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1. 1
Annotations: A new type of document in the Electronic Health Record
Sandra Bringay1
and Catherine Barry1
and Jean Charlet2
1
LaRIA FRE 2734, Université de Picardie Jules Vernes, 5 rue du Moulin Neuf 80000 Amiens,
{bringay,barry}@laria.u-picardie.fr
2
STIM/DSI/AP-HP & INSERM ERM 202 ,15 rue de l’école de médecine 75006 Paris, Jean.Charlet@spim.jussieu.fr
Abstract
Health Professionals still do not have at their
disposal relevant processing tools to manage the
Hospital Health Record. Those systems do not allow
them to reproduce all the practices carried out with
paper record. This publication deals with one of those
practices: annotation. By taking as a starting point
the approach of [Pedauque 2003]1
, we adopt an
original vision on documents. We consider them with
their annotations. Our objective is to show the interest
of electronic annotations in such an application and
to set down bases of an annotations theory.
Keywords: Documents, Annotations, Health
Record.
Introduction
In the multidisciplinary DocPatient Project2
, we
lead a theoretical study on documents resulting from
[Pedauque 2003]. We adopt an original point of view
by considering documents with their annotations.
Our experimental field is the Electronic Health
Record. DocPatient Project is based on the results of
[Charlet 1998;Lovis 2003]. These authors had shown
the interest of a documentary approach for such an
application. They consider the Electronic Health
Record as a set of documents. Information about a
patient has a sense only in the context of a document.
A document is generally produced to describe an
event and the context (circumstances) in which this
event takes place. For example, a physician meets a
patient. He carries out an act (interview, examination).
In order to store a trace of the knowledge produced
during this act, he writes a document. As [Charlet
1998;Lovis 2003], we thought that an adequate way to
present the Electronic Health Record is to turn it into
a hypermedia. This representation method seems to be
in conformity with care practices in the medical units.
By following this paradigm, we propose to add
new documents, annotations, in the Electronic Health
1
This paper presents group discussions tacking place within
multidisciplinary French topical network 33 of the CNRS
Information and Communication Science and Technology (STIC)
Department: "Documents and contents: creation, indexing,
navigation". It attempt to clarify the concept of document in its
transition to electronic form. This work was undertaken under the
joint signature "R.T. Pedauque".
Document:
http://archivesic.ccsd.cnrs.fr/documents/archives0/00/00/05/94/sic
_00000594_01/sic_00000594.pdf
Project site: http://rtp-doc.enssib.fr/
2
http://www.laria.u-picardie.fr/EQUIPES/ic/htsc
Record. On figure 1, we give two examples of
annotations. On the first image, a nurse sticks a post-it
on a document. This annotation includes information
aimed at her colleague who also works with the
patient. On the second image, a physician reads a
document and, according to his reading objective,
highlights, surrounds and comments some parts.
Figure 1. Examples of annotations
The change of medium (from paper to electronic
medium) implies the loss of knowledge due to the
addition of constraints on information capture. Most
of documents are forms, designed by the hospital
authorities (often the Heads of Department) and
imposed to the Health Professionals who write them.
Of course, others documents exist, designed and
written by the Health Professionals themselves.
Moreover, we realized that paper forms are often
annotated because the Health Professionals cannot fill
in them with all the information they want.
In addition, difficulties appear when Health
Professionals use electronic documents. For example,
they suffer from disorientation in hypermedia. They
cannot have a global vision of the record. Contrary to
the Paper Record which enables to put a set of
documents on a table, the Electronic Record allows
only the visualisation of a little number of documents
at the same time.
So, we assert that an annotation system is a part of
an Electronic Health Record in order to store all the
knowledge relative to a patient and to allow Health
Professionals to really work with electronic
documents. We want to store all the knowledge
included in the annotations and to build a framework
allowing Health professionals to work with the
electronic record.
In a first part, we will describe all the
characteristics of an annotation. We will focus our
attention on the consequences of the change of
mediumon these characteristics. In a second part, we

2. 2
will discuss the possible readers of the annotation, and
their uses. In a third part, we will talk about the result
of the multidisciplinary works (law, management,
psychology) led in DocPatient project and we will
describe several situations of annotations. For
example, the Health Professionals annotate to add
information during data capture in forms . Indeed,
forms are so structured and rigid, that they can’t fill in
them with all the knowledge they want. They also
annotate during their readings, when they want to
appropriate the documents and construct their own
vision of the record. They often use these notes to
build their synthesis. Finally, the various members of
the medical teams use annotations to exchange
knowledge. In the last two parts, we will go in details
about some theoretical problems pointed out in
[Bringay 2003], particularly the annotationsstatus and
their autonomy and time persistence. To finish, we
wonder why consider annotations as documents.
1. What is an annotation?
1.1.Annotation de finition
According to our readings [
Denoue 2002;Denoue
2003;Desmontils 2001;Zacklad 2003], we define an
annotation as follow:
An annotation is a particular note linked to a
target by an anchor. The target can be a
collection of documents, a document, a segment
of document (paragraph, group of words, image,
part of image, etc), and another annotation.
Each annotation has content, materialized by an
inscription. It is the trace of the mental
representation elaborated by the annotator
about the target. The content of the annotation
can be interpreted by another reader. The
anchor links the annotation to the target (a line,
a surrounded sentence, etc).
On figure 2, we find a first annotation in the
paragraph entitled "Electroencephalogram". The
target is "some puffs of former slow rhythms". The
anchor was created by underlining this succession of
words with a marker and by adding an arrow linking
the comment to the target. The content is materialized
by the comment "Envisage a new EEC in before 10
days".
In the paragraph "Conclusion", we find two
annotations linked to the same target "age a little
lower than the announced age". We can notice that
there are two different anchors: two different arrows
linked to two different comments: "Verify the
gestational age done by the maternity" and "Envisage
a new exam to determine the age".
