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Hazards and help in communications

The personal digital assistant: a new medical instrument for the exchange of clinical information at the point of care

Personal digital assistants can provide a portable, integrated platform for point-of-care clinical reference, patient management and data communication. Clinical reference programs allow the user to access information from the Internet and guidelines. Patient management programs allow doctors to access and store clinical information. Wireless technologies have potential for rapid exchange of clinical laboratory results and efficient "electronic patient handovers". Thus, these devices provide the potential for true continuity of care across the healthcare system.

Robert A Wilcox and Ralph R La Tella

MJA 2001; 175: 659-662

Applications of PDAs in clinical practice - Palm OS PDAs - Security issues - Choosing a PDA for medical practice - Conclusion - Competing interests - References - Authors' details -
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  The use of mobile "evidence carts", consisting of evidence-based medicine (EBM) and medical reference material stored in laptop computers or paper inventories, increases the extent to which evidence is incorporated into patient care decisions.1 However, "evidence carts" cannot be readily taken on bedside rounds or home visits.1 Doctors need a mobile instrument that can provide access to EBM and other clinical data resources at the point-of-care. Recent advances in computer technology have produced efficient, powerful and very compact computers called personal digital assistants (PDAs) (see Box 1 for illustrations of typical models), which have the potential to fulfil many of these demands.

PDAs offer built-in appointment, memo and address books, but are capable of much more than just personal information management. They can run a wide range of programs, document readers, databases and calculators. Many programs and data files can be found on the Internet, available at no charge ("freeware"), a nominal charge ("shareware") or commercially. These resources allow PDAs to function as sophisticated reference, organisation and communication devices.

PDAs have several important features that distinguish them from desktop and laptop personal computers (PCs). PDAs turn on almost instantly and crash less frequently. Palmtop PDAs use handwriting recognition systems or on-screen keyboards to allow text input via a stylus on a touch-sensitive screen. PDAs can connect to PCs to exchange programs and data. This process is referred to as "hot-synching" and is commonly accomplished via a "cradle" device connected to the PC. Many PDAs also use wireless infrared transceiver ports to directly communicate with compatible PDAs and printers (a process known as "beaming"). Some PDA models can also use compact flash or other memory cards for direct data exchange.

Two major operating systems (OS) exist: Windows CE and Palm. Windows CE seeks to be a miniaturised version of the Microsoft Windows OS used on PCs, but will not run Windows 95/98/2000/NT software. It allows efficient file transfer into many programs running under Windows and is popular within the business community. In contrast, the Palm OS has become the defacto standard for medical professionals. Thousands of Palm OS medical programs, databases, medical textbooks and medical web-sites are available.

As more than 75% of all PDAs use the Palm OS, most PDA medical software developers concentrate on creating applications for these PDAs. Consequently, we will focus primarily on reviewing Palm OS PDAs and the applications of most value to medical professionals in Australia.


Applications of PDAs in clinical practice

Point-of-care prescribing

When medication is given to a patient, four major processes occur: prescribing, transcribing, dispensing and administration.2 Most doctors are involved in prescribing and transcribing, and some are involved in all four stages. Dosing errors or inappropriate drug choice can cause predictable adverse drug reactions. These events are common in hospital and community practice.3-6 A recent study conducted by the United States Institute of Medicine reported that medication errors cause an estimated 7000 fatalities annually, exceeding the number of US workplace-related deaths.7 Many doctors are surprised to learn that most adverse drug events are primarily caused by physician error,3 and that many of these errors result from a problem with point-of-care drug knowledge.8

In the US, drug databases have been developed by "eProcrates".9 These deliver clinical drug information on Palm OS PDAs. The "ePocrates qRX" drug database is used by more than 300 000 medical professionals worldwide.9 Several major US teaching hospitals, such as Stanford University and Duke University, supply PDAs preloaded with ePocrates qRx to their physicians in the hope of improving prescribing and reducing adverse drug events.9 This initiative was supported by a survey of 870 users of ePocrates qRx, in which 50% of respondents were of the opinion that using ePocrates prevented at least one adverse drug event per user per week, with the added benefit of improved physician drug knowledge and a reduction in the time required for drug selection.10

Currently, there is no comprehensive PDA-based pharmacopoeia covering medications used within the United Kingdom, Europe or Australasia. However, many Australasian doctors will find ePocrates qRx valuable, albeit with the drawbacks of differing drug nomenclature and availability than in the US. A PDA version of the Australian Medicines Handbook (AMH) is in development and MIMS on PDA is scheduled for release in February 2002.

