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    The Medical Palm Review

    December, 2003 (V4N12) - Killer App or Just Killing the Budget?

    You would think that having two PDAs to play with would be enough for me but noooo. Now I am thinking about what I really want from my next PDA. Well, it is almost Christmas, so let's get into the spirit.

    Ghosts of Christmas Past, Present and Future

    As I noted in the November issue of this newsletter, until recently I believed that PDAs were primarily portable databanks. This has culminated in my Sony Clié. It is the fastest Palm I have ever used, with a screen so sharp it can play videos, lots of memory and two expansion card slots. It even has a decent digital camera with built-in flash. The downsides? It weighs a ton, the battery life is terrible, and reliability is poor.

    No, I don't mean that the hardware breaks down. The problem is software. Over the past six months I have installed video drivers, camera software patches and memory card driver updates. The Clié is trying to wear so many hats that the different multimedia and data applications trip all over each other causing crashes and resets. That's not satisfactory.

    Remember my mantra: backup early and often (well, OK, it's really Jerry Pournelle's mantra, but I have seen the light). Sooner or later those crashes are going to cost me data and time reloading everything. Fortunately the Sony comes with a robust backup application that preserves my data between crashes. I use it alot.

    I really should delete every add-on program and start again with a clean slate. That means making choices, choosing what I want to do, pruning the library of Palm software I could install to include just the ones I need and that will play nice with one other.

    My new Kyocera PDA-and-cell-phone combo was a heck of an early Christmas present. Suddenly, I had access to online services like browsers and eMail and I could dial phone calls straight out of my Palm's telephone directory. New vistas of portable networking opened up. The new gizmo has distracted me from fixing up the wonky Clié. But in its own way, starting out with the new PDA is alot like resetting the Clié because it involves the same process of trial and error to find out what software works, and to decide what I really need to carry around.

    However, the smaller screen and slower processor make it unlikely I will try to play videos or music on the Kyocera, so I will load fewer programs - and hopefully have a more stable device. Despite that, I already have discovered one incompatibility between the Kyocera's phone functions and BigClock, my alarm clock program.

    Here are some observations and comparisons between the two PDAs in my life. The Kyocera's strengths include:

    • lightweight and small -- and no need for a separate phone. I still marvel that the Kyocera weighs about a third of my cell phone and Sony Clié combined. How did I ever schlepp all that heavy stuff around?
    • integration with the Palm address book makes it easy to dial calls with one hand -- and no more painstaking reprogramming of cell phones with numbers from my Palm.
    • I have access to the web and eMail on the road -- but I have yet to really explore this in detail.
    • the phone keypad helps me find a phone directory listing but it also replaces a thumb keyboard -- works well for most tasks if I don't need to type fast (press "1" repeatedly to get "a" "b" or "c", etc.).

    Some minuses include:

    • lower resolution and physically smaller screen -- reading large texts or wide tables is not as comfortable.
    • the Kyocera is slower than the Sony when accessing applications on extended memory cards. This has to do with the processor speed but also the operating system -- 4.1 instead of 5.0 as on the Clié.
    • no built-in backup application to protect me from data crashes -- that will have to be purchased separately as it is essential.
    • the full benefit of the eMail system really cries out for integration with my desktop PC but that would require me to change the eMail software I use to Eudora or Outlook. Eudora lacks some of the power of Pegasus Mail and Outlook has terrible virus/worm/security problems I wish to avoid.
    • I need a separate HotSync stand and recharger for the Kyocera as it is incompatible with the Sony's. My desk is covered with a rat's nest of cables now.

    Can one of these, the Sony or the Kyocera, meet all my needs? Can one device do everything? For now, I have decided on hardware divergence instead of convergence. The Sony will go into my scrubs at the hospital so I can take advantage of its large screen for reading and teaching. The Kyocera gets the nod for everything else including when I am raveling to and from the hospital. How to maintain data files on the Sony? I'll just pop out the Memory Stick and bring that to my desktop PC for reprogramming.

    What about next time? Can I square the circle of wanting a big screen but a small device? Can I have a built-in phone and wireless internet access without recharging every few hours?

    Unluckily for me, new PDAs that provide communications capability and high resolution screens in a small package are not here yet.