University Hospital of Amiens North Hospital – 80054 Amiens Cedex 1
Functional Explorations of Nervous System
Pr. TheDoctor - Tel : 03 22 66 84 55
Unit of Functional Neuro-paediatric Explorations
Phone : 03 22 66 87 41
Fax : 03 22 66 86 22 Amiens, 12/03/2003
2003-000261 SB/JK
SANDRA THEPATIENT
Born 26/02/2003
Electroencephalogram of 10/03/2003 – MED PERINATAL HN
During the agitated sleep the layout is continuous, constituted of activities primarily theta during which we
observe well drawn frontal notches and some puffs of former slow rhythms.
Enough quickly, the child passes in calm sleep. The layout is rather semi continuous that alternating with
therefore hypoactive periods which appear a little more long for the announced corrected age of 40 weeks.
There is no element with pathological significance throughout this recording.
CONCLUSION
Layout highlighting an organization of the electro-genesis corresponding to an age a little lower than the
announced age without any element with a pathological significance.
Pr TheDoctor
Figure 2. Difference between anchor and target
Envisage a new EEG
before 10 days
Envisage a new exam to
determine the age
Verify the gestational age
done by the maternity

3. 3
1.2.Target, Anchor and Content
When we annotate, we start by placing an anchor,
to locate the annotation target. Then, we add a content
to this annotation. In the three following sections, we
will specify the notion of target, anchors and content.
In each section, we study the practices carried out on
paper documents and we wonder which practices are
necessary to reproduce in electronic documents.
1.2.1 Target
A target can be: a collection (a group) of
documents, a document, a part of document, a group
of words, a word, an image, a part of image, or
another annotation (
cf. figure 3). Let us imagine a
fellow, annotating the surgical report of a patient. The
senior physician, in charge of this patient, reacts to the
fellow’s comments by writing new annotations. It is
an example of a target which is another annotation. In
electronic documents, annotators must be able to
annotate the same targets than in paper documents.
Figure 3. Various targets
DOSSIER
ThePatient
N°23583
Annotation on a
collection
Surgical report
Jhkjhkjhkjhkjlkjlkjlj
lkjlkjlKjlkjlkjlkjkljl
k
Mlkmlkmlklùmlf,
ldflmksqdfksqdkflm
qksflklqkfmlqkfml
Annotation on a
document

4. 4
The table below (cf. figure 4) synthesizes the
typology of targets in paper and electronic documents.
A cross × means that the type of target exists in paper
(or electronic ) documents and a bar / means the
opposite. We will use the same legend in the other
sections.
Targets
Paper
Documents
Electronic
Documents
- a collection of
documents
× ×
- a document × ×
- a part of a document
(word, image, …)
× ×
- another annotation × ×
Figure 4. Typology of targets in paper and electronic
documents
1.2.2 Anchor
The anchor is the point of connexion between the
annotation and the annotated object. The anchor
establishes the context by linking the content to the
target. For example, if an annotator surrounds a word
in a text and adds a comment in the margin, we know
which part of the document is linked to the comment.
So, this anchor gives the reader the tracks to identify
the context of creation.
There are explicit and tacit anchors according to
the precision reached in the designation of the target
(cf. figure 5). An explicit anchor unambiguously
indicates the target. For example, a physician who
reads the nurses’ book underlines a value and
comments it in the margin. The target is explicitly
indicated. It is the underlined value. On the contrary, a
tacit anchor does not indicate precisely the target. For
example, a nurse sticks a post-it on a paragraph of a
nurse’s book. A priori, without reading the content, a
reader cannot say if the content of the post-it is linked
to the paragraph or to the document as a whole.
Figure 5. Explicit and implicit annotations
An annotation can be related to several targets
simultaneously. For example, a physician reads a
fellow’s thesis . He realizes that the fellow had put in
italic all the paragraphs referring to definitions. This
typography is reserved for the quotations. Near the
first definition in italic, he writes the comment
"Typology reserved for the quotations, rather frame
the paragraph". Near the second definition, the
professor writes "idem". After various definitions, he
does not write anything. It is the fellow who
associates himself the information to the concerned
paragraphs. We use the expression multi-target
anchors to designate the anchors linked to several not
consecutive targets. These anchors can be explicit for
some targets and tacit for those coming after in the
document. For the anchors linked to only one target,
we use the expression one-target anchor. For
example, a succession of consecutive underlined
words in a text is a one-target anchor.
It is possible to associate conventions to the
anchors. These ones enable to identify the target of
the annotation. If the annotator surrounds an image,
the annotation is related to this image. They also
enable to identify the location of the content. A reader
meets during his reading a number near a word. If he
knows this typographical convention, he will refer at
the end of page to read the associated footnote.
Therefore, there are conventional anchor and not
conventional anchor. A conventional anchor is an
anchor whose form and significance of this form
result from an agreement between several people. A
not conventional anchor does not result from such an
agreement. The reader of a not conventional anchor
does not know a priori the meaning of this anchor. It
can result interpretation problems because the reader
does not know the location of the target and the
location of the content.
The table below (cf. figure 6) synthesizes the
typology of the anchors in paper and electronic
documents.
Paper
Documents
Electronic
Documents
- explicit anchor
- tacit anchor
×
×
×
×
- multi-target anchor
- one-target anchor
×
×
×
×
- conventional anchor
- not conventional anchor
×
×
×
×
Figure 6. Typology of anchors in paper and electronic
documents
1.2.3 Content
The annotator transmits a message thanks to the
content of the annotation. This content is source of
meaning for him and for the readers.
The content can appear in the document (in
margin, at the end of the page, between two lines),
outside of the document (post-it stuck on a paper
document) or be merged with the anchor (highlighted
passage).
In paper documents, the content of an annotation is
presented in a textual form (a comment) or in a
typographical form (highlighted passage, surrounding
part). So, there are textual contents or typographical
contents. In the case of a comment linked to a word
Surgical report
Jhkjhkjhkjhkjlkjlkjljlkjlkj
lKjlkjlkjlkjkljlk
Mlkmlkmlklùmlf,gksmlf
Ldflmksqdfksqdkflmqksf
lklqkfmlqkfml
explicit annotation
Post-it : tacit
annotation

5. 5
by an arrow, the anchor and the content are distinct.
