Which electronic tools really work for internists?
By Edward Doyle
For internists tired of all the hype about how computers and information technology will change their lives, this year's Annual Session presentations brought a welcome change.
Instead of just praising the marvels of modern technology, speakers gave detailed presentations on the computerized tools that they use in their practice. In some cases, the technology is mature enough to be genuinely useful as a clinical aid; in others, the bugs are still being worked out and patience and time are prerequisites.
For an inside look at the technology that cutting-edge internists are using, here are some of the picks--and pans--from this year's Annual Session presentations.
Kudos for palmtops
Palmtop computers--those tiny devices that pack the power of a PC into a palm-size box--are still relatively new, but they continue to gain in popularity among physicians who want access to information on the run.
At a session on portable computing devices, Don Vine, FACP, a veteran user of portable computers, reviewed a number of palmtop and laptop computers on the market. And while the list of products gets longer every year, Dr. Vine, associate professor of medicine at University of Kansas School of Medicine, said that his tried-and-true palmtop, the Hewlett Packard 200LX, remains one of the best buys for physicians.
Dr. Vine is the first to admit that the HP palmtop is not very fast--it has the power and speed of PCs from 15 years ago--and that it doesn't have a very big screen, displaying just 14 lines of text. But the HP remains a favorite of technophile physicians because it easily fits into the oversized pockets of a lab coat, and can be linked to most desktop computers.
Dr. Vine's HP palmtop allows him to store and recall patient lists he has downloaded from his hospital's medical records department. Each list includes the date of the patient's last visit and a brief description such as "chest pain." "It may not be a complete patient record," Dr. Vine said, "but when I get that call at 3 a.m. it has all that I need to know."
Dr. Vine also uses his HP palmtop to keep up to date with medical literature. He downloads journal abstracts from commercial online services such as CompuServe (he typically downloads 200 to 300 abstracts each month at a total cost of $10 to $20) and downloads chapters from his personal library of medical CD-ROM titles. When he has time between patient appointments and paperwork, he pulls out his palmtop and begins reading.
Dr. Vine also has typed in key points from Agency for Health Care Policy and Research (AHCPR) practice guidelines. Most recently, he inputted the questions that the AHCPR says physicians should ask patients--and document--when treating angina. And Dr. Vine keeps an electronic copy of his schedule and his personal phone directory on his palmtop for instant access, no matter where he is. His nurse creates the schedule on her desktop computer; Dr. Vine simply downloads the schedule into his HP palmtop.
For physicians who don't like the idea of using a machine with such a tiny keyboard and screen, Dr. Vine noted that good news is on the way. A number of vendors, including Sharp and Casio, are introducing portable computers with larger screens and keyboards. While most cost more than the HP's $600 price tag, Dr. Vine said that prices are constantly dropping. But with these larger portables, he noted, there is a tradeoff: overall weight goes up (an important consideration for users who carry their computers everywhere they go) and battery lifespan declines sharply.
Thumbs down on decision support software
For one of medical computing's oldest products, diagnostic decision support (DDS) software, the verdict was not quite so positive.
DDS software, which helps physicians diagnose difficult cases by taking physical symptoms and creating lists of possible diagnoses, has typically received mixed reviews from internists. At a presentation on DDS software, researchers presented some possible reasons for physicians' mixed feelings about programs on the market.
Interestingly, several speakers said that physicians' apparent dissatisfaction with DDS software may stem not from the programs themselves but from the way that they are used. In a study of one popular DDS program, Iliad, physicians who had trouble diagnosing patients without a computer typically didn't do much better using DDS software.
The problem was that even those physicians who said that they liked the software often did not follow its recommendations. Researcher Charles Friedman, FACP, assistant dean for medical education and informatics at the University of North Carolina Chapel Hill, said he found that many physicians tended to stick to their own diagnoses even when DDS software suggested other plausible explanations for a patient's illness. "The program may display useful information, but it's not used," he said. "Physicians seem to be loyal to their own conclusions."