    • The Palm Tungsten T3 stands out for its high quality screen, fast processor and 52 megabytes of RAM (I know they advertise 64 megabytes but some of it is used for the operating system and is not available for data storage). With that feature set all that's missing is an integrated modem but there is an expansion slot which can accommodate a modem.
    • The Palm Tungsten W has the built-in wireless modem but is only available to AT&T customers. The screen is not quite as nice as the one on the T3. But it does have two expansion slots for memory cards.
    • The Handspring Treo 600 has many fine qualities but its screen is not as good as the new Tungstens. Currently you have to be a Sprint customer (in North America) to use the phone and internet access features. It does have a camera and MP3 player, however.

    Theses are all worthwhile products and priced in the USD400 range. In a few years things should be verrry interesting indeed. For now, two Palm PDAs will have to suffice

    Other Hardware

    What other features might add critical functions to your PDA? Here are some exotic and mundane ideas for Christmas shopping.

    • Stethoscopes and other sensors for iPaqs from Andromed.
    • Palm has new cases for Tungsten C and W models - the ones without flip covers to protect their screens from scratches. InfoSyncWorld has a review.
    • Software from Agile Mobile turns smartphones such as the Nokia 7650, 3650 and 6600 into portable lie detectors. The company that makes it claims it is for entertainment purposes only (they are known primarily for game software) but the possibilities are intriguing. Read more about it at their website or in this article from InfoSyncWorld.
    • Cell phones with the Symbian operating system are coming out now: many features of a PDA (organizer, calendar, phone book) are incorporated. Can one of these replace your Palm PDA?
    • Palm is offering bundles to health care workers: buy a new Tungsten PDA and get screen protectors, a belt clip, and a copy of PatientKeeper Personal v3.1 or Griffith's 5 Minute Clinical Consult.
    • Palm is also promoting a range of games such as Bejeweled, Tetris, Mojo, even Trivial Pursuit.
    • Using the Palm Reader software you can read any number of electronic books on your Palm. From the Palm Reader site I got a free copy of Bruce Sterling's "The Hacker Crackdown" which is very timely. Before 9-11, the feds worried about the end of the world being caused not by terrorists but by hackers. It makes for engrossing reading on the subway - but I digress. There are many other titles available from the Palm Digital Media site - free and not-so-free. You can find scads of additional titles at Memoware and Fictionwise. And it's so easy to take delivery of eBooks by eMail, without wading through snow drifts.
    • Beyond Contacts syncs with Outlook better than many other products out there (they claim). If you rely upon Outlook on your desktop PC, you may be able to integrate it onto your Palm.
    • How about a Matrix-style screen saver for Palm OS 5 devices from Handy Entertainment?
    • Mars Needs Cows. Really. OK it's really a game. If you ever played the board game Those Awful Green Things from Outer Space then you'll get a kick out of this. Popcap Games also created the hit game Insaniquarium.
    • Leonard Maltin movie guides and reviews received the thumb's up from InfoSync World.

    Medical Practice Management

    If you are going to spend all that money on new toys, you'd better find a way to pay for them. Practice management software for your Palm will help you track your patients and schedule appointments, generate prescriptions, and even do billing. Traditionally a desktop PC application suite, lately many systems also offer a component for PDAs. To give a few examples: TurboDoc, PocketPractitioner, eBill, and DrFirst all integrate some mobile components into their practice management solutions. A casual search for "practice management PDA" on Google elicited about fifty thousand hits so there is no shortage of alternatives out there.

    The structured nature of billing and scheduling explains why there are so many potentially useful packages out there. Software for electronic medical records (or eMR) are less widely used and are often viewed as unsatisfactory by many doctors. To find out more about what's out there, try another Google search (here's one that turned up about one hundred companies selling mobile or partly mobile electronic charting packages). Ectopic Brain also lists a number of applications to get you started.

    However, your mileage may vary. If you work in a very structured environment, where charting is mostly filling out templated forms or ambulance run sheets or checklists, then eMR may work for you and your organization. Procedure-oriented physicians (eg. surgeons) may also find it useful to have preselected or checklist-based templates to prepare their operative notes. But it might be a stretch for many medical situations.

