The Death of the Pen

Article Outline

• Electronic health records
• Impact on scientific writing
• Impact on scientific publication
• References
• Copyright

As I rounded on our inpatient service recently, I realized simultaneously that I had forgotten my pen—and that it didn't matter. I am uncertain whether to lament or marvel as we move beyond one of the great technological developments of our time: the use of pen and paper. As physicians, we have come to expect a pen in our pocket and a stethoscope around our neck. Both habits are changing, but I will focus on the pen. This change will have important implications for how we practice and discover new knowledge in medicine.

We use pens to transfer information and thoughts to others, both immediately and for historical record. In medicine, we communicate with patients and other health care providers through writing our thoughts, diagnoses, and treatment plans in the medical record. As scientists, we record our hypotheses, methods, findings, and interpretations through written, usually peer-reviewed, publications of new discovery. The value of recording our knowledge is without question; however, the methods we use to do that greatly impacts what we can record and who can read it.

The ability to transfer knowledge efficiently through writing has been at the core of human civilization. Indeed, most scholars date the advent of civilization to the ancient cultures that developed writing, initial pictorial representations, then hieroglyphics, then phonetic writing which culminated in the Mesopotamia culture.¹ Early writing using pictorial representations began as early as 30,000 years ago with early Chinese written symbols as far back as 6000 bc.²

The technology for writing has undergone equally dramatic and increasing rapid evolution. From early carvings of Cuneiform by the Sumerians in the 4th millennium bc to papyrus, developed by the Egyptians, to parchment made of leather, to modern wood-pulp paper developed in Germany in the 1840s.³

Writing with pen and ink began as early as 4000 bc when ancient people carved crude pens from hollow reeds that held a column of pigmented liquid. In approximately 500 bc, quill pens from feathers came into use and remained so until the 1800s, a remarkable run for any technology.⁴ The fountain pen was patented by L.E. Waterman in 1884 (Figure 1), and later the ballpoint pen was patented in 1888 by J.L. Loud. It was popularized when World War II pilots (hence the “pilot” pen) discovered they could write at high altitude in flight.⁴

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• Figure 1. 

  The original fountain pen patent from Waterman 1884 (US Patent Office).

Writing with pen and paper is highly convenient for personal use yet highly inefficient for distribution. Modern methods of mass production of the written word have paralleled modern abilities to rapidly disseminate knowledge with the advent of the printing press, digital documentation, and modern-day file sharing and Internet publication. We have evolved methods for both peer-to-peer (e-mail, text messaging, tweeting) and peer-to-masses (web-logs or “blogs”), to public repositories of medical and scientific knowledge (Public Library of Science, BioMed Central).

How will these technologies change the practice of medicine and the process of discovery?

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Electronic health records 

Recently, much attention has been focused on the value of electronic health records (EHRs), which reduce unneeded repetition of testing and afford rapid access of opinions and results from other physicians. Medical records have undergone a slow change from the individual physician's “file,” to the integrated health dossier developed by Henry Plummer at the Mayo Clinic in the early 1900s,⁵ to digital electronic records used in many practices today. Unfortunately, most of these systems are still organized centrally by the medical provider (eg, the doctor's office, group practice, or academic medical center). Although EHRs have made communication within these practices substantially more efficient, they have not significantly improved communication among different groups. An exception to this is where very large groups of providers (eg, the Veteran's Administration) have formed national common standards that allow widespread provider access to a common medical record.

The personal health record is still in its infancy but is person-centric instead of provider-centric. Systems such as Microsoft's HealthVault and Google Health allow patients to organize their records in a secure, central location for any provider to access with proper password protection. Although there is need for format standardization and ensuring security, such patient-organized health records have the potential to realize many of the goals of electronic medical communication.

EHRs also have the potential to substantially improve the day-to-day efficiency of doctor–patient communication, but much of this has been “lost in translation.” The need to digitally input data, largely through a keyboard, has restricted entry to only the fastest typists, or has required the additional cost of transcription. As voice-to-digital recognition systems, such as Dragon Naturally Speaking Medical, become more efficient and widely used, we can eliminate the inefficiency of keystroke entry.