The anchor is materialized by the arrow and the
content by the writing of the note. In the case of a
typographical content, the anchor and the content are
merged. For exa mple, the anchor is materialized
during highlighting. The typographical content
corresponds to the meaning of the anchor form. For
example, a doctor reads a medical publication. To
facilitate his analysis, he highlights in blue the
definitions and in red the most important parts. So, the
colour of the anchor is meaningful of his reading.
The formof the annotation content, as anchor form,
can be or not be conventional, that is to say that the
content form and the significance of this form result
from an agreement between several people "The form
can reflect the conventions of notation built by the
collective" [Schmidt 2002]. For example, a medical
secretary sticks pink post-it on the documents to be
classified, yellow post-it on the documents to be filled
in. This organisation is conventional in her service.
So, we use the expressions conventional contents and
not conventional contents.
With an electronic medium
, we can imagine other
types of contents than the textual or typographical
contents. The content can be defined in an audio
format, with a fixed or animated image, with a
hypertext link to another document, or another part of
the document, or another annotation, with multi-
media information.
The table below (cf. figure 7) synthesizes the
typology of the content in paper and electronic
documents.
Paper
Documents
Electronic
Documents
- content present in the
document
- content outside the
document
×
×
/
×
- conventional content
- not conventional
content
×
×
×
×
- textual content
- typographical content
- audio content
- content by fixed or
animated image
- multimedia content
- link content
×
×
/
/
/
/
×
×
×
×
×
×
Figure 7. Typology of contents in paper and electronic
documents
1.2.4 Conclusion
We identified the characteristics of the annotations
in paper and electronic documents. According to the
syntheses carried out in the tables of this section, it is
obvious that the change of medium
, although the
problems of reading (confusion in hypermedia), allow
to add new annotationnal practices as the possibility
of annotating documents with contents other than
typographical and textual.
The interest of an electronic medium for the
annotation practice is also based on the automation of
information addition (annotator’s name, date of
creation). Moreover, it is easy to associate a type to
the electronic annotations and to carry out
calculations according to their types. This practice is
not possible on paper medium.
2. Who are the addresses and readers? For
which uses?
2.1.Annotations addresses and readers
We wonder in this section who are the addresses
and readers of the annotations.
In paper documents, once the annotation is placed,
all the readers of the document will be able to read its
content, even unexpected readers. The annotator does
not know, when he writes an annotation, the potential
readers. For example, a fellow writes a comment on a
paper document of the Health Record. This record
stays in the box of the child. The parents can read the
document and the comment, whereas the Health
Professional did not think to them when he wrote the
annotation.
With an electronic application, the annotator can
specify the readers concerned by his message: the
addresses of the annotation. He can associate to an
annotation access rights for the reading. [Zacklad
2003] distinguishes two spheres: the private sphere
and the public sphere. The public annotations are
aimed at everyone. For example, when a fellow writes
the child’s report of entry, he adds footnotes, to
complete the information in the texts. These
annotations are aimed at all the readers. The private
annotations are only aimed at the annotator. For
example, when he writes the previous report, the
fellow adds the comment "Mother seropositive. Is the
father being aware of her state? ". This information is
important for the child care, but it does not have to be
revealed to the father. In addition, the medical
intervention is increasingly related to the
responsibility of the medical team taking care of the
patient. So we add to the two previous spheres, the
sphere of the group. The annotations for a group are
aimed at a community of people. For example, the
previous fellow wants to indicate to his colleagues the
state of the mother. Only the medical team must be
able to know h is opinion.
Why is it so important to specify the addresses?
We saw in the previous examples, that the notes are
not always relevant to communicate. In addition,
[Wolfe 2000] showed that the annotations have also a
social and cognitive impact. This impact is not always
in adequacy with the reading objective of a reader.
Indeed, meeting an annotation means that someone
else has already read the same document and has
interpreted it. So, the annotation modifies the mental
representation elaborated about this document.
According to the context (if the reader knows the
annotator and his point of view), the annotation can

6. 6
distort reader’s thought about the document, or on the
contrary encourage him to develop a critical spirit.
Having information on the annotation context of
production (annotator’s name, his point of view, date)
facilitates the interpretation of annotations and texts.
The table below (cf. figure 8) synthesizes the
annotations typology, according to addresses, in paper
and electronic documents.
Paper
Documents
Electronic
Documents
- public annotation
- private annotation
- annotation for a group
×
/
/
×
×
×
Figure 8. Typology of annotations according to addresses in
electronic and paper documents
2.2.Intention of communication
In this section, we describe the various intentions
of communication of an annotator.
2.2.1 Annotations used to facilitate the
reading
While reading a document, scribbling some
comments or highlighting a group of words, helps the
reader to build his document perception, his mental
representation of its content. These annotations act on
document interpretation. They participate to the
design of knowledge, by the annotator, during the
interiorization process of the information consulted in
the document. So, these annotations facilitate
annotator’s reading.
Annotations produced during the reading can be
consulted a posteriori of their creation by the
annotator or another reader.
Concerning the annotator, annotations form a
"reading road" [Marshall 1999], a road of the points
he considered as important. For example, if a nurse
reads a document and annotates several paragraphs, it
is because she paid attention to these paragraphs.
These ones have a certain interest for her, according
to her reading objective. A posteriori, these
annotations ensure a fast second reading of the
annotated document. Indeed, the annotator formulated
these ones with his own terms. However, when the
acts of annotation and reading are distant in time, the
annotator has sometimes difficulties to understand
himself. We often forget what was our reading
objective during the act of annotation. When a
document is read, if the reading objective is different,
we interpret it differently and annotations are
different.
Concerning new readers who visualize the
annotated documents, annotations improve or
distorted their reading. Indeed, these annotations are
the traces of a previous interpretation of document
content. According the credibility of the annotator, the
reader will agree or not with his comments.