    If you aren't self-employed, your eMR software will need to be compatible with what everyone else is using. Adding eMR capability, particularly mobile or PDA-based charting, to an existing setup is a much more complex proposition.

    Noone should be deceived into thinking that eMR and practice management software will save them lots of money and "pay for itself". Even assuming that you can find a system that is as easy to use, durable and reliable as paper you will need computers, training and support. eMR has special advantages in

    • big organizations (possible economies of scale)
    • dispersed practice environments such as multi-site clinics or hospitals (easier to share info)
    • highly computerized workplaces (easier to integrate lab reports into the patient record)
    • third party billing (good billing systems which help in claim recovery will partly cover system costs)

    Still interested? Think carefully about your needs and what you are prepared to pay. Don't be too quick to believe claims made for overhead reduction and recovered costs. Ensure that the needs of all the stakeholders in your organization are addressed.

    Killer App or Road Kill

    Computer pundits are fond of writing about the "killer app" - the software application that is so cool or so transformative that it drives people to buy the hardware just to be able to perform that one task.

    Is there such a killer app that makes your PDA essential? Up until recently I would have said the primary purpose of my Palm was to carry medical reference data and perform DayTimer-like functions such as my ToDo list and phone directory. Others might depend on their wireless eMail.

    Such ideas are okay for individuals. We can buy hardware and software off the shelf and use it "as is". Ready made solutions for organizations are much less common. Developing a killer app for the Palm PDA in a medical environment is not easy. What would it be? Reference text access? Wireless lab data sharing and charting? Billing and scheduling? The catch is that for most of these ideas you need to continuously update the database or content. If you are the hospital IT guy, you need to provide working hardware, a functioning wireless network, and service to customers whose stuff has broken down. If you are the client (doctor, nurse, patient) you want reliability, speedy operation, and no "dead zones" where your portable computer is cut off from the network.

    If you are developing such a system, give lots of thought to the logistics "tail" that your dragon will require... For example, will you build a wireless network or can you rely instead on cell phones? Do you want the flexibility to pipe data (eg. lab results) to many different targets (PDA, desktop, Blackberry, cell phone, etc.)?

    One proposed killer app: hybrid charting at the bedside: templates for review of systems and chief complaint; dictated voice notes and digital photos for other stuff. (Why not go whole hog and video the encounter with the patient's answers and appearance recorded directly? You can even use BP cuff, stethoscope, etc. with a direct link to the PDA to record vital signs and other parameters. Why not? For one thing: imagine the size of the hard drives you'd need for storage!).

    Another idea: wireless linking to patient charts and reference texts using context-sifting and and computer-assisted diagnostic software with treatment templates that help health care workers treat their patients. This kind of PDA won't work like or look like the things we carry now.

    But don't stop there. Look at the health service encounter from the flip-side: the patient might use a PDA to record his medical chart, old ECGs, his medication list, and info handouts beamed from his MD about his medical condition. He could use it to wirelessly transmit cardiac rhythm data to a service provider, or monitor blood glucose or dietary calories. He might receive alerts about upcoming medical appointments or (from a pharmacy) reminders to renew prescriptions.

    This could be more intrusive than cell phones!! And I am not sure I trust my Clié to drive my insulin pump. In all this the PDA gets compressed: it absorbs cell phones, desktop computers, stethoscopes and glucometers. With this opportunity comes risk: ONE broken device seriously degrades capability. Single-function dedicated devices provide reliability through diversity.

    Medical Computing

    Here is a case study of wireless computing to enter and retrieve data from patients' charts with special attention to data security issues at Penn State.

    Look at MIT's Wearable Computer Project for some ideas that are waaay cool but not ready for prime time yet.

    In Times to Come

    Do you use your PDA as a portable reference tool? Can you also use it to collect new information from journals, medical websites and other online resources? Next month we look at "data mining" on the Palm handheld.

    And, because it is a new year, we will see what's new with software like HanDBase, PEPID, and drug formularies.

    Happy Holidays!

    This is one of a continuing series of newsletters on Palm handheld computers, prepared for doctors, nurses, IT professionals, educators and other people who need tools that work. Feel free to pass copies around electronically or on paper. To subscribe, or complain, contact the author at the following address:

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