Even the documentation-driven system of reimbursement has inadvertently led to substantial inefficiencies. Anyone reading a modern medical record knows that a large amount of what is written is for reimbursement purposes, more than patient care purposes. As long as we are paid based on what we do, and accept that we didn't do it if we didn't document it, we cannot eliminate this inefficiency. Outcome-based reimbursement (“pay for performance”) has the potential to eliminate much of the waste in the medical communication by going back to what providers should focus on, namely, the needs of the patient for an accurate diagnosis and an effective treatment plan. Indeed, it is a rare pleasure to read a short, succinct summary of a doctor's thoughts, as opposed to a 3-page, electronic office document where much of the thought process is buried in administrative requirements.

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Impact on scientific writing 

Collaborative research through teams of experts has led to many great recent discoveries, but presents great challenges in terms of scientific writing. Small laboratories and clinical researchers, until recently, could draft a manuscript, circulate a printed copy to co-authors, await edits, and revise a final draft without huge logistical hurdles.

The first phase of technology that changed manuscript writing was the ability to draft digital documents using word processors and e-mail them to colleagues. This was followed quickly by methods that allowed tracking and rapid integration of editorial changes such as Microsoft's “track changes” tool. This was still peer-to-peer (e-mailing each document to each person, and back to the original writer). The process becomes very complex in multi-author papers as each co-author edits and sends back changes. Although software allows one to “merge” documents, the final product can often appear almost illegible.

We are now entering into what I call the “wiki” phase of medical manuscript writing, where a single document can be placed in a central digital location and simultaneously edited by co-authors, much as an entry on Wikipedia can be constantly updated by any reader. Most modern word processors allow editing of documents in a shared space (eg, the “cloud” of storage on the Internet). Google Documents is a good example of how a draft can be uploaded, e-mail links sent to all co-authors, simultaneous edits performed, and a single, final document emerges. The history of each change is tracked and can be “back-tracked” if changes are unacceptable. Like Wikipedia, this has the potential to give preference to the “last” editor as this is the one held in the final version. Also like Wikipedia, it allows constant peer review and scrutiny so that errors are generally weeded out, and consensus opinion, where feasible, emerges.

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Impact on scientific publication 

Much as the clay tablet was a stable, yet laborious method of recording cuneiform writing, ink on paper, distributed through medical journals provide a satisfying “heft” but at the cost of slow, inefficient communication. This inefficiency has some advantages. Like cuneiform, it forces us to think, peer review, and refine very precisely what we say. Indeed, the modern scientific manuscript is a highly polished, peer-reviewed, factual document that serves as a stepping stone for new discovery. Unfortunately, this inefficiency also slows the process of new discovery and results in repetition of experimentation by researchers unaware of new, yet unpublished, discoveries by other researchers.

There will be significant challenges to the evolution of scientific publishing. What business model will support the cost of publishing (although cloud/Internet-based publishing is inherently much less expensive)? Who will peer review and choose what is published or read? How will credit for discovery be assigned? What will be the role of the journal?

There will be a continuing important role for publishers. However, it is likely to be less in “publishing” than in knowledge searching and refining. Much as Google came to dominate the Web search engine business, publishers' roles will likely involve systems to allow physicians to quickly find answers to simple questions and do so at the point of care, and for researchers to rapidly identify current knowledge gaps and methods to address them.

So what will happen to the pen and paper? It is hard to imagine that a technology that has been with us for >6000 years will so rapidly fade away. At least in the short term, the other modern transportation technology, the airplane, will keep us using our pens (as the original “pilots” did), paper, and reading our hardcopy journals, at least between take-off and 10,000 feet!

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References 

1. Shotwell J. An introduction to the history of history (Records of civilization, sources and studies). New York: Columbia University Press; 1922;
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2. Archaeologists rewrite history. China Daily. 2003;
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3. Sjöström E. Wood chemistry: fundamentals and applications. New York: Academic Press; 1993;
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4. Pen Facts. 2009;
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5. Clapesattle H. The doctors Mayo. Rochester, MN: Mayo Clinic Foundation; 1969;
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