Annotations are written by the annotator either to
add information not present in the document, or on the
contrary to extract some information from the
document. So there are extensive and intensive
annotations. Extensive annotations are extensions of
the document. They bring new information to the
annotated document, to inform, illustrate, emphasize,
alert, document, comment, clarify, criticize,
compare,... For example, near a glycaemia result, a
Health Professional adds the comment "Glycaemia
too high. Possibility of diabetes. Look for the family
antecedents and practice a provoked glycaemia". The
physician adds information: his interpretation of the
result. Intensive annotations do not bring new
information to the document. On the contrary, these
ones enable to extract information to synthesize,
classify, organize, structure,... For example, a fellow
replaces a colleague sick. He reads rapidly the
patient’s record in order to find relevant medical facts
and highlights some information. He does not want to
add new information. He wants to build a fast view of
the patient’s state by identifying relevant information.
Annotations used to facilitate reading allow the
addition of information relative to the annotator’s
original point of view on the document. The reader
becomes the writer. Thanks to annotation practice, he
can appropriate partly the annotated document.
"Annotations on paper documents and books reflect a
reader’s unselfconscious engagement with the text."
[Marshall 1999]
2.2.2 Collaborative annotations
Collaborative annotations allow various actors to
communicate in the context of a document. They are
the support of information exchanges.
There are different types of annotation according to
the situations during which there are produced. The
annotations as editorial help are used to build a
document collectively. These ones facilitate the
process of writing, correction and evolution of the
document. The readers use annotations to suggest
modifications. For example, in margin of his fellow’s
thesis, a physician senior adds comments: "Change
the police size", "Add an example". Annotations for
argumentation allow to communicate, to discuss and
to argue. ([Zacklad 2003] uses the term “critical
annotation”). These annotations are useful to store
because they enable to find the problems and
sometimes the solution which occur to reach a
decision or an action. For example, near a
prescription, there is a comment "Insufficient
posology. Verify?". Annotations of planning assure
tasks coordination. These ones concern project
management and coordination. There are only useful
during the task. For example, on the meeting staff
report, a nurse sticks a post-it "Think of calling
Professor Y". After the phone call, the post-it can be
thrown away.

7. 7
3. Scenarios of annotations in the Electronic
Health Record
As we have said in introduction of this publication,
when we study the documents of the Paper Health
Record, we realized that they are very often
annotated. Annotations include a lot of information,
traces of the knowledge elaborated by various types of
actors who are handling those documents.
In this section, we will describe four situations
during which Health Professionals annotate electronic
documents.
3.1.Addition of knowledge in forms: a
question of shared readability
Most of the documents in the Paper Health Record
are forms created by the Heads of Departments
(designers) to be filled in by the Health Professionals
(writers) belonging to their medical teams. These
forms are often annotated (cf. figure 9). After having
described the way in which the forms are created,
filled, read and annotated, we explain why the
annotations are essential not to lose information in
such documents.
Figure 9. Addition of knowledge in the forms
Create a document is a way of representing its
social comprehension, of glossing the reality by
communicating, clarifying or commenting some
events. In the Health Record, documents correspond
generally to events taking place during care process (a
blood report obtained after the event: blood test).
Some syntheses about a set of events (a patient
discharge summary ) also exist. Thanks to their
knowledge and know-how resulting from their
experiment of the medical practice, the designer
formalizes the medical domain by defining the
organization and the content of a form. A Head of
Department creates a Hospitalisation Report. He
wants the physician to fill in the paragraphs of the
form with some information. This intention appears in
the descriptive headings of the fields and in the
structure of the document.
The writer, a fellow, perceives the organization of
the document. He answers the "questions" of the
designer by consigning information resulting fromhis
headings interpretation. Thereafter, a new reader,
another fellow, who consults this document, interprets
the designer’s headings and the information added by
the writer. "A doctor who reads a hospitalization
report knows in advance that i
t is a physician who
wrote it, for one of his colleague. He knows also that
it is a summary of the medical events (...). There are
interpretative r
ules indicating him how to read the
contents (...)" [Bachimont 2001].
In the electronic documents, [Pedauque 2003]
defines the concept of shared readability. "An
electronic document is a data set organized in a stable
structure associated with formatting rules to allow it
to be read both by its designer and its readers". In
forms, the designer adds rules about information
capture aimed at the writer and reading rules aimed at
the reader. This addition results from this concept of
shared readability. However, the addition of rules
does not able to represent all the situations of capture.
Medical forms are often structured. Health
Professionals do not have enough freedom to add
comments not envisaged by the designers. So, these
designers, who are not able to envisage all the
relevant medical facts which have to be captured, add
fields’ texts: the memos. These memos do not
preserve the context of creation of the added
information. These ones are not in relation with the
part of the document source of the comment. For this
reason, in paper forms, experts rather use annotations
to connect the comment and the annotated part by a
graphical way (an arrow, an underlined word). So,
annotations added to the medical forms, not envisaged
by the designer, take part in the readability of the
information written in the record, by preserving traces
of the context of their writing that we can identify
thanks to the anchor.
A new reader will be able to interpret the document
and to leave traces of his comprehension in the
annotations. Annotations allow the storage of
knowledge not envisaged by the designer and written
this time by an annotator different from the writer
envisaged by the designer.
We affirm that an annotation tool is essential in a
computerized system used for managing patient
record, in order to contextualise the information not
envisaged by the designers and which are produced
during information capture and reading. Indeed, the
dimension of shared readability between author and
reader will be reached only if the writer and the reader
annotate. If not, these ones do not have sufficient
means to leave traces of the writing context. As
[Pedauque 2003], we propose a definition as an
equation:
Annotated form = designer’s structure and knowledge +
writer’s knowledge + reader’s knowledge
This equation shows reader and writer’s insertion
in the process of the document building. So, these two
actors are authors themselves. The form is created by
a designer who structures it and leaves traces of his
knowledge in the descriptive headings. The form is
filled in by the writer who leaves traces of his
comprehension in the zones to be filled and in the
annotations. The reader will also leave traces of the
knowledge produced during his reading in the

8. 8
annotations. As explains by [Bachimont 2001],
annotation practice is a way, for the reader, to
appropriate the document, to rewrite it according to
the wished used. So, he becomes the "author of his
reading" [Bachimont 2001].
