February, 2005 (V6N2) - Decisions, Decisions

There is a vast library of software available for Palm devices. Whether it's medical references or programming utilities, there are several choices in almost every category imaginable. When there is more than one tool that meets your needs, which one do you load on your PDA?

Help Me

When I was a medical student, everyone in my class carried a copy of the Washington Manual. This spiral-bound book fit (barely) into a lab coat pocket and strove to be all things to all MDs. It combined differential diagnosis with medical management and procedures, and much else besides. Few of us could get through a single day without referring to it. Of necessity, the book was light on detail and illustrations. The "bibles" of medicine, like Harrison's Principles of Internal Medicine had more detail than anyone could encompass but were simply too big to carry around the wards.

These days every medical student in North America carries at least one medical reference text on his or her PDA. Both Harrison's and the Washington Manual are available from Skyscape. Every other medical reference text I have ever used is also available for handheld computers, courtesy of one publisher or another.

But there are new ones which only exist in electronic format. The change in medium from paper to computer has permitted radical changes in content, format and organization. These texts can incorporate calculators for diagnosis or for drug dosage. Others provide the ability to look up interactions between different medications - formerly a tedious manual task. Some publishers (like Skyscape) cross-link their products so that clicking on the name of a medication in a medical reference opens a link to the drug's info in a prescribing formulary.

Differential diagnosis, the art of winnowing a short list of likely diagnoses from a larger set of possibilities, is easier with some of these electronic references. Some, like Diagnosaurus from McGraw-Hill, are even "free" which is yet another point of differentiation from traditional medical publishing.

With such a crowded field, one could be forgiven some confusion: just what is "best"? What should I buy? Recently I received a review copy of a new book, Current Consult Medicine 2005, from Unbound Medicine. I already own PEPID and Skyscape's 5-Minute Emergency Medicine Consult. Do I need another book? Is this new one suitable to replace an existing one? One could seek to finesse this question by simply adding a bigger memory card to the Palm and loading up more stuff, but would I use the new text even if I could shoehorn it in?

In the following I will briefly and non-exhaustively point out a few features of a few medical references. My goal is to give a sense of the range and variety rather than to comprehensively review any one product. (I apologize in advance if I offend any readers who feel I slighted their favourite text. Feel free to drop me a line and I may respond to comments and criticisms in a future issue.)

First off, just how does the venerable Washington Manual shape up in its new computer incarnation? The Manual is typical of most medical references in its organization. One can search an alphabetical index or look for a topic through the table of contents, which corresponds to the chapter index of the hardcopy edition. The forte of this text is its concise presentation of a core set of medical disorders, with diagnostic and therapeutic strategies clearly laid out. It also has a fairly elaborate navigation system which takes a bit of getting used to (note all the icons in the top right corner of this screen shot). The Washington Manual can share links with other Skyscape products, increasing its utility if you own other texts in the series. Another nice feature: once you purchase it, this book works forever. Sure it may become outdated, but you can purchase a new edition whenever you choose instead of when the publisher's logic bomb cripples the application and you suddenly discover that it doesn't work any more.

My verdict: still useful after all these years.

CURRENT CONSULT Medicine 2005 for the PDA is written by the same authors as Lange's CURRENT Medical Diagnosis & Treatment. It covers hundreds of disorders. You can search alphabetically by symptom, by disease or by organ system. There is an integrated differential diagnosis section with more than five hundred findings. This allows you to start your exploration for a diagnosis from a clinical finding and then link to discussions of individual disorders. Many of these topics are organized by subtopics such as Clinical Findings, Diagnosis, Treatment. References are also provided including URLs to online publications. Regrettably, these links are not active and won't let wireless-enabled PDAs retrieve the references. Also, unfortunately, some topics are not organized in that way. For example, when you select the table Drugs for Hypertensive Emergencies, you have to scroll linearly through the description of all of them rather than being offered a list from which you can choose them individually. The info which is provided on a range of topics which I looked at seemed current and reasonable. Updates can be had by HotSyncing to the company's web site.

There are no pictures or demos of the application online. Furthermore, the installation process for the Current Consult demo requires you to register and HotSync while connected to the Web. This process is not described adequately before you begin the installation. Actually, it is not described at all except for what is provided during the installation itself. This is all excessively tedious for a demonstration version of software that you may choose to look at then discard. This approach to installation management is not unique to Unbound Medicine or to Skyscape by any means but I think it is an imposition on the user (and on reviewers like me).

