July/August, 2005 (V6N6) -

How do you get software and reading matter to users? Let me count the ways. Actually, let me look at just a sample of means, some unorthodox, for distributing ...

Spread It Around, Part 1

I subscribe to PEPID, a reference program for emergency medicine. Until recently, I would obtain upgrades by downloading the latest version from the company's web site.

The folks at PEPID are constantly adding features and capabilities to their products, and the upgrade process has also evolved. Needless to say (but I will say it anyway) I would back up my PDA before attempting an upgrade, and restore it from the backup if everything went pear-shaped.

During the first half of the year the installer for the latest version (v6.0) of PEPID repeatedly gave me grief unless I disabled my firewall software (ZoneAlarm) and my spyware detectors. I wasn't keen on doing this when online but the alternative was a failed upgrade, reinstalling the program and lots of aggravation.

The problem largely stemmed from the failure of anti-spyware and firewall software to give warnings when they disrupt online processes, like the PEPID installer validating that the correct subscriber's PDA was in the HotSync cradle. The PEPID installer couldn't handle the interruptions and then I was cooked. (Editorial comment: that's just one more reason not to let software update automatically on your PC or PDA. The chances of a clash between programs is just too great. Where possible, I download update files and install them manually. Takes more time up front but avoids meltdowns.)

Annoyingly, despite all my precautions the upgrade process would still fail sometimes. My PC would crash, and my PDA would delete the PEPID files.

The PEPID site does provide a way to update online for people whose spyware blockers, anti-virus programs, and firewall software put up roadblocks. It took them a while to put this option in a more prominent place on their web site so I could find it before I screwed up with the regular version. The "lite" version of PEPID Manager lets you download the update to your PC, unpack the files, then HotSync. No more online validation and stumbling over firewalls.

Another new idea they have is to mail periodic updates to subscribers on a Secure Digital (SD) expansion card. The OnCard system works well (I tried it in May). I received a 64 Mb SD card with the program files and an installer program that ran automatically when I inserted the card in my Palm handheld.

Problems might arise if you don't have an SD slot on your PDA (not many of those around any more) or if you have special SD devices (GPS locator, LED projector link, etc.) that need to be in that slot because you need to keep the OnCard in the PDA while running the program. On the flip side, the 64 Mb card has room to store other files and programs. Thus, you might be able to move software to the OnCard from your other SD expansion card.

Whichever route you take to update PEPID, it runs faster from your handheld's internal memory than from an expansion card. PEPID has gotten hefty and needs far too much RAM on my 16Mb device so I was obliged to move some other applications to the SD card to make room. When faced with this sort of dilemma it's time to either delete some programs or (heh, heh) upgrade my handheld to a model with more memory.

This all must seem like a lot of bother to maintain a current version of a medical reference work. PEPID makes upgrading worthwhile to me in two ways.

First of all, the package encompasses so many tools that I use every day at work and constantly adds new features. As with many similar packages I can look up diseases and drugs, perform specific medical calculations and get treatment algorithms for cardiac dysrhythmias. The latest edition adds treatment guidelines and EBM-style answers to practical clinical questions from FPIN (a nonprofit grassroots organization that tries to bring Evidence-Based Medicine to family practitioners). There is a section on medical literature analysis, NNT, using tests, explaining options to patients. I find this stuff tricky at times so a pocket reference is handy. Calculators, interaction generators are accessible from within any topic - don't require swapping apps - a nice touch due to the limitations of the Palm OS. They even have a visual acuity testing chart now.

The other handy feature is that I can access PEPID online using my subscription ID. Thus if my PDA croaks, I can still use familiar software tools until I get a replacement handheld.

PEPID has several options for downloading or updating their software and also provides access on your PDA or your desktop PC with the same subscription. This flexibility should suit many users and probably contributes to the widespread use of their products. These features also illustrate nicely several approaches to distributing updated content to subscribers.

Spread It Around, Part 2

PEPID creatively uses online software distribution models for its software. But what else can be done with books or textual material?

Many publishers of printed texts arrange to have them released in digital format by teaming up with digital publication houses. A popular example is Griffith's 5 Minute Clinical Consult, which is offered in digital and bodybuilding hardcopy version. Skyscape and Mobipocket are two popular publishers with proprietary reader software or text organization. Their web sites offer large selections of print books.