3.2.Documents creation thanks to all
the resources of the record and the
annotations : A question of
Hypertextual and Annotationnal
Semantics
3.2.1 In paper documents
While studying the paper Health Record, we
realized that it often includes documents resulting
from the combination of various resources. These
resources can be annotations and parts of documents
(cf. figure 10). This combination is rewritten by the
Health Professional. For example, a physician wants
to write the part "Hospitalization Causes" and
"Disease History" of the entry report. He reads the
maternity Paper Record. He looks for information
relative to the family antecedents of the new born. He
also looks for information about the events which
have occurred during the pregnancy and the
childbirth. He annotates the points he considers
important. He gathers them in the concerned
paragraphs. He rewrites them to build something
understandable. In such a scenario, the reader
becomes a reader-author (or reader-script [Stiegler
2000]) because he carries out two tasks: the document
reading is the base used for the writing of a new
document (or a part of document).
Figure 10. Creation of new document thanks to the
passages selected in documents and annotations
There are two types of documents created
according to this practice: the documents envisaged in
the record but which are built thanks to the reading of
other documents of the record (patient discharge
summary) and the documents "improvised" by the
Health Professional (personal note, synthesis).
The reader-author carries out reading and writing
activities quasi simultaneously. He reads the record,
identifies relevant parts in the documents. He writes
on a sheet his comments and reads again. His
objective is to identify portions of documents, to
extract from these ones some knowledge, in order to
reinvest them in other speeches, in another context. Of
course, these re-use results from a knowledge
appropriation (interiorization). During the rewriting,
the work of knowledge reorganization is not limited to
the knowledge extracted fromthe documents. Indeed,
the reader-author must be able to add knowledge
resulting from his inspiration of the moment. The
possibility of writing during the reading determines
the type of the reading. C
ollecting, combining and
rewriting modify the strategies used during the
reading of the paper documents.
3.2.2 In electronic documents
In electronic documents, we can propose a
functionality which allows users to carry out the same
practice as in the paper documents : leave the
possibility to the users of choosing annotations and
passages in documents, of recombining them and of
rewriting the result. It is also possible to propose to
the user a new practice thanks to the calculability of
the electronic documents: privileged annotations
combinations according to their type. We will go into
details about these two practices in this section.
A first functionality: creation of new documents
thanks to a recombination resulting from the
user’s reflection
When the reader-author reads electronic
documents, he suffers from many difficulties.
Abundant researches [Rouet 1998;Dubois 2003] in
cognitive psychology underline the complexity of
information research in hypermedia. This research of
information is made thanks to cognitive (data
processing) and meta-cognitive (strategy of
navigation and control of the information relevance)
processes more complex than those implied in the
reading of paper documents. The reader is often
disorientated by the too many requests (buttons,
links), which overload his memory. The reader-author
is therefore disturbed in his reading task. In addition,
he generally does not have relevant software allowing
him to visualize all the documents he wants to read
and the document he is building at the same time .
Conscious of the difficulties encountered by the
reader-author when he works with an electronic
medium, we want to develop a first documentary
functionality. It consists in enabling him to create new
documents by choosing passages selected in the
documents (targets of the annotations) and
annotations content. The reader-author must be able to
gradually rewrite the results of this collection.
[Soubrié 2001], who builds this type of tool3
,
affirms that such a practice facilitates the
development of new intellectual operations as
statements comparison, location of agreements and
correlations, organisation into a hierarchy of elements,
3
AUKAPIWeb http://isko2003.iut2.upmf-
grenoble.fr/Interventions_converties/Soubrie/Soubrie_interv.html
Annotated
document 1
Comment on
document 1
New Document
Underlined part in
document 1
Comment 1
Comment 2
Annotated
document 2
Comment on
document 2

9. 9
reorganization and addition of structure. For example,
the fact of putting information collected in different
documents one after the other facilitates detections of
contradictions.
Some software as iMarkup4
and Xlibris 5
, TheBrain6
already generate a synthetic view of the document by
gathering in a new document all the annotations
linked to the initial document. In these applications,
only the comments placed in the annotation contents
are used for the generation of new documents and not
the target of these annotations. We think that the two
resources (contents and targets) are relevant to
combine.
A second functionality: creation of new documents
thanks to the combination resulting from a
software calculation.
Let us imagine a reader-author, navigating in the
record, with the intention of building the patient
discharge summary. He annotates parts of the record
and types his annotations as "Patient discharge
summary annotation". To gather all the annotations
typified in this way in a predefined document "Patient
discharge summary" has a sense. Of course, the
reader-author must be able to modify this document
by working on it again.
Contrary to the first functionality which consists in
letting the reader-author choose the annotations that
he wants to gather, it is this time the machine which
proposes to the user some predefined combinations.
Who is responsible of these new electronic
documents? How contextualise these new
documents when they are not predefined?
The reader-author of the new document is the
person who reworks the recombined elements. He is
responsible of the content of this new document and
not the authors of the various recombined sources.
In addition, the meaning of the "improvised"
documents (not predefined in the Health Record), is a
priori known only by the reader-author. In order to
facilitate the interpretation of these documents by new
readers, it is necessary to store traces of the context of
creation. For that, links to documents or annotations
used to build them must be stored. So, a new reader
will be able to consult the resources used for the
generation of the document.
Which annotations are combinable?
We wonder if all the annotations or parts of
document can be combined. It depends on the
annotations and the selected functionality.