My verdict: potentially useful but marred by the incomplete implementation of digital era navigation within the text and by its annoying installation process.

ePocrates is well known for its free prescription drug manual. They now also offer a diagnosis manual and a lab test interpretation guide. All three works are available as a bundle called ePocrates Essentials. The result is a nice mix of drug information, drug-drug interaction checker (including herbal remedies), formula calculator, and medical reference. This product is well integrated and comparable to its peers. ePocrates offers a thirty day refund guarantee but no free trial. As you would expect from such a combo, Essentials is more expensive than one of its separate parts, or texts like Current Consult Medicine. After a subscription period of one or two years, you have to renew or you cannot obtain updates. The free version of ePocrates Rx was infamous for refusing to run at all if you hadn't updated "recently". The web site is rather vague about whether the applications will work at all once the subscription lapses. But if you dig through their support FAQ page you get strong hints that "expired" applications won't work at all. In other words you don't buy ePocrates Essentials, you only "rent".

My verdict: an effective package but expensive.

Longtime readers of the Review will know that I personally subscribe to PEPID. I won't do into great detail here again except to touch on a few points. Rather like ePocrates Essentials, PEPID is quite comprehensive with diagnosis manual, medical calculator, drug-drug interaction generator, and much more. Recently they added a lab test interpretation manual. There are several versions (for doctors, nurses, paramedics, students). I like that there is a version with a tilt towards Emergency Medicine because that is what I do. PEPID is also one of the few publications which includes the names of medications marketed in Canada. It suffers from its own unique variant of the appalling installation system used by Skyscape and others. If you have read this far you know my opinion of those systems. PEPID is comparably priced to ePocrates Essentials and offers free trials. I think that PEPID used to be more expensive in previous years so there may be a bit of an arms race here.

My verdict: effective and features Canadian drug names (a plus for Canadian users).

A perennial favourite in the internal medicine category is Griffith's 5-Minute Clinical Consult. This text is driven by its alphabetical index. It has an internal navigation system which is similar to other Skyscape products with some unique features of its own that make it easier to focus on different arts of each topic. Its brief articles are a quick read but sometimes too brief for my taste Content is quite up-to-date. There is an online Flash demo slide show and free trials are available. Same old Skyscape installation process I love so dearly. If you prefer, you can obtain the same text from Unbound Medicine instead of from Skyscape with different internal navigation and installation systems.

Verdict: quite usable and helpful. Marred by the installer.

eMedicine is a wonderful online resource for health care workers. Different parts of the online material can be downloaded to your PDA (e.g. Emergency Medicine, Dermatology). There is no online demo and only a modest FAQ so I cannot say whether the publisher has addressed two previous issues: images and tables from the online version reproduced poorly or were not included in previous issues that I purchased for my Palm. The second problem was that the book would refuse to load if the subscription was not kept up. These texts are updated extremely frequently. Content is comprehensive but a little pricey compared to the less authoritative texts reviewed above. The publisher intends that one be able to update as often as desired during the subscription period, but this system is not in place yet. No free downloadable trials are available but one can peruse the online content.

Verdict: works better online than on my PDA but still very capable.

PocketMedicine is a source of original (they use the innovative term "not re-purposed") medical texts for Palm or PocketPC. The site has an extensive library of texts. They appear to use the Skyscape technology both for navigation and installation. The table of contents of the PocketMedicine/Internal Medicine text appears to be quite a bit briefer than Current Consult or eMedicine but chapter content on selected topics I examined was comparable to other internal medicine programs discussed here. List prices are moderately cheaper than some of the alternatives and there is a large library of subspecialty texts I did not have an opportunity to examine (yet). Demo versions can be downloaded to try before you buy.

Verdict: not as comprehensive as its peers but the trial download policy makes it easy to evaluate for suitability. The price is lower than others in the same category.

[Ed. note: This article originally contained some assertions about the editor and publisher of Pocket Medicine/Internal Medicine which I have learned were incorrect. Specifically, I mistakenly gained the impression that the work was a publication of Chiron Corporation. This is certainly not so and I am indebted to the publisher, Lewis Raines, for bringing this fact to my attention. The PocketMedicine web site makes it clear that the company is the product of a publication philosophy that seeks to put useful clinical references into the hands of clinicians at the bedside. Hence the extensive library of specialty and subspecialty programs on offer. As Mr. Raines makes clear, these works are not former hard copy books transferred to a new medium but written from scratch with handheld computers in mind. I am sorry I got that wrong and apologise to the publisher and editors and my readers for any confusion that may have resulted.