Less commonly, some publishers release versions of print texts as crippleware (parts of the text are not available unless you have paid up). MeisterMed has released a splinting manual with pictures, text, step-by-step instructions in iSilo format. This is a digital version of the Ortho-Glass Splinting Course Manual published by BSN Medical. Not all of the material is available in the free version.

The Internet is also a great source of homemade or customized medical reference texts that run in text reader programs like TealDoc, or iSilo, and in database programs like HanDBase, or JFile. There are numerous web sites where this sort of material can be downloaded and then HotSynced to your PDA. Check out Memoware, a huge collection of documents in various formats. Much of this material is free or asks for a nominal fee.

If you create your own material in, say,iSilo format, you then have numerous options for distribution. Files can be e-mailed, put on central servers, or converted from webpages. Other software (readers, databases, medical calculators, web apps) can be made available in similar fashion (search the MPR archive for some specifics).

Other media besides the printed word can be downloaded. Medical illustrations or ECG tracings can be added to teaching files. People also enjoy downloading music from the Internet to their MP3 players or PDAs.

Recently radio programming has become available for downloading to Apple iPods. Podcasting, as this is known, is becoming popular now for educational material too. I can see a wide use for this in non-textbook instructional materials. Lectures, video demonstrations of clinical techniques, language lessons, or recorded interviews with simulated patients are all amenable to this format.

And I thought blogging was a form of vanity publication! How about podcasting your lectures or classes? To get a feel for this, check out Podcast Alley - a place to download "radio shows" in MP3 format. Listen to them on your PC, iPod or multimedia PDA or cell phone. Imagine the MPR as a "live" monologue by Paul Arnold. Hmmm, gotta find something sexier than that.... Also, see the article in the March 2005 issue of Hub: Digital Living. Get software for your PC to capture web radio or audio for packaging into MP3 files, for example at SourceForge. There are also commercially available RSS/Podcasting applications for Palm and PocketPC.

Also read more about Podcasting in the Wiki Encyclopedia. This is a fine convergence: Wikis are blogs with shared contribution and input - another excellent way to disseminate material, if not software.

This is all certainly much more creative than handhelds HotSyncing at shared PC workstations.

Clinical Support SW Tools

Health care workers are accustomed to reading background material on an illness or treatment in order to help us make decisions. Some software and web sites attempt to provide more explicit directions such as treatment algorithms, best-practice guidelines and decision support tools. Here is a very brief selection of what's out there.

The American College of Physicians has a downloadable software application which brings its PIER online modules to handheld devices. It offers guidelines and detailed information about selected medications. See illustration at right.

InfoRetriever brings POEMS, Cochrane systematic reviews and Griffith's 5-Minute Clinical Consult to your handheld device. It also incorporates thousands of medical calculators, clinical decision rules and practice guidelines. You can update it periodically but don't need a wireless connection to use it. In addition to expert advice, InfoRetriever provides summaries of the underlying evidence and critical appraisals.

West Portal will actually build customize decision support and educational tools for you and gives a few examples on its web site.

ebm2go offers guidelines and evidence including regular downloads to your PDA. The software is free but the content received a poor review in the British Medical Journal. The site is sponsored by pharmaceutical firms and has links to their advertising.

C-Tools 2.0 is free software for cancer diagnosis, treatment and counseling. It is available at the American Cancer Society's web site.

FERNE offers a download with a NIHSS stroke scale calculator, indications for t-PA administration and some references. This tool may be useful if you are trying to decide whether to administer t-PA to a stroke patient. The software was developed by a team of physicians at the Mount Sinai School of Medicine under pharmaceutical firm sponsorship.

Medical Computing

HealthTracer offers a system for sharing patient health care records. Patients who subscribe use a computer or PDA or cell phone to authorise a hospital or physician to access their electronic records. Because the records are available wherever there is a computer or mobile phone connection, they are about as portable as they can be without tattooing information on the patient's skin. I imagine this would also be a great system for doctors to e-mail their patients when it was time for a recheck or vaccination, and for patients to upload home testing results (blood pressure, blood sugar, etc.) to their health care providers.

PatientKeeper offers software for mobile devices to access hospital-based electronic medical records. A recent article from Mobile Health Data about a Texas hospital highlights this system. The article discusses briefly why the hospital opted to use Treo smartphones instead of either cell phones or PDAs. PatientKeeper integrates various systems on its clinical desktop, and permits mobile device access to data, dictation, billing, prescribing. The suite integrates with LexiComp, Skyscape and ePocrates reference products. Although there is an order status module, I don't see a module for ordering tests per se. Perhaps that needs to be custom-developed for each user? Obviously, being able to order tests on the move or remotely greatly increases the power of the system, as well as its security risks.