In the case of the first functionality, we think that
all annotations are combinable. For example, it seems
useless to combine annotations as "The doctor
increased the rate of caffeine" and "Proportioning of
4
http://www.imarkup.com [Marschall 1999] [Golovchinsky 1999]
5
http://www.fxpal.com/xlibris/
6
http://www.mines.inpl-nancy.fr/~tisseran/tsie/02-
03/etudes/thebrainssite/
caffeine in 48h". However, the association of these
two contents allow the nurse to elaborate the
following knowledge written in a note (cf. figure 11):
Sandra Bringay
20/09/04, 13h
Note for the night nurse:
A proportioning was envisaged in 48 hours. The
physician had increased the posology, So, I remind you that
the proportioning must be brought forward of 24 hours
Figure 11. Creation of a note thanks totwo annotations a
priori not-combinable
We cannot suppose of the creation of knowledge
by a reader-author. Even two contents are at first sight
useless to combine, they can make sense together, by
association of ideas, for a person, at a certain moment.
In the case of the second functionality, it is more
difficult to answer this question. Which predefined
combinations can we propose to the user? All
annotations relative to a system (cardiovascular
system, respiratory system)? All the annotations
relative to medical acts in order to built the synthetic
form dedicated to the administration? Can we mix
several types of annotation? We are working actually
on the Hypertextual and Annotationnal Semantics
HAS. It consists in defining the possible combinations
of annotations placed in a hypermedia. This work will
be soon the object of a new publication.
Conclusion
To conclude, we can say that the change of
medium, form paper to electronic mediuminfluences
the way we read and write. Reader’s role is modified.
Thanks to the annotations and the documentary
functionalities, the reader-author becomes
increasingly active. He adapts the document by
personalizing it. We agree with [Soubrié 2001] who
speaks about "writing-reading" to indicate the fact
that the reading and the writing become
consubstantial activities. [Stiegler 2000] "The
electronic annotation, which exploits the dynamic
virtues of the electronic medium, enables to register
the reader’s actions in what he reads. What we mean
is that reading and writing become inseparable".
[Soubrié 2001] specifies that "Besides, this new way
of "communication" with the text is strongly induced
by the computer itself, as it is presented to the user: a
screen for reading and a keyboard for writing".
3.3.Link between documents
Health Professionals also use annotations to link
documents, to guide the reading from a document to
another (or to a part of document). For example , we
met in the margin of a report the following comment:
"cf. thorax radiographs". This practice can be very
relevant compared to the new French laws concerning
Health Professionals’ information. From now on, the
physician must prove that he had referred to
guidelines during medical acts. To keep a trace of this
consultation, an annotation can be placed in the

10. 10
document which led the Health Professionals to
consult the guideline. The content of the annotation
are a link to the consulted document (and a comment
if the user adds one) (cf. figure 12).
Figure 12. Addition of link annotation between a document
and a guideline
We agree with the concept of annotationnal
solidarity of [Bachimont 2001]. This author affirms
that the comprehension of a document in a
hypermedia influences the reading of the others
documents. In order to keep traces of the reader’s
navigation, it is very relevant to link documents
through annotations.
3.4.Information Communication
through annotations : A question of
social links
Working time reorganization in the units
accentuates the problem of information transmission
between the various teams taking care of the patient.
In paper record, there are annotations used as a
support for these information exchanges. When
Health P
rofessionals create a document, they often
add comments in post-it aimed at their colleagues.
They communicate in an asynchronous way
[Churchill 2000] in the context of a document (
cf.
figure 13).
Figure 13. Annotation used for information transmissions
between nurses
With the electronic medium
, and thanks to
annotations, we can also imagine to make
communicate two Health Professionals in a
synchronous way [
Churchill 2000]. For example, a
Health Professional asks a colleague to help him to
build a diagnosis . In general, they use a first medium
to visualize the document they are building (a window
with the document) and a second medium to
communicate about the document (a phone, a window
for chatting). They work on precise parts (some lines,
a table, etc.). A lot of time is lost to identify these
parts because they cannot simultaneously see what the
other interlocutor visualizes. If the two Health
Professionals used an annotation tool to comment the
document, they would exchange information
contextualized thanks to the anchors placed in the
document. They would know the discussed part and
the context in which it is located.
So, annotations can be the support of social
interactions (exchanges related to reading act and
annotations writing act). For this reason, annotations,
as documents [Pedauque 2003], establish social links
between the various actors handling the Health
Record. Annotations acquire by this way a social
status. Some tools as Anchored conversation7
and
Annotea8
support synchronous and asynchronous
conversations. Annotations of communication include
traces of Health Professionals ’ medical activities.
3.5.Conclusion
In this section, we described four situations during
which annotations are used in the documents of the
Electronic Health Record. According to the
theoretical bases presented in section 3, the following
table (cf. figure 14) recapitulates annotations
characteristics in each scenario.
7
This tool have been implemented by FXPAL laboratory de Palo
Alto [Churchill 2000]
8
This tool have been implemented for a W3C project [Koivunen
2001]
Document
link to a
guideline
(Comment)
link
Guideline
New perfusion at 18
o’clock because the
glycaemia is higher
than 1.5g. Decrease
the glucose
concentration.

11. 11
Scenario 1 Scenario 2 Scenario 3 Scenario 4
Target
- a collection of documents
- a document
- a part of document
- another annotation
/
×
×
/
×
×
×
×
×
×
×
×
×
×
×
×
- explicit anchor
- tacit anchor
×
/
×
/
×
/
×
/
- multi-target anchor
- one-target anchor
×
×
×
×
×
×
×
×
Anchor
- conventional anchor
- not conventional anchor
×
×
×
×
×
×
×
×
- textual content
- typographical content
- audio content
- content by fixed or animated image
- multimedia content
- link content
×
×
×
×
×
×
×
×
×
×
×
/
(×)
/
/
/
/
×
×
×
×
×
×
×
- content in the document
- content outside the document
×
×
×
×
×
×
×
×
Content
- conventional content
- not conventional content
×
×
×
×
×
×
×
×
Addressee
- public annotation
- private annotation
- annotation for a group
×
×
×
×
×
×
×
×
×
×
×
×
Intention
of
communications
- annotation as reading help
* intensive annotation
* extensive annotation
- annotation of collaboration
* annotation as editorial help
* annotation for argumentation
* annotation of planning
--------
×
×
--------
/
/
/
--------
×
×
--------
×
×
×
--------
/
×
--------
/
/
/
--------
×
×
--------
×
×
×
Figure 14. Synthesis of the annotations characteristics in the four scenarios
4. Annotation Status
An annotation is autonomous if it is understandable
when the anchor is removed. However, we have said
(cf. §1.2.2) that the anchor provide the context of
creation. So, wondering if an annotation can become
autonomous, it is wondering if an annotation has a
sense without its context of creation.