I'd also like to re-emphasize that although the table of contents lists a more limited range of subjects compared to similar programs described in this article, the depth of coverage of the chapters I examined was comparable. I think it is only fair make that point more clearly. Some readers will find that this work meets their needs as well as others described above.]

And now we come full circle to Harrison's Principles of Internal Medicine. McGraw-Hill still offers the two volume hard cover reference bible. It also offers an online service to access the electronic version. The PDA version is available from McGraw-Hill's web site, Unbound Medicine and from Skyscape. This is a comprehensive internal medicine reference work. It is not the first choice for a quick look at a clinical problem but works well as a sit down reference reader, if you are comfortable browsing through the text on the small PDA screen. Cost and installation systems are in line with similar products from the same vendors.

Verdict: not my first choice for mobile work but a substantial reference volume.

After all this, have I come any closer to deciding which text to use? Well, at least I have some ideas for how to decide:

• Read online product descriptions. Some products have online "demos" such as screen shots or Flash movies (check out the helpful demo on the Washington Manual site).
• Download trial versions. Some are only available if you register. To avoid receiving unwanted e-mail solicitations, consider registering under an assumed ID or give a throwaway e-mail address (e.g. an account on HotMail) that you can cancel or change if junk mail starts to pile up. Make sure to uncheck any boxes offering to let you opt out of receiving junk, er, "targeted advertising".
• If you haven't room on your PDA for all the products you want to test, consider running the Palm Emulator or the Palm Simulator. These programming tools run on your desktop PC (Mac support is very limited in the Palm world). When running they appear as a Palm device running in a window on your desktop. The principle advantage of the Simulator over the Emulator (for non-programmers) is the use of colour. You can install downloaded applications to either system to get a look at without disturbing your physical PDA. Next month we will take a look at using these tools for testing applications.
• Do a Google search for reviews of the book you are interested in. Be a little wary of reviews posted at the publishers' or vendors' own web sites.
• Check out discussion groups online at pdaMD for example. If noone has posted any comments or reviews of the products you are interested in you can enter comments or questions yourself to get feedback from other readers.
• Poll your colleagues and fellows at work. Look over their shoulders and see how they use what they use. If everyone in your working environment favours a particular product it may be due to inertia, special pricing, unique features or a combination of all three that make it attractive.
• Try not to have more than two books covering the same field unless they have distinctive content or organization. I have three medical diagnosis manuals but almost never look at two of them. Why not make space on my PDA for something else? I have room on the memory card so I just leave them all on - but this takes a toll in terms of performance.
• Make sure that you know how to turn off automatic update software. Some publishers think that theirs is the only program you will ever run. It installs itself in such a way as to try to "phone home" every time you HotSync, or even every time you boot your PC. They usually don't provide instructions how to turn off those features unless you phone their support staff. This practice should be condemned. Meanwhile, try to make sure you know how to control and (if necessary) uninstall any programs before you buy.

Overall, there is a rich buffet of choices in the medical palm reference area. Go ahead, dig in. But don't overload your plate with stuff you can't finish. With your PDA, there is no limit but you can get indigestion.

Help Yourself

The Review frequently looks at tools for developers of medical reference material for Palm PDAs. Programs like iSiloX or AvantGo let you create text or web documents. Traditionally, we think of such things as static texts. Readers look up the thing they want to know then turn to something else.

But sometimes what we need to know is dependent on the answers to prior questions. Sometimes what we really want is a decision tree or algorithm to guide us through a more complex process.

The Rash Diagnosis Algorithm v2.0 by Marc Roy is a good example of what can be done with iSiloX. This algorithm started as a journal article by PJ Lynch and SC Edminster (Dermatology for the Nondermatologist: A Problem-Oriented System, Ann Emerg Med, 1984; 13:8, pp603-606). It has become available online in many places such as eMedicine, and the National Centre for Emergency Medicine Informatics (NCEMI). Using any text editor or web site development software like Dreamweaver, one could build a simple web page to work much like these sites but more readily convertible with iSiloX to use on a Palm PDA. That is what Marc Roy did and the results can be downloaded from the MeisterMed site. With a web page editor you could also add photos of rashes to complement the algorithm. On a good screen (Tungsten or Clié) you would have a good reference or teaching tool. In this way you can build up

Working with web site development tools means when you are done you have a Palm document and something to put on a CD or online. If you want to work from HTML material but don't want to use iSilo, AvantGo is another option. AvantGo has recently been updated and is worth a look for publishing materials to PDAs.