Document managers

Document managers are applications used to create an electronic text library on the PDA. The Palm OS stores text in "doc" files, which are read and sometimes composed in various "doc readers".11 Among the more popular shareware doc readers are TealDoc12 and iSilo.13 Documents-to-Go14 includes a document and spreadsheet reader and editor that allows conversion of Microsoft Word and Excel files to doc format. Similarly, Wordsmith15 allows the free transfer of fully formatted word-processor files between PCs and PDAs and replaces the standard Memopad of the Palm OS with a searchable memo and document-handling application. Doctors can thus create documents or take pre-existing medical protocols from their PCs and convert them to the doc format. Hundreds of useful doc and smaller "memo" files can be downloaded from medical PDA text file repositories.16-20

Database managers

Database managers are another important group of applications for organising medical data. These programs allow the user to design data entry forms for tasks such as tracking patients, comparing normal and abnormal laboratory results, or comparing similar diseases. Database files are ideal for rapid medical reference instead of laboriously searching through doc files. Popular database programs include JFile,21 TealInfo12 and HandDbase.22 HandDbase is particularly powerful because of its "relational" database features. For example, this allows clinicians to construct a patient-tracking system with links to drug details, differential diagnoses and medical procedures and protocols. The use of PDAs for point-of-care database entry has been successfully trialled in emergency medicine,23 clinical audits,24 clinical trials25 and for clinical encounter and procedure logbooks.26-28 Furthermore, patients themselves have been provided with PDAs to document their own symptoms in real time.29,30

Medical electronic textbooks

Medical electronic textbooks (e-texts) have been published for PDAs, usually based on US medical publications. The most popular titles include the 5 Minute Clinical Consult, Harrison's Principles of Internal Medicine Companion Handbook, the Merck Index and the Washington Manual of Medical Therapeutics.17-19,31,32

Web clipping

 "Web-clipping" programs allow capture of web page content for use on a PDA. PDA users choose medical sites they wish to review regularly. When the user activates the program, the PDA connects to the Internet through a desktop PC during hot-synching or via a mobile phone-modem connection. The PDA then saves the web pages for later viewing. The most popular freeware web-clipping program for Palm OS is AvantGo.33 Some useful sites include medical news updates and reviews (eg, Medscape34), journal abstracts (eg, British Medical Journal35) and EBM web pages (eg, the Centre for EBM in Oxford36).

The Palm OS offers considerable flexibility as a communications tool with the addition of the Eudora Internet kit. With this kit and any infrared, modem-enabled phone, one can send and receive email and access web "Palm Query Applications" (PQAs).37 PQAs are essentially web-clippings or scaled-down versions of useful web sites which can be rapidly accessed. Some useful PQAs for physicians are available at EmedHome.38 These include journal articles and clinical protocols.

Medical calculators

Medical calculators help doctors make better decisions, give better advice to their patients and avoid calculation errors. Hundreds of medical calculators are available, and some programs consolidate several calculators to a single PDA application (Box 2).

Clinical organisers

Doctors are constantly striving to be efficient coordinators of patient care. In group practices or during hospital ward rounds, the PDAs of each team member can be synchronised and patient information beamed in an efficient "electronic handover". In addition, several excellent patient management applications have been written (see Box 3 for a typical screenshot).46-48


Palm OS PDAs

Within Australia, three major companies market Palm OS PDAs: Handspring, Handera and Palm. Comparisons and reviews of each model can be found at "PDA-Buzz".49 The Handspring PDAs use a proprietary "Springboard" expansion slot that allows addition of modules with extra memory, some pre-packaged medical books, and devices such as cameras, modems and phones. However, Springboard expansion modules are quite expensive and can only be used in Handspring PDAs. In contrast, Handera PDAs use industry-standard "compact flash" data storage cards, and Palm 500/505 PDAs use the smaller industry-standard "multimedia cards" and "secure digital" cards.

Handera pioneered software allowing programs to be run directly off a compact flash card, making these PDAs ideal for large applications and e-texts. Furthermore, the entire memory can be saved and restored from the card independently of "hot-synching", and card readers are available to allow direct PC connection independent of the PDA.50 Palm and Handera PDAs also use multimedia cards and secure digital cards to allow addition of devices including digital cameras, modems, phones and Bluetooth radios. Handspring have recently released an adaptor Springboard that allows their PDAs to use compact flash cards.51 However, the Handera 330 retains the unique advantage of possessing expansion slots for multimedia, secure digital, and compact flash cards.52

The Bluetooth wireless technology is a particularly exciting development for PDAs. It provides high-speed, reliable, short-range radio links between PDAs, PCs, mobile phones and other devices.53 Bluetooth wireless technology has built-in security encryption and authentication, and could potentially fulfil an important role as an in-hospital communication and data exchange system for confidential patient information.


