The Big Questions

There has been a steady stream of publications and journal articles looking at the use of PDAs by medical students and residents. Young, computer-literate and with mountains of data to manage this is the demographic group most likely to spend money on computer devices. Their example has spurred hospital staff doctors and nurses to take the plunge also. And others have also taken to using handheld computers. Home care nurses and paramedics are starting to integrate PDAs into their work. Even nursing homes, not usually thought of as being at the cutting edge, are getting in on the trend.

But many of us, after the initial excitement, stop using our Palm devices. Often it just seems to be too much trouble to learn to use some features. It can be disappointing to find that computer programs really don't solve all our problems. Furthermore, noone wants to change long-standing work practices just to gain some added benefit from a mobile computer. And frustration sets in fast when a PDA is hard to use due to poor software. The result: many users retreat from high value but complex uses (patient management, educational material development) and stick with built-in applications (ToDo list) or just park the Palm in a desk drawer.

How about you? Are you carrying around a pocket medical library or a glorified electronic phone book? Is it a patient list manager or just a grocery list? If you are curious about what use other health care workers make of their gear, look at some of the primary literature and some news reports.

First of all, the software vendors and medical IT gurus continue to bang the drum about convergence. Here are just a few examples of recent articles promoting the idea of integrated health care computing systems:

• CPOE Systems : Success Factors and Implementation Issues, Sengstack, Patricia P. and Gugerty, Brian. Journal of Healthcare Information Management, v18 n1, Winter 2004, p36-45.
• Critical Success Factors Relating to Healthcare's Adoption of New Technology : A Guide to Increasing the Likelihood of Successful
  Implementation, Leonard, Kevin J. Electronic Healthcare, v2 n4, 2004.
• Evolving a Connected Healthcare System, Rillstone, Mike. Health Care and Informatics Review Online, v7 n1, November/December 2003.

For more scholarly reading, the online Arizona Health Sciences Library has a bibliography of published journal articles about handheld computers in health care, dating from January 1981 to December 2002. Newer articles can be found on PubMed, searching on "computers, handheld".

When you do some digging, you'll learn the sad truth: even many medical journal publications are industry-sponsored or by medical software developers - all predicting a glowing future if only we adopt more technology soon. Only about one in three articles in a PubMed search describe what front-line health care workers are actually doing in research, administration or patient care.

If you look at the listed articles you will discover that noone ever (and I looked at three hundred abstracts and summaries) describes how handheld computers failed to meet the author's goals or caused a patient care error. Yet I can think of scenarios that might lead to heartache (e.g.. battery failure: loss of patient data). Why isn't that getting reported? C'mon folks, these are electronic computing devices! They have to fail and give us grief from time to time. Just for comparison, imagine if only positive results of drug trials were reported in the medical literature - there would be an outcry about bias in publication! Oh.

Perhaps we do need a way to merge our PDAs with our pagers, cell phones, patient care desktop systems and still somehow keep our hands free to cut, sew, bandage and soothe. But desktop computers with Web and hospital info system access are ubiquitous and meet most needs even if they are not right at the bedside. The idea of interconnected computer systems to enhance health care delivery does not depend on using handheld computers. In fact, with concerns about patient confidentiality and wireless network snooping, handheld computers may be step in the wrong direction.

I think we need to see a candid discussion of these issues and widespread training to cope with failure of computing devices if we are to have their role expand yet more widely in health care. We all need to have training in backup procedures, data recovery and security measures and the appropriate safeguards need to be implemented by default on the first day we turn on the screen. The increased confidence that comes from mastery and knowing that there is a "safety net", would allow more creative and widespread use of technology in health care to flower. What do you think?

Do It Your Way

So you can't tap into your patient's lab test results at the hospital? Can your PDA still prove useful to a health care worker in a big hospital? The answer requires you to think outside the box.

Of course, standard medical references or drug information can be useful, but even more valuable on a portable platform is to include information or guidelines that are unique to your particular working environment - stuff no publisher is going to sell anytime soon. Some examples:

• for housestaff doctors: internal phone numbers for your hospital
• for homecare nurses: instructions for setting up the IV pumps you use
• for paramedics: decision rules for choosing which hospital to transport patients to

In all of these cases, someone has to create a document to import onto the handheld device. This topic has been covered extensively in the Review in previous issues (see the February and March issues in this year's archive).. New products to help with this process enter the market all the time.

For example, RepliGo converts various files (including Word, Excel, PowerPoint, PDF, HTML and more). It costs US$30 for the converter which runs on a PC, but the viewer is free and it runs on Palm, PocketPC and other platforms like Symbian, and Windows PCs. I have written previously about Plucker, AvantGo and iSiloX which provide similar capabilities and Adobe has a converter for its PDF format files. Look in the Review archives.

HandStory, like Plucker, AvantGo, and iSiloX, converts websites into something you can read on your handheld.

