Paperless Medical Records Using Pen-Based Computers

Immobility and impractical input devices used in existing Computerized Charting Systems (CCS)cause disruption of established work processes and thus discourage widespread clinical acceptance.A novel design based on hand-held computers which recognize handwriting is presented. An electronicstylus (pen) is used to "write" onto a hand-held computer (clipboard) that uses wireless networkingtechnology to update and retrieve data from a "back-end" server which integrates information collectedfrom a variety of sources. Unique desirable features of this CCS design are that it is as fast and easyto use as paper and pencil, requires minimal training, accommodates mobile users, captures and validatesdata while observations are being made, requires no parallel paper records, and is enjoyable to use. TheCCS design will be implemented and then piloted at an Intensive Care Unit. Delayed parallel operationof the CCS using existing manual records will allow preliminary evaluation of adaptability, reliability, easeof use, data accuracy and accessibility, and general user acceptance. The objective is to develop a CCSwhich enhances patient care, documentation, nursing efficiency, and QA while being directly usable bynurses, physicians, pharmacists, dietitians, and others in ICUs, emergency rooms, outpatient clinics, andgeneral hospital wards.