If you want a PDA-based algorithm but don't need a web document consider Idea Pad. This free program lets you build a static algorithm which users can scroll through. The algorithm can be viewed as an outline of nested statements or as a graphic map. You can manipulate the statements or the map to collapse or view the subsidiary parts. The resulting flowcharts and diagrams can be viewed on the PDA or exported to desktop graphics programs. Notes can be attached to items in the map.

Similar capability to create lists and outlines can be found in programs like Progect. Progect has the additional ability to provide check off and date stamping of action items. Like Idea Pad, Progect permits you to append notes to items in the outline. Progect is another free program which is available for download from the author's web site. Progect outlines can also be exported to Palm DOC format files, or to Memos for the Memo Pad applet. There is a desktop version available for testing but it still needs some work.

I will wager that there are other programs like this out there although I have not tested any others at this time. But I have found that in the Toronto area there is a programmer who develops application software for the Palm platform. Dennis Christopher recently created a task tracking and time billing program for the Facilities and Services Department at the University of Toronto. I had a chance to take a look at the software and how it was deployed at the University. I may try to write more about it in a future issue as this is a good example of how one can take a concept and deploy something useful to a large group of workers and their managers in just a few months.

Mr. Christopher has been working on a program called GraphViewer which allows users to step through an algorithm or decision process with simple stylus clicks. Individual items in the process can have attached notes. The program will link to desktop flowchart software and permit graphical and nested outline views (see screen captures). The ability to click on choices to link to the next screen extends the capability of programs like Idea Pad to the next level and looks promising. Interested readers are invited to contact Dennis Christopher directly.

There you have it: more tools and tips for building your own Palm applications and reference materials. What more could anyone ask for? Longer holidays...?

Medical Computing

There is a review article on emergency medicine PDA software in the ACEP Pediatric Section Newsletter. It discusses applications for both children and adults (with special discussion for pediatric patients). This article is archived on the ACEP Pediatric Section website. The article can be found if you link titled "Selected Articles from the Section of Pediatric Emergency Medicine Newsletter". The article is entitled "Personal Digital Assistants (PDAs) and Pediatric Emergency Medicine: Powerful Programs for Pint-sized Patients".

Another good site with an Emergency Medicine bent is Emed Informatics. This site has a nice review of many programs useful programs.

The Medical Palm Review was itself reviewed by another publication - and theirs looks interesting too. The American Thoracic Society web site has a monthly Palm Tips column by Dr. Tom Stibolt. The articles are well written and informative. Worth bookmarking in your web browser.

Nuts and Bolts

Every now and then I fantasize about a PDA which offers a seventeen inch colour screen. I know it sounds contradictory but it would go a long way towards making handheld computers a useful substitute for laptops and desktops.

Head-mounted displays offer some hope of achieving my dreams. These are bound to make you look even more weird on the subway but have interesting potential. Icuiti (horribly cute name!) is the latest to announce a range of head-mounted displays and visors. The M920 model is an alarming US$800 and only works with Pocket PCs. Oh well, maybe when I am rich....

Hack of the Month

This month we have made a few more enhancements to the HTML code we use in the Review.

Henceforth there will be a DOCTYPE statement on every page. This makes it easier for web browsers to interpret the code properly so you see the Review the way we intended it to look.

Furthermore, the DOCTYPE tag notifies web browsers that the Review is an English language document. This makes life easier for anyone who is using a text-to-speech converter in their web browser.

We were also going to put meaningful titles on every page (including archived issues) but then I realized that we already have that feature thanks to the excellent work of Randy Showalter. Couldn't have done any of this without you, sir!

You can read more about DOCTYPE and related issues in the excellent Dive into Accessibility reference or in Jeffrey Zeldman's article on A List Apart.

In Times to Come

Next month we will be making goulash from various news items and tips I didn't have time or space to throw into the pot before this issue's deadline.

Until then, enjoy!

This is one of a continuing series of newsletters about Palm handheld computers, prepared for doctors, nurses, IT professionals, educators and other people who need tools that work. The Review is published monthly on our web site. Subscription is free; the principal benefit is receiving e-mail notification of new issues.

To subscribe, comment or complain, please contact us at the following address: p.arnold.mpr@sympatico.ca.

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