But what if you want to access data on a remote PC or server, without the hassle of file conversion and import to your Palm? Here are some creative solutions:

• WiFile gives you access to networked PCs with WiFi-equipped PDAs. WiFile solves the problem of keeping information current on the Palm: it doesn't. All data files reside on the server, which the Palm accesses wirelessly. If the information on the server has been updated, the remote user sees the changes automatically.
• PalmVNC can be used to access a files on a PC running the VNC server software. This provides access to any Palm device using it's cradle or a wireless network connection. More VNC software can be found here.
• The Pebbles Project is creating tools much like Palm VNC.
• E-mail client software can access messages you have sent to yourself at a special account. Attached documents can then be reviewed by logging on and selecting the desired message. Attachments can be read using suitable software like Doc2Go. When it becomes available, Google's free gMail service (still in testing) will offer such a big inbox that you may decide you don't need a laptop or a CD burner either.
  
• PalmOne's new Tungsten T5 (see article below) has the ability to act like a USB external drive - just plug it into a local PC to access files stored in the Palm's RAM.

I don't like having to edit documents for conversion either. That's why I created a web document based on the ACEP Core Curriculum in Emergency Medicine (see the October 2002 issue of the Review). I put notes, tips and tricks into the relevant sections of the web document from time to time. I have programmed iSiloX to convert the whole thing once per week, which is then automatically uploaded onto my Palm the next time I HotSync. As long as I diligently put the notes into the Web file, iSiloX takes care of conversion, formating and all the rest.

I do something similar for hospital phone numbers that I frequently need but usually can't remember. I put them in a text file on my PC. The file is incorporated into a Memo on the Palm and is updated automatically using the FileLink process (see your Palm Desktop software manual, or numerous back issues of the Review).

Sure it would be nice to be access hospital patient files and data using my handheld but in the meantime I am personalizing my work setup using these tools.

Hardware

Just in time for Christmas shopping, the folks at AvantGo commissioned a survey to find out what users were looking for in a new handheld computer. According to InfoSync World better battery life, built-in wireless phone or Web access and integration of Palm and phone features were high on the list. Built-in cameras were not.

By amazing coincidence PalmOnes's new Tungsten T5 just happens to hit many of those targets. Its high resolution screen has several "innovations" like the ability to drop out the Graffiti area, or to rotate between portrait and landscape modes which were actually pioneered by Handera and are not news. Of more interest is the 256 Mb of flash memory used for RAM. This is much more memory than usual for a PDA. It's also nonvolatile: if you forget to recharge and the Tungsten "dies" the information will still be there next time you goose the battery. And, with the included cable, you can plug your Tungsten 5 into a PC's USB port and copy files to and from the Tungsten's RAM or its Secure Digital extra memory card as though they were external hard drives. The included Bluetooth capability lets you use a Bluetooth-compatible phone to access the Web and e-mail but there is no WiFi or phone built-in. Perhaps not quite what AvantGo says we are looking for but pretty good for a start. InfoSync World has a review.

And Palm's new SD WiFi card for some models has been reviewed at InfoSync World. This would let your Tungsten T5 access the Web directly without a phone as a modem.

Moving in the other direction, Hong Kong manufacturer E28 has a new smartphone based on Linux that has a camera, video recorder and excellent phone-computer integration.

Portable medical records using memory cards are an idea being mooted by Storcard and Sandisk. The Sandisk cards are being tested by a US army unit in Iraq. The USB flash memory units are worn around the neck like dog tags and store identification and medical information. What if all our patients had them? Patients in Omaha, Nebraska are to get health data cards from their doctors. Paramedics in that city are to get PDAs able to read the cards.

Medical "Doc" of the Month

The Limited Use Formulary for the Province of Ontario is available for Palm and PC from Toronto physician Lawrence Kwan at his website.

Medical Computing

By the way, PubMed on Tap provides access to wireless-enabled PDAs. Get software and manuals here. If you want to search PubMed while on the move, this is the way to do it. And you be even more effective at bedside team rounds....

Were you curious about what is being written about hospital medical housestaff usage of pocket computers? Here are some recent articles:

• Assessing Medical Residents' Usage and Perceived Needs for Personal Digital Assistants, Barrett, James R. et al. International Journal of Medical Informatics, v73n1, February 2004, p25-34.
• Handheld Computing by Resident Physicians : Enhancing Performance and Demonstrating Competence, Sousa, Aron and Zaroukian, Michael H. Seminars in Medical Practice, v6 n1, March 2003, pp. 21-32.
• MercuryMD conducted a survey examining the impact of hospital computer systems on resident work hours. The study's findings can be accessed at the Medical Records Institute. "Our study asserts that mobile patient data technologies, such as MData, can help solve the current resident work hour problem by decreasing the number of hours residents spend manually gathering data. According to the study, today's residents are spending up to 24% or even 38% of their time performing data management activities and as little as 16% of their time in direct patient care."
• The CEO of PEPID wrote an article entitled "Personal Digital Assistants and the Reduction of Medical Error" in the Spring issue (V5N1) of the Harvard Health Policy Review. This provides useful background and describes how ready-to-hand resources can improve and accelerate treatment.
• A University of Hong Kong study published last year in the BMJ may be of interest. See Randomised controlled trial of clinical decision support tools to improve learning of evidence based medicine in medical students .

In Times to Come

Coming up soon: a description of how we extracted information from a departmental work schedule for individual physicians to put on their PCs and PDAs.

We'll also have more hardware news and some suggestions for software you may want in your pocket.

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 of on paper. To subscribe, comment, or complain, contact the author at:p.arnold.mpr@sympatico.ca

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