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    The Medical Palm Review

    September, 2003 (V4N9) - Back to Work

    Now that summer is over, it's time to tackle rewriting the Emergency Department website. What tools and rules can I use to make the site Palm-friendly?

    Build It and They Will Come

    The downtown teaching hospital emergency department where I work is a busy place. I'm not referring to patients, but memos, newsletters, bulletins, policy-and-procedure manual updates. Every day physicians and nurses are bombarded with a blizzard of stuff. If we don't want to carry copies around, or plaster the walls with printouts, we need a reference repository for all the bumpf.

    We have developed a website that resides on a corporate server. We park lots of reference materials, some teaching files, clinic directories and all the administrivia you can eat on that site. Currently it has about three hundred pages and links to about one hundred more (See the home page here. Sorry, but the links don't work outside the UHN firewall).

    The work process and patient flow in the department is such that, most of the time, it makes sense to access these resources from a desktop PC. But some tools might be effective at the bedside. If it would reduce the amount of walking I do around the department, I'd be all for it. We don't yet have wireless networking to our PDAs, so anything I want to refer to on the move will need to fit into the memory of my Clié.

    Here's an example: a 45 year old man with infected diabetic foot ulcer. If I could look up the medication I need to prescribe and the phone numbers for our social worker and the Plastic Surgery clinic for the patient to arrange for follow-up then I wouldn't have to return to the nursing station to do the paperwork. To discharge the patient on the spot would save me walking back and forth.

    Can I leverage the webpages that I already developed for the desktop PCs, and put that material on my PDA? That depends on several factors, some of which I describe below:

    • form factor. Most PC screens are set up to show 800 pixels in width, but the PDA screen is only 160-240 pixels wide (depending on the make and model you use) so webpages need to look OK when squeezed horizontally.
    • tables. Tables of information won't look right if squeezed, but are a nuisance if you have to scroll around to see them. If possible, they should be formatted to be as narrow as possible before converting them for the Palm.
    • page length. Unlike screen width, there is no practical limit to how long a web page can be when it is viewed on my PDA. Just keep scrolling, right? But data would be easier to peruse if it was organized to fit into "screenfuls".
    • ease of conversion. The website has MS Word, MS Excel, PDF and HTML documents. Not all of these are simple to convert to Palm format without loss of style and organization with a big change in appearance.
    • style. Using the term "style" loosely, I refer to font size and appearance, underlining and italics, paragraph structure, and so on. The Palm screen looks very cluttered with more than two typefaces. And exotic fonts will not be rendered as the Palm only recognizes a few basic types unless special software is loaded.
    • navigation. Webpages use hotlinks to jump to different sections or other documents. For a big document on a PDA, a Table of Contents and bookmarks are at least as effective and help draw the material together into a coherent whole. Most conversion programs (Plucker, iSiloX and AvantGo) can incorporate the navigation aids you insert into your website.
    • appropriateness. What is reasonable to review or lookup while on my feet? Standing on one spot for five minutes thumb-scrolling through a treatise is immobile, not mobile computing. Another way of looking at it: it makes no sense for me to look up phone numbers on my PDA while standing in a back corridor where there is no phone handset to make the call. I might as well look up the numbers while sitting down at the nursing station.

    There's a nice overview of the problems of webpage conversion on the dive into mark site.

    A quick review of the files on the website reveals that few of them meet the criteria for mobile utility. The whole site was conceived to supplement the hospital's core patient management system: its innards reflect the unstated work process of juggling a few cases while looking up reports and speaking to colleagues on the phone. Despite that, phone numbers for services and consultants I use frequently look to be a good bet for portability. The outpatient follow-up clinic directory will also be handy as I give those numbers to patients at time of discharge. Prescription codes for restricted or limited use medications are another thing I might need while not sitting at a desk.

    But much of this information is formatted in tables that are 800 pixels wide. Conversion to Palm will be difficult. Perhaps it would be easier to start from scratch? Fortunately, help is available to advise how to develop Palm-friendly websites. Avantgo has a style guide online. Following their suggestions will definitely improve the ease of converting a website to be usable on a Palm PDA. In essence, AvantGo recommends that, before creating your website, you prepare a template file. This incorporates the features that will make individual webpages compliant with the AvantGo converter.

    More discussion can be found by following the links from's bibliography on this topic. I found this article from Intranet Design Magazine particularly worthwhile.

    Other worthwhile sites include:

    • Palm OS Emulator (POSE) - useful for testing webpages without draining your PDA batteries
    • Webpage design for PDAs - webmonkey has articles here and here
    • Open Mobile Alliance has some material on developing web content for cell phones and other devices

    A closing comment on this subject: forget equivalence. What research that has been published shows that reference reading and data retrieval using small screen devices takes longer than on desktop PCs (see abstract). Efficiency suffers on the Palm?? Perhaps I should stick with PCs! But the saving grace of handhelds, despite the claimed inefficiencies, is that they are in our pockets when a desktop PC is simply not available.

    Where Were You When The Lights Went Out?

    The recent massive power failure in Toronto was educational in many ways. My Sony Clié has only a modest battery life. During the outage, as I stumbled back to the house in the dark, I wondered how I would recharge and how to protect data in the handheld's memory. The first thing I did after lighting a few candles was use the Sony backup software that is factory-installed on the PDA.