OK, everybody is doing it. This article describes a similar mobile access to patient data at Genesys Health System with a twist: the software in the middle (between the hospital databases and the doctors) is not brand-specific. This means that not only can you pick out what you need from a range of different databases and display patient data on a smorgasbord of hardware devices. It also means that you can integrate that data in different ways to help make management decisions. I like that flexibility.

This sort of software would be perfect with new hi-tech Band-Aids with sensors. Health care workers could monitor patient location, vital signs, blood glucose remotely while also retrieving previous results . All while never leaving the coffee shop or call room. Well, I can dream, can't I...?

Nuts and Bolts

My poor Kyocera smart phone has taken a beating over the past few years. I bump into stretchers and countertops at the hospital. My dog has knocked it out of its holster onto the ground. My daughter sat on it once to see how tough it was. Fortunately it has survived, but the shell is looking a little battered. Otterbox offers rugged cases which have been favourably reviewed. They even float.

Hack of the Month

Development tools for handheld programmers are out there.

Rexx is a programming language for Palm devices.

VoiceIt has a software development kit to help create voice controlled applications.

ecamm has several products for software developers, including Nutshell which gives you a way to install multi-file apps as one simple package.

PowerRun is not a developer tool but it is so handy I had to tell you about it. If you find you are running out of memory install apps to RAM, move them and their databases to your external memory card. PowerRun has superior features to the utility that comes with Palm devices (Palm OS 4 or greater) and moves databases that the Palm applet can't.

Links

PEPID and software distribution and publishing

• PEPID: http://www.pepid.com
• PEPID OnCard: http://:www.pepid.com/products/onCard/default.asp?product=onCard
• Zone Alarm: http://www.zonelabs.com
• Skyscape: http://www.skyscape.com
• MobiPocket: http://www.mobipocket.com/en/HomePage/default.asp
• Meistermed Splinting Manual: http://www.meistermed.com/isilodepot/isilodocs/isilodoc_meister_splinting.htm
• TealDoc: http://www.tealpoint.com/softdoc.htm
• iSilo: http://www.isilo.com
• HanDBase: http://www.ddhsoftware.com
• JFile: http://www.land-j.com/jfile.html
• Memoware: http:www.memoware.com
• Podcast Alley: http://www.podcastalley.com/
• Hub Canada: http://www.hubcanada.com/
• SourceForge: http://ipodder.sourceforge.net/index.php
• Palm RSS: http://standalone.com/palmos/quick_news/
• PocketPC RSS: http://www.happyjackroad.net/pocketpc/pocketRSS/pocketRSS.asp
• Wiki on Podcasting: http://en.wikipedia.org/wiki/Podcasting

Clinical Decision Support Tools

• ACP PDA: http://www.acponline.org/pda
• InfoRetriever: http://www.infopoems.com/
• West Portal: http://www.westportal.com
• ebm2go: http://www.ebm2go.com and review at http://ebm.bmjjournals.com/cgi/content/full/9/5/157
• C-Tools 2.0: http://www.cancer.org/docroot/COM/content/div_TX/COM_5_1x_The_C-Tools_20.asp?SiteArea=
• FERNE: http://www.ferne.org/

Medical Computing:

• Review of HealthTracer: http://www.mobilehealthdata.com/article.cfm?articleid=1395
• PatientKeeper: http://www.patientkeeper.com/ and review http://www.mobilehealthdata.com/article.cfm?articleid=1419
• Treo: http://www.palmone.com/ca/products/smartphones/
• Genesys: http://www.mobilehealthdata.com/article.cfm?articleid=1439
• Hi-tech bandaids: http://news.bbc.co.uk/1/hi/health/4617633.stm

Hardware:

• Otterbox: http://www.otterbox.com/ and review http://www.palmtops.about.com/od/guidepalmreviews/fr/Armor1900.htm

Developer and memory management tools:

• Rexx: http://www.jaxo.com/rexx/index.html
• VoiceIt: http://palmpowered.com/ct.html?rtr=on&s=3,r1,w,8vo7,8r0w,507x,gcwy
• Nutshell: http://www.ecamm.com/palm/nutshell/
• PowerRun: http://simple-palm.com/powerrun/index-e.html

In Times to Come

That's it for the summer, folks. I am taking a short vacation, then coming back to scout around the edges of the mobile computing scene. There will be more news in September.

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.

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