However, [Charlet 2002] had showed that medical
information has only a signification in documents to
preserve their context of creation. In the case of an
annotation, the context is provided by the anchor.
Thanks to this one, we knows which is the object
related to the annotation. However, the annotation
content can also include context traces.
In most of cases, an annotation has no signification
without its context of creation, but in rare cases there
are autonomous.
Let us take the example of the annotations
produced to fill in medical forms (
cf. §3.1). These
forms correspond to an event which occurs during the
patient’s hospitalization. A Health Professional who
finds the results of biological analyses in the Health
Record, can deduce that this patient was examined,
the date of the examination and who is the physician
who has practiced the examination,... In this case, the
annotation content corresponds to information on this
event. The anchor allows to establish the link between
the content, the form and so the event. The annotation
loses any significance without this context of creation.
It is not autonomous.
Let us consider the annotations of communication.
A day nurse sticks a post-it for the night nurse on the
"placard9
", containing the message "Continue to
record the temperature each hours" (cf. §3.4). She
could have left the same post-it on the Health Record
near the incubator. The annotation content is not
related to a particular document but on the patient.
The nurse chooses the "placard" because it is the first
document consulted when a person enters in a box.
Annotation context is the patient. Such an annotation
remains understandable as long as it is attached to an
object related to the patient. On the other hand, it is
not autonomous because this context is essential to
make it understandable. If a box contains two patients
and if a nurse sticks the post-it on the door of the box,
her colleague will not know who is the patient
concerned by the post-it.
9
A placard is a particular document which sumps up every day the
principal vital data of the patient in a table.

12. 12
Now let us take for example the case of the
annotations produced during the reading. A doctor
reads a medical publication. To facilitate his
comprehension, he underlines the relevant parts,
paraphrases them and adds comments. The annotation
is therefore understandable alone, even if we do not
have any more access to the target because this one
was reformulated in the annotation content (cf. figure
15). An annotation can become more autonomous if it
includes sufficient context in its content. This context
will allowa future reader to interpret the annotation.
Surgical Procedures
Surgical procedures are classified as optional,
required, elective, urgent, and emergent based
on the patient's medical condition. Optional
surgery consists of operations that are not
required but which the patient chooses to
undergo as with some types of cosmetic
surgery. Required surgery is performed when
only surgery will correct a problem-such as
cataracts-but the surgery can be delayed for a
period of weeks or m onths. Urgent surgical
procedures are perform ed when a patient's
condition is not immediately life-threatening,
but failure to treat it may result in death.
Figure 15. Reformulation of the target in the content of
an annotation
[Zacklad 2003] affirms that "annotations do not
have in theory an autonomous existence
independently of the principal document, container of
the initial texts and schemas they complete". We
agree with this principle but we nuance it. We affirm
that in most of cases, annotations are not autonomous
documents. However, in rare cases, there can be
autonomous as certain annotations produced during
the reading. These last ones can become little by little
autonomous, be understandable without anchor nor
target. For reaching certain autonomy, the annotator
must leave traces of the annotation context of creation
in the content. He must add signs enabling to
materialize the events at the origin of the annotation
writing. However, this type of autonomous annotation
is very rare.
Besides, this addition of context is easier if the
medium is electronic. It is possible to transfer
automatically to the annotation content some
information as: the target, the annotator’s name, the
name of the annotated document, the interpretation of
the anchor content if this one has a particular
signification (if by convention, yellow underlined part
means "important", it is necessary to store this
information),… In addition, we can envisage new
reading devices of the annotations. Indeed, on paper
medium, the annotation is strongly linked by the
mediumto the annotated document. We never read an
annotation without simultaneously visualizing the
annotated document. On the other hand, on electronic
medium, it is possible to present the annotation
without the annotated document. For example, the
reader can visualize a list of the annotations relative to
the Health Record, and reach, thanks to this list, the
annotated documents and the annotations content.
This move to a most important autonomy of the
annotation occurs during the creation of a new
document thanks to annotations and parts of
documents (cf. §3.2). When the reader-author works
on a document, he adds signs (titles, paragraphs
headings). A reader will be able to recognize a certain
documentary format and therefore identify the context
of creation of this new document. After this work of
rewriting, we do not speak any more about an
autonomous annotation but about a new document.
We wonder now if all the annotations are relevant
to store in the Health Record. Let us take the case of
the annotations of planning (
cf. §2.2.2). These ones
become obsolete once the task is carried out. It is not
relevant to store an annotation as "Change the
perfusion this day", once the perfusion is changed. On
the contrary, some annotations must be stored not to
lose knowledge. It is the case of the extensive
annotations added to the medical forms (cf. §3.1). The
permanent annotations, once created, must be stored
definitively in the record. The temporary annotations
are anchored in a document until a user finds them not
relevant for the reading. What about the annotations
linked to a document removed from the system. Must
there be stored in the record? We think that we should
store in the record only the autonomous annotations
because all those which did not acquire enough
autonomy will not be understandable any more alone.
Of course, medico-legal problems must be added to
these reflections. The last French laws stipulate that
all the documents with an electronic signature must be
stored and be accessible for the justice and the patient.
These last laws are vague about the personal notes .
Currently, it is difficult to know if all the electronic
documents and therefore all the annotations will have
to be stored in the Electronic Record.
In addition, contrary to paper documents, an
electronic document is not fixed in an intangible form
because of its immateriality. It can be modified. For
example, it is possible to present the same contents
according to several presentations: a literary form
(with sentences) and a tabular form. What happen if a
comment is linked to one of these two presentations?