    Once everything was safely copied to the Memory Stick storage card, I could then consider my recharging options. Where could I find "juice" to keep my PDA going? Possibilities included:

    • Fetch my recharging cable from home and plug it into an emergency power wall socket at the hospital. Besides being unethical (medical equipment clearly had a higher priority than my pocket computer), this option wouldn't work if the hospital's emergency power supply failed, as it threatened to do a few times.
    • Recharge using electricity drawn from my car. A variety of automobile recharging devices have come to market. I have never tested any of them and don't own one.
    • Recharge from a set of alkaline batteries (see MPR, February 2003 issue)
    • Recharge from a solar cell, fuel cells or even 9-volt batteries (see MPR, September 2001)
    • Buy a spare battery for the Clié. The NZ90 model has removable batteries that "only" cost about C$100 each.

    In the end, I didn't need any exotic technology. I did what every other Torontonian did: saved energy by cutting back on how often and long I turned on the equipment. I also adjusted the Clié's automatic shut down mode to kick in after only thirty seconds of inactivity instead of two minutes. My handheld easily hung on until the lights came back. But, what to do about next time?

    Get Lost

    Returning home from the hospital at 0200h during the power blackout was a trip. There was no street or traffic intersection lighting at all. If it had been truly pitch black, I could have used GPS to find my way home. Not that there was any hot dinner waiting for me by that hour. Still, here are a few possibilities for GPS navigation on Palm PDAs that I read about lately:

    • Garmin makes PDAs that are as capable as the best Palm or Sony devices, and have GPS receivers built-in.
    • Another GPS device is from Palm itself - but it works only with their own PDAs.
    • There are a variety of GPS plug-in cards or gizmos available from Navman
    • There is a slew of clever internet-based software solutions from GPSPilot. All you need is an internet link (eg. a wireless network module in your PDA, or Mocha-W32 PPP from MochaSoft to link to your PC). Nice features of GPSPilot's TripPilot are that it has maps of Canada (unlike Rand McNally Streetfinder).
    • There are other software solutions - many of them freebies - if you have the GPS plug-in module already or find one on eBay.

    Note: you will need lots of RAM for big maps. Also, your PDA is probably not ruggedized - maybe it's not suitable for orienteering or Iraqi deserts. Think about protective cases before doing anything too dynamic.

    For more info about GPS on handheld devices, check out Dale DePriest's GPS site.

    During my trek home in the wee hours, there was just enough starlight and moonlight to find one's way. Maybe instead of GPS, I should get a sextant and steer by the stars. I wonder if there is a Palm attachment for that....

    Medical "Doc" of the Month

    Instead of one document, this month I draw your attention to whole libraries of texts. PalmLoyal is a website where you can find links to other sites the contents of which are optimally formatted for converting to your Palm using iSiloX or AvantGo. When you find a site with material you want to download to your PDA, it's easy to convert and read on the go.

    Hack of the Month

    A new version of FindHack has been released. Now compatible with Palm OS5, it sports many enhancements over the built-in Find function. Available at PalmGear, which has an excellent summary of the features. FindHack is highly recommended if you want to narrow your search to include or exclude large databases. Available to try before you buy,

    Not exactly a Hack, but still noteworthy, antivirus software has been announced for Palm devices from Symantec. You can read about the new products at InfoSync. Symantec will extend the Live Update capability of their desktop PC software to the PDA. This means that every time you HotSync, Symantec will attempt to go online and download updates to the installed antivirus program. Virus attacks are still practically unknown on Palm devices, so it seems to me that Symantec is jumping the gun. But I can't dispute that handhelds are merging with the Internet and with cellular phones so the threat may materialize eventually. A cynic might point out that, with PDAs linking to the Internet more, they make more tempting targets for virus writers. Read about it and make up your own mind.

    Medical Computing

    Wayne State and Detroit Medical Center are using Palms and WiFi networks for mobile access to patient charts, test results, memos, eMail and medical references texts. In short, they are doing what I want to do in my department with my dinky website, only better. Sigh. Read about it here.

    Handhelds are also enjoying wide use in research, as this example on PDACortex shows. Scheduling, phoning patients, keeping track of protocols or inclusion/exclusion criteria (staff can show the information to doctors or patients without carrying around lots of paper), beam information to coworkers, the Palms do it all. A nice bonus is the ability to synchronize data files on offsite and onsite PCs. Not as well funded as the Michigan folk mentioned in the paragraph above, this group have to cadge any old PDAs as their owners upgrade, then pass them along to coordinators in order to meet demand for handheld devices.

    The Medical Palm Review was recently mentioned at the Ectopic Brain site. They are one of the oldest sites dedicated to Palms and medical computing. But why are they calling my Newsletter a blog? Since I only update the site monthly at best, I wouldn't call it much of a running commentary. Still, any free publicity is good.

    The Informatics Review has a nice little list of links to resources for medical handheld users. There's lots of interesting material to browse through - you should definitely bookmark this site.

    In Times to Come

    Look for updates on my progress (if any) redeveloping the departmental website, and enhancing its content for use with Palm devices.

    What, that's not enough for you? OK, all the usual items will again be featured next month....

    Until then, enjoy!

    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, complain, or just share some news and opinions contact the author at the following address:

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