|The Medical Palm Review |
January, 2005 (V6N1) - Housecalls
This month we will sample a smorgasbord of hardware, software and websites of interest to health care workers who are on the move. Anyone who is horizontal and not working hard can stop reading right here....
The Doctor Is In
In previous issues we have looked at all sorts of hardware and software that you can buy to make your Palm handheld a powerful tool in medicine, nursing or prehospital care. I don't want to rehash all those products - but I will anyway. Also I will mention some new or improved ones. I think you will agree that there is an extraordinary range of products available. Software publishers, booksellers, medical societies and special interest web sites all offer Palm software that you can use.
The handheld computer as portable resource is now firmly mainstream. Medical organizations such as the American College of Emergency Physicians (ACEP) and the Canadian Medical Association (CMA) offer a range of medical texts on their web sites. ACEP focuses on just a handful of titles of interest to emergency physicians and paramedics including Rosen and Barkin's 5-Minute Emergency Medicine Consult, Ron Walls' Pocket Emergency Medicine for PDA and the Emergency Medical Resident Association's Antibiotic Guide . The CMA offers members several hundred software titles for purchase, covering many disciplines. Each organization has tailored the scope of its offerings to reflect its membership and goals. Many medical schools provide a suite of software tools, sometimes along with a handheld computer, to their students.
Some products are free (such as ePocrates qRx) because the developer generates revenue from advertising or hopes to catch your eye and sell a "deluxe" version. Others can only be "rented" (e.g..PEPID), requiring an annual subscription to maintain access on your PDA. Yet others can be purchased outright either online from the publisher or through third parties such as special interest web sites or even bricks-and-mortar bookstores. Many educators and health care workers have created their own medical software and offer it free. And a great deal of copyrighted medical software is pirated - illegally shared among multiple users.
Some electronic books or "e-texts" are straightforward computerized versions of their well-known paper predecessors. For example, Skyscape offers the 5 Minute Clinical Consult and the Washington Manual series. Others take advantage of the handheld computer to offer better indexing and search capabilities than any paper edition can hope for. These publishers include eMedicine (creators of the eponymous guides), Redi-Reference (publisher of a range of guide books) and Unbound Medicine (partnered with many publishers such as the British Medical Journal and McGraw-Hill).
If you visit the web sites of online medical e-book sellers like Handheldmed or Franklin you will find Harrison's, the Merck Manual, Tintinalli's Emergency Medicine Comprehensive Study Guide and many more titles.
Computerizing a text allows one to consolidate or specialize content. Both trends are apparent. ePocrates has branched out from a prescription handbook to lab test interpretation and a diagnosis manual. PEPID encompasses a medical reference text, drug prescription handbook, drug interactions handbook and medical calculator.
Medication prescribing handbooks are very popular and almost every publisher has gotten in on the act. ePocrates has qRx. LexiComp offers LexiDrugs. FA Davis (DrDrugs), Mosby (MosbyDrugs) and Lippincott Williams Wilkins (A2zDrugs) all have titles in this area also. Some, like LexiDrugs, even fill niches like offering Canadian brand names. Many web sites offer free e-texts with information about prescribing drugs for particular patients (e.g.. pediatrics).
Now Big Pharma is getting on the bandwagon. The ebm2go web site is sponsored by AstraZeneca and offers a range of books and automatic updates of various clinical guidelines. They also provide a handbook for looking up Limited Use codes which Ontario doctors may find useful. As usual, enterprising doctors with time on their hands and a Palm in their pockets devised Ontario Limited Use handbooks to download long before the ebm2go site appeared. See Greg Higgins' or Lawrence Kwan's web sites.
Medical and nursing journal articles can be downloaded. Medscape and HighWire Press offer access to a broad range of journals, many of which have PDA versions. Services like AvantGo can capture any journals whose content can be reached online. JournalToGo lets you peruse journals for free but you must endure advertising on your PDA. Unbound MEDLINE and other services developed by Unbound Medicine give users mobile access to MEDLINE and online medical journals. You can create a search and obtain your answers the next time you HotSync or via wireless networking. Even if the online journal article you want to download has no PDA version, web page or PDF file conversion software will capture the material of interest to your handheld computer.
When was the last time you saw someone using a wheel-shaped pregnancy calculator? Handheld software has eclipsed those plastic analog devices (e.g..PregCalc). Take a look at ABGPro, MedCalc or MedMath if you want to obtain a range of physiological and medical results. There are programs devoted to calculating medication dosages and IV drip rates (DoseCalc and RxCalc for example or the warfarin adjustment program Anticoagulation Advisor). Calculators have even proliferated into specialized niches such as calculating likelihood of disease and cardiac risk factors (Statcoder, MedRules). While reading up on research studies, you can check pre- and posttest probabilities, NNTs and likelihood ratios with the University of Toronto's Evidence-Based Medicine Calculator.