Security issues

Security of confidential patient information on PDAs is a significant concern. These devices are small and can be easily misplaced or stolen. Consequently, physicians should address security issues before entering confidential patient information. There are a number of security programs that provide password control of confidential files.12,16 Although individual PDAs are easy to secure, it must be remembered that the PDA contents are usually replicated on every PC with which the PDA is hot-synched. Protection for this hot-synched data is essential. One solution may be the distribution of clinical updates, laboratory and pathology results via compact flash, secure digital or multimedia cards, or via encrypted broadcast data systems, thus removing the requirement for hot-synching. Doctors at Cedars-Sinai Medical Center in the US have recently reported a successful trial of secure remote access to clinical data repositories using encrypted transmission and wireless PDAs.54


Choosing a PDA for medical practice

There are a number of important factors to consider when choosing a PDA for medical practice.

Physical size: The device should fit into a pocket or easily clip onto a belt.

Battery life: Efficient point-of-care computing demands a battery life at least as long as your medical workday. Most PDAs have battery lives of 2-8 weeks, with colour displays depleting batteries about twice as fast as monochrome screens.

Screen clarity: Current PDAs offer very high-resolution screens; nevertheless, clarity can depend on the software applications used. Both Handspring and Palm offer colour screens. Colour can improve screen clarity, but is currently used by few medical applications.

Adequate memory: Medical applications, especially e-texts, tend to be large (1-5 MB). Thus, 8 MB memory should be considered the minimum for a PDA. Many medical users will soon find they require the memory expansion slots.

PC synchronisation: Choose a PDA which can easily synchronise with your PC. Newer PCs may require USB (universal serial bus) synchronisation docks and cable connectors.

Some useful resources for use of PDAs in medical practice are listed in Box 4.

Conclusion

PDAs will soon take full advantage of wireless communication technology. These PDAs will integrate the electronic medical records, medical references, EBM and guideline implementation and allow coordination of clinical communications. Thus, with increased use of PDAs by doctors, there should be improvements in the quality and continuity of patient care. Australian doctors can help achieve these gains by actively participating in the development and use of these devices. In the near future, many doctors will find their PDA to be an essential medical instrument, as indispensable as their stethoscope.

Competing interests

Ralph R La Tella is the editor-in-chief of The Guide to Handheld and Palmtop Computing Resources for Health Care Professionals and receives payment for this publication. Neither author has received any remuneration from any personal digital assistant hardware or software developer, manufacturer or retailer discussed in this article.

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(Received 24 May, accepted 10 Sep, 2001)  


Authors' details

Department of Medical Biochemistry, Flinders Medical Centre, Bedford Park, SA.
Robert A Wilcox, MB BS, BSc(Hons), PhD, Registered Medical Officer and Medical Researcher

Ashfield, NSW.
Ralph R La Tella, BSc(Hons), Health Information Consultant

Reprints will not be available from the authors.
Correspondence: Dr R A Wilcox, Department of Medical Biochemistry, Flinders Medical Centre, Bedford Park, SA 5042.
wilcwhitATozemail.com.au

©MJA 2001
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1: Examples of personal digital assistants

Handera 330
Handera 330		Palm m505
Handspring Visor Pro		Handspring Visor Pro
Palm m505
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2: Medical calculators for personal digital assistants

ABG Pro: Calculates arterial blood gas and acid/base status.39
DoseCalcPlus: Calculates the dose of paediatric drugs based on the patient's weight.40
Doser: Calculates drug infusion rates in various units (mg/kg/min, etc).41
MedMath: A freeware program for calculating various equations used in medicine (eg, body mass index, creatinine clearance rate).42
MedRules: Calculates various clinical prediction rules (eg, pre-operative cardiac risk).43
RiskyDisky: Uses predictive models to calculate the risk of female breast cancer.17
STAT cardiac risk: Automates the latest update of the Framingham Heart Study prediction scores.44
STAT Growth Charts: Calculates the growth percentiles of children.45

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3: A typical screenshot from "WardWatch",47 a PDA patient management application

Figure 3

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4: Resources for medical users of personal digital assistants

The 2000 Guide to Handheld and Palmtop Computing Resources for Health Care Professionals55
A guide to medical resources for all PDA platforms, compiled by La Tella, coauthor of this article (downloadable for a small fee). Explanatory notes accompany each product, often with actual screen shots of the application.

PDAs for Health Care Providers56
A webpage providing links to health-related resources for Palm OS and Windows CE PDAs from the Arizona health services library.

Additional sites containing reviews and downloads of medical software for PDAs:
Tucows PDA16 Palm Gear17
Handango18 Handheld Med19
Washington University Medical
  Palm Initiative57 		pdaMD58
Healthy Palm Pilot59 Peripheral Brain60
The Medical Piloteer61 Doctor's Palm62
Physics Palm Pilot Pages63 Pediatric Pilot Page64
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