Must it be transferred on the other presentation? It
depends on the context of creation of the annotation.
If this context (present in the anchor, the target and
the content) is not related to the presentation of the
annotated document, the annotation will be
transportable (
cf. figure 16a.). On the contrary (
cf.
figure 16b.), it is not transportable.
The autonomy and the time persistence of the
annotations are conditioned by the way the annotator
leaves traces to materialize the context of creation.
Surgery acts are practiced if and only if one
operation can solve a problem (as cataract)
but it can be delayed several weeks or month.
ð Verify the delay for an operation
ð paediatric unit

13. 13
Figure 16 a. Transportable annotation
Figure 16. b. Not-transportable annotation
5. Annotation: a particular document?
In this last part, we explain why we consider
annotations as particular documents linked to other
documents.
The annotation and the target are perceived by the
annotator and possible readers as two distinct objects.
When an annotation is placed in a document, as a
comment in the margin, the reader differentiates it
from the annotated document because the form (the
writing) and the content (two different points of view
in the document and in the annotation) can be
different. It is possible to consider that this annotation
is a part of the document which becomes, once
annotated, a new document. According to us, there are
two documents relative to two different intentions of
communication. The author of the document and the
annotator are (or not) two distinct people. Only the
inscription medium
, in the previous example the paper
sheet, is the same. When the annotation is outside the
paper document, as a post-it, it is more obvious to
consider them as two documents. The inscription
mediums are different. On electronic medium, in
order to treat the annotations independently of the
target, we define an annotation as a particular
electronic document linked to a target.
During the collective writing of the document
[Pedauque 2003] and during the special journey
organised the 15th
January 2004 on electronic
documents10
, some researchers wondered about the
status of document. When an object become or not
become a document? Having defined an annotation as
a document, we want to position ourselves on this
topic. [Pedauque 2003] affirms that to acquire the
status of document, an object must verify two
conditions:
- "To be legitimate, the inscription must have a
scope that is beyond private communication
(between a few people)",
- "The legitimacy must be more than ephemeral (go
beyond the moment of its enunciation) and
therefore be recorded, inscribed".
Concerning the second condition, an annotation is
not ephemeral since it results from traces inscription
on a medium
. The annotator interprets the document
according his point of view. He formulates a
knowledge which is recorded in the annotation. This
information exists as long as the annotation exists. As
for traditional documents, document status of the
annotation is not acquired definitively. An annotation
can be forgotten by the collective consciousness
before being retrieved and therefore re-legitimized
[Pedauque 2003]. It is particularly true for some
annotations of communication (cf. §3.4) not stored in
the record for ever.
All the contributors of the text [Pedauque 2003] do
not agree with the first condition. Some authors think
that, as the annotations are not communicated, as the
private diary or the shopping list, there are not
documents. "A diary is not a document unless
someone takes the initiative of making it public or at
least communicating it beyond the circle of relations
of its author". For these authors, a document not
published, do not allow a social relation. Indeed, by
addressing to himself, the author stops any
relationship with the world around him. We position
ourselves in the second category of authors who think
that annotations are documents. The value of a
document "preexists to its communication or
recording". To create a document, an author uses
knowledge resulting from his comprehension of the
world. He builds two mental representations: how the
document he wants to create looks like and which
knowledge he wants to consign in it. The author wants
to create a document in conformity with these two
10
http://h2ptm.univ -paris8.fr/dnumerique/

14. 14
representations. So, i
t is not possible to say that a
document can be created without social link. Even for
the annotations or the private diary, the author built
the two representations thanks to his world
comprehension.
In conclusion, a document does not need to be
communicated to a group of not intimate people to
acquire the status of document. On the other hand, as
long as it is not perceived by a reader (
maybe the
annotator himself), not recognized as belonging to a
group (the annotator verifies that his annotation is in
conformity with the annotations group) and
interpreted (the annotator interprets what he
annotates), an object does not acquire the status of
document. So, Health Professionals are used to write
and consult annotations. A generic form and a generic
content give a status of document to annotations.
We reformulate the first condition as follow:
- The inscription must have a scope that is beyond
private communication more by the status of the
document, instituted, and accepted as a mode of
usual communication, than by the real number of
people who read it.
Conclusions
In the framework of the computerization of the
Health Record according to a documentary approach,
we considered in this publication, particular
documents: annotations. [Stiegler 2000] uses the
example of Little Tom Thumb to describe the fact that
thanks to annotations, the reader leaves traces of his
navigation. He affirms that the "genius of the
machine" consists in automating these additions of
information in the documents. As [Stiegler 2000], we
think that the possibility of annotating electronic
documents makes it possible the reading to join
"naturally" the writing. The electronic annotations
exploit the properties of the electronic medium, by
registering the actions of the reader in what he reads.
Read and write become two inseparable activities.
By following the theoretical result of [Pedauque
2003], we defined in a first part, the annotations and
in particular the anchor, the target and the content. We
showed that the electronic mediumallow to carry out
new types of annotations.
In a second part, we discussed the possible readers
of these annotations and in their uses.
In the third part, we described various situations
during which it is possible to use annotations in the
Electronic Health Record. Besides, we are convinced,
and the Health Professionals who are working with us
have the same point of view, that an annotation
system is essential not to lose knowledge in such a
record and to allow Health Professionals to really
work with the Health Record.
In the fourth part, we tried to specify the
annotations status and particularly their autonomy and
their time persistence. This work allowed us to
conclude in the last part that annotations are finally
documents themselves.
On a theoretical point of view, this first works
underlined one need. It consists in defining the sense
of the various documents created thanks to all the
resources of the record (need of a Hypertextual and
Annotational Semantics).
Currently, we are now working on the construction
of an application to manage the documents and the
annotations of the Health Record. This application
will be use in the Paediatric Unit and we hope that our
experimentations will confirm our hypotheses of
research.
Acknowledgements
We thank Physician G Krim, Head of Department
of the Paediatric Unit II (Amiens Hospital), for his
help during the writing of this publication.
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