It seems that there is a tool for every task in the mobile health care worker's day....
The Doctor Is Out
... but what if there isn't handheld software for a particular calculation or reference book you need? The versatility of PDAs is outstanding. With a bit of time and effort you can roll your own. At its most basic, this means creating a text note from scratch and putting it in the Memo applet or word processor software on your Palm.
At the next level, you can use conversion tools (e.g..AvantGo, Plucker or iSiloX) to take an existing website or electronic document and make it usable on the Palm.
Medical calculators come with preset formulae (see above) but some can be programmed (e.g..Medical MathPad). Truly programmable calculators for complex algebra can also be found (read a review of several programs at the Singapore Palm User Group web site)
A decision tree or treatment algorithm can be represented visually with IdeaPad or HLE. A checklist-style algorithm can be created with Progect. You can even share the algorithms via a server or by beaming to other PDAs. These are developing projects, or designed for the classroom so you may not find them to be robust enough for more than experimenting.
Information that you need may reside on central server computers and may not be readily portable to your PDA due to the size of the database. Extracting what you need to your PDA using wireless or infrared networking may let you gain access to patient files or complex web pages. Some electronic patient record systems can be configured to send updates (e.g. results of lab tests), or notifications (e.g.. completion of x-ray imaging) to a wireless device as e-mails or instant messages. The hospital where I work is investigating Misys Insight for this purpose.
Once you can link to the web or any other resource wirelessly, mobile health workers will really have it made. Triage and registration of patients in the Emergency Department, consulting clinical guidelines and treatment regimens all become possible. Wireless networks in your office or clinic let you lookup info and chart patient visits without the need for hardware in each consulting room. These networks also facilitate data collection for research without the need to HotSync the PDA to a central PC.
Wide-area wireless networking allows mobile health workers to export many support functions to the web. For example, hospitals might use handheld devices to link to government web sites during a disaster (see the article by Edward Barthell, The National Medical Extranet Project, Journal of Emergency Medicine, Vol 24 No 01, pp95-100, 2003)
Of course you will need to think about issues such as hardware theft (strap the PDA to your wrist?) or data theft (secure log-in, encryption of communications, storage of patient data on the server not on the PDA).
Wireless will also facilitate dictation, billing, prescription writing and submission and correspondence by e-mail (In November 2004 palmOne updated the Microsoft Outlook conduit for its devices. It will now be a little easier to share calendar and contact list information between desktop and handheld devices).
And patient communication can be improved as well. There is an encrypted e-mail client for the Treo. This will meet US government requirements for confidentiality between health care providers and their clients and patients. The City of Philadelphia, PA, is setting up city wide WiFi with Verizon with implications for public health, disaster management, prehospital care, and patient/doctor communication. Philadelphia plans to provide free or cheap high-speed wireless to all residents.
Forget about doctors using PDAs. Give 'em to the patients. They outnumber us so the leverage ought to be greater. How about notifying all your clinic patients by e-mail that it is time for their flu shots? How about notifying them by text message when it's time to leave the Starbucks because the doctor is ready to see them? It works at Disney World....
Others have looked at using the web to involve patients in their own care plans. Grand River Hospital has created a portal for patients to look at treatment plans, appointments and prescriptions. With attention to the portal web site design they could do that while on the move.
Much has been written about telemedicine using desktop PCs and web cameras between linked hospitals. PDAs may also play a role in telemedicine consults from the patient's home. Paramedics or other health workers would be able to tap into remote resources and consult with colleagues in hospitals. Addition of a camera would allow the consultant to see what is happening "in the field".
This all sounds promising but I will know that it is really going to develop when I can order and pay for a pizza delivery to the hospital using only my PDA-phone.
Medical "Doc" of the Month
BCC's quarterly updated directory of mobile medical/nursing software is even better now that you can click on links to the different software packages. You can download it and use it to explore quite a range of medical tools that run on handheld computers. Recommended.
The October 2004 issue of Critical Care Forum has an interesting article by a group of intensivists working in Toronto teaching hospital. They provided Palm m505 PDAs loaded with reference software to ICU doctors in local hospitals. All the devices were configured to obtain updates via HotSync or infrared modem. The ICU staff at the subject hospitals were evaluated on whether the portable resource improved their decision-making in patient care. The report is refreshing for its candid assessment of the strengths and weakness both of the study methodology and the technology. Thanks to the eclectic bibliography, including a selection of articles about PDAs in medicine and numerous references deemed important for intensivists to be familiar with, this article provides an interesting perspective on mobile medical computing tools. [Ed. note: The publication of the Medical Palm Review is hosted by the same lab that performed the original research described here.]