Eta Berner, EdD, an educator from the University of Alabama School of Medicine and author of last summer's New England Journal of Medicine study of DDS systems, reported similar quirks in the way that physicians use Quick Medical Reference (QMR), another popular DDS program. As part of research she is conducting, Dr. Berner found that physicians trying to diagnose identical cases varied wildly in the information that they supplied the program. Some physicians failed to tell the program that a patient suffering from dizziness and rapid heartbeat was also experiencing chest pain; others failed to mention the presence of a grade I late systolic heart murmur. And in another case, physicians interpreted an EKG stress test so differently that some inputted the results as positive while others reported them as negative.
Besides providing the software with a wide range of physical findings, Dr. Berner said that physicians typically used only limited parts of the program. Most didn't use features of the software that would allow them to further refine a diagnosis, for example; Dr. Berner noted that these same features could help physicians who entered inadequate or incorrect information.
Despite these shortfalls, Dr. Berner said physicians participating in the study found the program helpful in confirming diagnoses. Dr. Berner said the physicians were very good at ignoring plausible diagnoses that weren't relevant. But coming up with the right diagnosis is what many physicians want DDS software to do, and for that reason they may find it somewhat impractical. Robert Wigton, FACP, professor and chief of general internal medicine and dean for graduate medical education at the University of Nebraska in Omaha, has been using QMR on the wards with medical students to study its usefulness. And while Dr. Wigton said that he likes the program, he confirmed many internists' suspicions about DDS software: that for internists, at least, it has fairly limited uses.
Dr. Wigton said that he was surprised at how infrequently--two or three times a month--he saw cases complicated enough to use the program. "Most questions are management problems, not diagnostic questions," he explained. "You already know where you're going with these patients, you're just not sure exactly what you need to do."
Headed toward the future--online
E-mail. Newsgroups. Information retrieval. There has never been a better time for physicians to try these online tools, said Daniel Masys, FACP, director of biomedical informatics at the University of California at San Diego School of Medicine in La Jolla. Not only is getting there easier than ever--most computers now come equipped with modems and special telecommunications software--but the online offerings for physicians have never been greater.
Dr. Masys said that the most exciting online developments for physicians are those that will help with day-to-day duties. The National Library of Medicine, for example, offers several databases for physicians. Medline, the NLM's collection of more than 6 million journal abstracts, allows physicians to quickly search for medical journal abstracts. Physicians can also access Physicians Data Query, a source of clinical and patient handout information on cancer for physicians and AHCPR practice guidelines. (Call 800-638-8480 for more information on NLM services.)
A variety of commercial online services are geared toward physicians, including the College's own ACP Online and the American Medical Informatics Association's MedSIG, both on CompuServe (800-848-8990). In addition, Physicians Online (800-332-0009), GeoMedica (800-797-2633) and U.S. HealthLink (800-832-1000) offer resources ranging from the text of medical journal articles to free access to DDS software and drug interaction programs. And free or inexpensive software designed for physicians is also available on the Internet.
How to get started? Besides a computer (see related story, next page), you need a modem. Modems are rated in baud, or bits of information transmitted per second; Dr. Masys suggested buying a 14,400 baud modem. While faster modems are available, he said that they are still new and may not be compatible with emerging services.
Joining a commercial online service such as CompuServe or Prodigy is an easy way to get started, Dr. Masys said, because you will be supplied with all the software you need. And if you want to get on the Internet, Dr. Masys suggested asking if the university or teaching center you're affiliated with can sign you up. (Ask the information services department.) If not, find a local Internet provider that will link you to the Internet through the phone lines and give you the software you need. The easiest way to find a list of these providers, Dr. Masys said, is to buy an Internet guide from your local bookstore.
And though Dr. Masys said that the Internet offers great potential, he warned that because the information superhighway is still under construction, the ride can be a bit bumpy.
He talked about "hacker hysteria," the overwhelming concern that the Internet is not secure. While encryption software is one way to keep confidential information out of the hands of hackers, Dr. Masys also recommended that physicians pay attention to password "netiquette," and not use dictionary words or users' first or last names as passwords. Seventy percent of network break-ins, he said, are due to violations of this simple rule.
But physicians cruising the Internet are likely to encounter a more common problem: technical glitches. Even Dr. Masys, a 20-year veteran of computers, couldn't connect during an attempt to do some real surfing during his session and had to get some technical assistance.
Paula S. Katz contributed to this article.
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