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And next in our museum tour … Paper

What will people write on in the future? Hint - it doesn't come from trees
Samsung's 'Intel Inside' ATIV-Q tablet (Photo credit: Courtesy)
Samsung's 'Intel Inside' ATIV-Q tablet (Photo credit: Courtesy)

A couple of years ago, I was watching an online presentation by Eric Schmidt, who was the CEO of Google at the time. I personally greatly enjoy his presentations. He is always informative and has a very pleasant way of speaking and delivering his message. Everyone knows Google and knows that it is very much at the cutting edge of technology. That is why I found it surprising and even amusing that all of his notes were hand written on paper.

This was not a prepared speech that he read word for word from the paper. These were clearly his personal notes, intended to direct his presentation and to make sure that he did not forget to emphasize the key points. The question that I had was quite simply, why is the CEO of one of the top technology companies in the world, still using pen and paper to record important information.

It may be that after he wrote these notes, he had them scanned into his computer and then saved on one of Google’s servers. If that was the case, then he could’ve used a cellular phone or even a tablet [which were bulkier and much more expensive back then] to read from. But he chose to leaf through a set of paper, in order to deliver his speech.

To this day, it is still very hard to beat paper for its simplicity, availability, lack of need for an electrical charge, light weight, ability to host written text or drawings, and low cost. Paper can be recycled. It can be thrown into a fire and used for energy. It is not dangerous to the environment. I could go on.

The use of paper continued to be a sensitive topic in the development of my EMR while I was at my previous place of employment. I kept being asked when we will finally switch over to tablets and digital pens. For the 11 years that I worked on the development of my EMR, my answer was always the same, that “in five years from now, tablets will be thin enough, light enough and cheap enough to replace paper”. I think it goes without saying that my predictions fell short.

Nevertheless, digital paper is coming. The time will be when a piece of plastic will be as malleable, light and cheap as a piece of paper, and as such finally become a legitimate alternative for killing trees. I have seen demos for features of such digital paper. I have seen digitally created videos that demonstrate how such digital paper will work. The pen that will be able to write on this digital paper will also have to be cheap and readily available. Everyone knows that there is a black hole in the back of everyone’s house which sucks up two things: one sock of each pair, and pens. So clearly, digital pens will also have to have anti-blackhole technology.

I never did incorporate tablets into my EMR. The tablets were never cheap and light enough. It was possible to fully record a clinical assessment by typing onto the screen of the computer, thus rendering the paper chart useless. So, strictly speaking, my EMR was paperless. Nevertheless, I allowed users to continue to use paper, to record all of their notes on it, and then to scan the paper charts into the computer. In addition to a typed two line summary of the case, this actually worked well. There was a small percentage of physicians whose handwriting was truly illegible. But otherwise, the physically written charts on paper meshed very well with the rest of the digital chart.

Even today, the cheapest 10 inch tablets are still far too expensive, fragile and heavy to be used for eight hours straight on a shift. In fact, most such tablets do not hold an eight hour charge if they are constantly being used. To equip the entire staff of multiple clinics with such tablets would cost a couple of hundred thousand dollars. And all these tablets would ultimately have to be replaced [due to theft, damage, wear and tear] every 3 to 4 years. When presenting such a plan to the chief financial officer of the company, the legitimate immediate question is “will I see a return on investment of more than $200,000 from these tablets”. And the answer is a definite no.

I personally expected that tablet technology would advance far faster than it did. I still believe [and here comes another prediction] that paper will be dead by 2030. In other words, in the next 15 years, digital paper will finally advance to a point that it is financially superior to analog paper. Publishing of all books will finally become digital, newspapers will no longer be printed and quite simply, the demand for paper will no longer support the industry.

I personally run a nearly paperless office. I believe that in the last year, I have printed less than 10 sheets of paper, and these were for prescriptions that I wrote for patients. This definitely begs the question of what will happen to physical libraries, which will no longer be visited. Any and every book will be available to any and every child and adult via the Internet, on digital paper. Whether the digital paper is housed in a box resembling that of a book, I do not know. But I suspect that the grandchildren of my grandchildren will only see paper in a museum.

By 2030, I obviously hope that digital paper will finally become a legitimate replacement for the paper charts presently used in medical environments. Digital paper will be able to entirely change its interface, force certain types of data entry, allow for speech to text recognition,  have excellent OCR, allow for immediate translation from one language to another, and anything else you can think of.

The totally integrated medical chart will finally become a reality. A remote consultant will be able to see what the doctor is writing as it is being written. Photographs will be embedded within the digital page, as will any audio information  [such as the sounds of the heart]. Other data such as x-rays and MRIs and ultrasounds will all be included on the digital page. All data from all sensors will be available via the digital page. The user will be able to swipe up-and-down and right and left to get to various parts of the case. And of course, most importantly, artificially intelligent data analytics will constantly survey everything on the chart in order to assist the physician in interpreting data and reaching a diagnosis.

Imagine a doctor saying to the digital page, “just show me allergies”, “show me blood pressure over time relative  to medications used”, “show me the last three chest x-rays”, “show me hemoglobin level relative to liver function over the last two years”, and so on. And the digital page will do this all. And when the doctor is done, he will fold the digital page into four sections and tuck it away into his coat pocket.

Even with all of the growing pains that come with present day EMRs, it is clear that they will soon revolutionize all of healthcare to such a point that we will wonder how we managed without them until now. And one day, we will look at a piece of paper and try to imagine how an entire medical history including intelligent diagnostics were all crammed into this 11 inch space.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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