MedicalSoftwareforPDAs is a web site that offers a look at new hardware and software. You can buy the software they recommend right on the site and there is some advertising. There are a number of links to other sites which would be of interest to medical PDA users. Worth a look.
In December there were news reports that "game" software developed by the Joslin Diabetes Center in Boston helped children and teens to check their blood glucose more diligently and improve glucose control. The kids entered blood sugar readings into the software called DiaBetNet running on Palm Visors. Data from the Visors was beamed to a central database. The participating patients got feedback in the form of graphs showing trends in glucose readings, which apparently motivated them to keep checking. The software is not commercially available but may become part of wider efforts to create online resources for diabetics. Software like this has great potential for managing chronic illnesses as it facilitates communication between caregivers and patients and tracking of the patients' status.
Nuts and Bolts
Voltaic Systems has a portable recharging solution for outdoor workers and travelers. The Backpack can recharge a PDA, camera or cell phone using either solar panels or the included AC and car chargers. A range of adapters is included. The pack weighs only a few pounds including is lithium-ion battery pack and has many clever and useful features. The manufacturer claims that a typical PDA or cell phone requires six to eight hours to recharge using their solar panels (less if indoors using the AC adapter?). Innovative as this is, there is no protective cover for the solar panels (replaceable for US$30 apiece) when not in use. Is the Backpack ready for an airport baggage handling facility? Maybe it's just for carryon....
At the end of November 2004 palmOne announced that it has updated the drivers for its WiFi Card. The card fits in the SD slot in palmOne PDAs. The update fixed certain technical issues and made the card compatible with the Tungsten T5. For some reason palmOne has not yet made the card work with the Treo 650. But hackers have done it already (look here). By the way, if you use your Treo 650 on Sprint, there is a patch for the Bluetooth feature so that you can access the Internet using the phone as a modem. These updates should be treated with some caution - backup your data before trying them. Despite the Wild West aura around these software updates, it is clear that users want to have maximum flexibility and performance on their handhelds and that includes wireless networking and cell phone capability. Such capabilities would allow a physician to use the Treo 650 as cell phone, pager and electronic charting tool all in one hand.
Hack of the Month
As we discussed last month, web developers can do a great deal to make their sites more accessible to people with visual or motor disabilities. These measures also go a long way to making web sites more accessible to mobile computers - whether by conversion or by wireless browsing.
At the Medical Palm Review we are rising to this challenge. This month, a little baby step in the right direction: we are using the ALT= parameter in the <img> HTML tag to create a caption for any graphics in the newsletter. This text will be handy for people who can't see images on-screen, for example, or whose web browsers read aloud to them.
This is augmented by using a popup tooltip, making use of the TITLE= parameter. When your mouse pauses over any image in the Review you will see a brief text message. Our popup and alternate text describes the image and provide a link to its source URL but it could be any short message we wanted. You can check out this feature on any image in this and future issues.
Take advantage of your web browser's ability to look at the source code of a web site and search within this issue of the Review for the terms "ALT" or "TITLE" to see the grammar of coding these statements in HTML documents.
You can read more about the ALT feature in chapter 24 of the excellent online book about web site design called Dive Into Accessibility. More insight can be gleaned from A.J. Flavell's web page or from Jukka Korpela's guidelines on Alt text. The TITLE attribute is nicely described in chapter 6 of Building Accessible Websites by Joe Clark.
When converting a web document into a Palm file, different applications have different strategies. iSiloX, AvantGo and Plucker can include the ALT text of any web site images into the Palm document created but you will have to experiment as each has its idiosyncrasies.
Browser software on PDAs and cell phones can also be configured to display images, or not. Support for ALT text is variable. One thing for certain, disabling image display in those browsers certainly speeds up the web-browsing experience so ALT parameters are important in the design of sites aimed at mobile users.
These is no support for the popup TITLE feature in any converter or PDA web browser that I can find so far, but I don't think that this is a problem by and large..
The bottom line: attention to web design can pay off for disabled website users, mobile content developers and mobile web browsers. Next month we will see what else we can do to enhance web site accessibility.
In Times to Come
Next month, a look at some new tools for developers. We'll also roll out a few more modest changes to the Review as we strive to meet our accessibility goals. We will also review one or two medical reference texts in a bit more detail.
Until then, enjoy!