With such large numbers the feedback has inevitably been mixed, but the overwhelming majority of users like the simplicity of the digital pens and the fact that they’re almost no different from using an ordinary pen. Users also appreciate the security benefit of not carrying a visible laptop. 
The technology
The way digital pens work is very straightforward. Clinicians write out the diary sheet, including the patient’s name, number and type of visit including SNOMED codes. Each form is automatically time and date stamped. At the end of the day, the clinician follows a simple docking process using the pen’s built-in USB connection and a PC router. 
This transmits the recorded data automatically from the pen to CSC’s secure NHS data centre, where destiny® software converts the handwriting into text. It also carries out pre-iPM validation, checks such as the validity of codes and mandatory information such as start and finish times. 
The data is then transmitted back to us as a PDF copy of the original form and an XML file, which is integrated automatically into our iPM patient record system, although our administrators do still have the facility to review and edit any forms via destiny’s® secure online Manage service. This whole process takes less than a minute to perform after the clinician has docked the pen.
To date we have reduced our administration costs by approximately £200,000 (€230,200) per annum. More importantly, we have achieved our aim of freeing up more time for front line patient care. Previously, there was a mixture of some clinicians doing their own data entry while others employed admin staff to do it on their behalf. In both cases we’ve helped them to find an extra three to four hours of additional time per week to spend with patients – on average an 8% gain. Originally, data entry used to take up to five minutes per contact – that’s an hour per day with twelve contacts – and this time is now reduced to zero.
The accuracy of our data has also definitely improved – by as much as fourfold. Before, we had to spend time checking up on errors, and sometimes data entered via the admin team may have masked the lack of mandatory data. Now, the requirement for data at source and the verification within the forms should mean they’re correct first time. Our data quality team can now look at any rejected forms and quickly validate or correct them. It’s true that iPM can be a bit unforgiving and our acceptance rates are currently approximately  80%, but we’re looking at how we can improve them to at least 90%.
With growing emphasis on activity-based income, we’re now able to capture the information we need in an accurate and timely manner. 
We know exactly what an individual nurse or clinician has done, and that gives us a good baseline from which to work. We can generate income activity reports, but just as importantly we can know for sure where each patient is on their individual pathway, based on information that’s updated every day. And that in turn is helping us to make sure we can achieve quicker and better outcomes – which, after all, is ultimately what we’re all here for.