NOSTOS: a paper-based ubiquitous computing healthcare environment to support data capture and collaboration.

NOSTOS: A Paper–Based Ubiquitous Computing Healthcare Environment to Support Data Capture and Collaboration Magnus Bång, Anders Larsson, and Henrik Eriksson Department of Computer and Information Science, Linköping University, Sweden ABSTRACT In this paper, we present a new approach to clinical workplace computerization that departs from the window–based user interface paradigm. NOSTOS is an experimental computer–augmented work environment designed to support data capture and teamwork in an emergency room. NOSTOS combines multiple technologies, such as digital pens, walk–up displays, headsets, a smart desk, and sensors to enhance an existing paper–based practice with computer power. The physical interfaces allow clinicians to retain mobile paper–based collaborative routines and still benefit from computer technology. The requirements for the system were elicited from situated workplace studies. We discuss the advantages and disadvantages of augmenting a paper–based clinical work environment. INTRODUCTION Computer technologies promise benefits by supporting the management, execution, and follow–up of clinical care. However, taking fully advantage of computers in this context requires effective user–interfaces that support the routines of the clinician.1 The traditional desktop workstation design and Graphical User Interfaces (GUIs) that are available today have several shortcomings. Many present hospital information systems impose unnecessary and costly organizational changes and lead to inflexible clinical workflows. Meanwhile, mobile data entry is an important but still a mainly unsolved problem in computer–based healthcare information systems.2 These issues, together with the steep learning curves that are often associated with these systems, constitute a definite obstacle against gaining returns from investments in computer systems. Researchers have discussed the importance of physical information objects, such as paper forms, folders, and sticker notes in the workplace.2,3,4 Although they acknowledge that paper technologies have many disadvantages compared to computers, they also point out that paper has subtle but powerful supporting features that are difficult to capture in a GUI. For example, paper forms offer unprecedented screen resolution as well as mobility, which makes them excellent tools for data capture. Moreover, paper documents encourage collaboration because they are easy to share and handover. Also, the spatial arrangement of documents bestows local importance on the workplace and provides an overview and deposition of information that facilitates memory recall and the tracking of work processes. Nonetheless, current approaches in Medical Informatics have aimed at substituting physical information objects for their digital counterparts (e.g., the paperless clinic efforts). We suggest an alternative to clinical workplace computerization. Our objective is not to replace, but instead embrace, the established paper–based practices and enhance them with computer power. The NOSTOS environment offers a physical interface to a Computer– Based Patient Record5 (CPR) system that consists of digital pens, special paper forms, and a digital desk. This approach hybridizes the benefits of mobile data capture and teamwork with the advantages of CPR technology for storage and access of the information. Furthermore, our approach enforces minimal changes in established workflows and local routines. The incentive for the design came from studies carried out in a healthcare setting in which we observed how clinicians used paper–based records and other pervasive workplace objects to improve cognitive performance and promote collaborations.6 The theoretical motivation for the design was provided by distributed cognition; a view that highlights the relationship among cognition, activity, and the supporting physical tools.7 The aim of this paper is to provide a design rationale for medical ubiquitous computing environments with a specific focus on the digital paper interface approach. UBIQUITOUS COMPUTING Ubiquitous Computing8 is an approach that attempts to make computers available through the physical environment. Inspired by sociologists’ work on how people interact with ordinary physical tools, researchers have endeavored to develop systems that blend into the work environment to create more natural ways of using computers than through the windows and buttons of GUIs. Tablet and early medical pen–based computing9 approaches were clearly part of these developments. Of special interest in our report are the efforts that have been made to amplify ordinary physical tools and environments with functionality from computer technology.10,11 Several experiments have been conducted to enhance everyday tools, such as augmented paper12 and digital desks.13 Various kinds of paper can be augmented in several ways. For example, a digital pen has been developed AMIA 2003 Symposium Proceedings − Page 46 with a camera that scans paper printed with a unique pattern to capture pen stokes.14 This approach enables the design of active applications such as paper–based email and improved sticker notes that can be sent directly to a computer. Radio Frequency Identification technology (RFID) can be used to connect paper forms and folders to the electronic world.15 RFID tags are small electronic chips that contain unique identifiers and can provide physical tools with IP addresses. The tags can be read from a distance by an antenna, which enables the tracking of tagged objects in physical space (usually at a range of about 10 cm). With these techniques, ordinary paper documents and folders can be activated and connected to computers and then viewed as part of a class of physical interfaces called Tangible User Interfaces. Tangible User Interfaces. Tangible User Interfaces16 (TUIs) facilitate interaction between physical objects and computers. Traditional GUIs consist of virtual buttons and windows that are seen on a screen and can be manipulated by use of a mouse and keyboard. By comparison, TUIs are used to convey the results of manipulation of physical objects directly to computers. Fitzmaurice has stated the following about the properties of this class of physical interfaces:17 “[TUIs] act as specialized input devices [to computers] which can serve as dedicated physical interface widgets, affording physical manipulation and spatial arrangements…By using physical objects, we not only allow users to employ a larger expressive range of gestures and grasping behaviors but also to leverage off a users innate spatial reasoning skills and everyday knowledge of object manipulations” Ullmer, Ishii and Glas developed a TUI for controlling video recorders,18 and their system utilized small wooden blocks that serve as physical icons for the containment, transport, and manipulation of media. Related to our work is Jacob and colleagues TUI approach.19 They developed a system in which users control comp (...truncated)