American College of Physicians: Internal Medicine — Doctors for Adults ®

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What the growth of tiny computers means for medicine

Competition among personal digital assistants means new choices for physicians trying to stay organized

From the October 1998 ACP-ASIM Observer, copyright 1998 by the American College of Physicians-American Society of Internal Medicine.

By Howard Wolinsky

Karl Hsu, MD, a third-year internal medicine resident at Johns Hopkins Hospital in Baltimore, carries what he calls his "peripheral brain" in his pocket. Instead of fumbling with papers or searching through textbooks and phone books, Dr. Hsu keeps the data he needs at his fingertips in his personal digital assistant (PDA), which fits snugly in his shirt pocket.

PDAs and electronic organizers have been on the market for years, but changes in technology during the past two years have attracted millions of new users. According to the San Jose, Calif.-based market research firm Dataquest, consumers bought 2.4 million handheld computers in 1997, a 65% increase over 1996.

Dr. Hsu's success with his PalmPilot Professional, the second generation of 3Com's PalmPilot PDA, helps explain the phenomenon. Because he has a terrible time remembering names and dates, Dr. Hsu taps into his PalmPilot four or five times a day to check on appointments and retrieve phone numbers and addresses. Stored within his PDA are the names, phone numbers and medical conditions of the 100 patients he follows in an outpatient continuity clinic. Included are case history numbers in the event he is near a desktop computer and wants access to more complete records.

Dr. Hsu also uses his PalmPilot, which costs less than $400, to take notes during grand rounds, and he keeps copies of key practice guidelines, such as those for immunizations and cancer screening, in his PDA. He has even developed special calculators to compute such factors as creatinine clearance and fractional excretion of sodium. The programs are given away as "freeware" at PalmPilot Web sites such as Doctor PalmPilot (oac1.oac.tju.edu/~info/JMG/index.html).

In short, Dr. Hsu said, his PDA helps him keep his life and practice in order. "The way medical information expands, there is too much to keep in your head and too much to put on paper in your pockets," he explained. "My PalmPilot can hold all that information and keep it organized."

Since its introduction in 1996, the PalmPilot family has sold a whopping 1.6 million units. And though PalmPilot products control roughly 60% of a $1 billion market, it is only one of many PDAs.

The PalmPilot is considered a palmtop because of its tiny size, but a number of other larger PDAs, commonly referred to as handhelds, are on the market. J. Michael Kramer, MD, a resident in the combined internal medicine/pediatrics program at the University of Michigan, uses the Philips Velo 1, a larger handheld device that costs about $600. Dr. Kramer said the device easily fits into his lab coat or a hip bag. (Other handheld devices include the Sharp Mobilon HC-4600, the Psion Series 5, the Casio Cassiopeia Handheld, the Hewlett- Packard HP 620LX PC and the LG Electronics Phenom Ultra.)

"It has changed my life and how I organize information," said Dr. Kramer, who runs an e-mail discussion group on handheld and palmtop computers. "I take notes in lectures and while reading journals using handwriting recognition. It takes no longer than writing on paper."

Dr. Kramer also uses Pocketchart, software that allows him to produce patient notes that meet HCFA documentation guidelines. (See www.physix.com for more information on this software.) He prints his notes directly to a printer on the wards, or he connects his Velo to a workstation so he can edit his notes using a full-size keyboard.

To make sure that they are accessing up-to-date information, users "synchronize" their PDAs by exchanging data between their palmtop or handheld and their desktop computer. The mobile devices are placed into a cradle linked by wires to the laptop or desktop; within seconds, calendars, to-do lists and other data are updated.

Jim Thompson, MD, an emergency physician in Charlottetown, Prince Edward Island, Canada, consults his PalmPilot 15 to 20 times a day. By synchronizing his laptop computer, his home computer and his PDA, Dr. Thompson has all the information he needs at his fingertips. "If someone asks, 'Can I meet with you tomorrow to discuss the testing protocol?' " Dr. Thompson said, "I can quickly look and determine whether my meeting time is free."

Physicians can also receive faxes and pages, view Web sites and access e-mail by installing special "cards" in their PDAs that allow for wireless communication. Modems for PalmPilots and the Windows CE palm-size PDAs cost about $129.

Handwriting recognition

One of the biggest issues in using a PDA is how to get information such as patient notes into the machine. While some PDAs have tiny keyboards that allow users to type in notes, most physicians say they prefer to handwrite their notes directly onto their PDAs.

Dr. Kramer, for example, likes to take notes as his patients talk. "No one can sit down and type in a patient room," he said, "and it isn't easy enough to type on most handheld PC keyboards anyway."

But getting PDAs to recognize handwriting and convert it into computer text is not always easy. Numerous handwriting recognition programs are on the market, but users sometimes have to spend a fair amount of time practicing to become proficient. The PalmPilot, for example, uses a program called Graffiti that requires users to learn a special alphabet. The manufacturer, however, claims that users need to spend only about 20 minutes to master the software.

Dr. Kramer prefers to use a program called Jot, developed by Communication Intelligence Corporation, in part because he did not have to learn a special alphabet or undergo any special training. But there is a learning curve with any of the methods of inputting data. Handwriting recognition programs may mistake an "s" for a "$" or a "c" for an "i."

Dr. Kramer suggested trying several programs. "Your success may vary based on your writing style, and it is worth your while to find one you are happy with," he said. Software developers offer demo versions that can be downloaded for free to help users decide.

Some veteran users of handwriting recognition software claim that they can write notes just as fast when using handwriting recognition with a stylus on the screen as they can when putting pen to paper. But Dr. Thompson said that most physicians using Graffiti can write only about 25 words per minute. "You still find yourself backing up and correcting as you go along," he said.

That's why Dr. Thompson prefers to use a keyboard to input data. But the foot-long keyboard, which costs $110 and requires a hardware adapter plug, adds bulk and inconvenience. A more compact keyboard for the PalmPilot, with "touch-type" keys comparable to those found on laptop computers, is supposed to be available this fall. Similar devices for palm-size and handheld computers are expected to follow.

Crowded market

This summer, a new wave of PDA models appeared, complicating the market even further. For most users, the single most important decision they will make is whether to buy a PDA that runs Windows CE or stick with PDAs that run on less complex systems.

Windows CE is a scaled-down version of the Windows operating system used on most PCs. It is designed for handheld and palm-sized PCs, and is already being used on 600,000 larger handheld computers. The newest version runs on new palm-size PCs that are trying to steal market share from the PalmPilot.

Units running Windows CE include the Philips Nino 300, the Casio Cassiopeia E-10, the Everex Freestyle and the Uniden UniPro PC 100. 3Com is scheduled to release its newest version of the PalmPilot, code-named Razor, later this fall.

For some, the issue of whether to use Windows CE leads to a philosophical debate about the overall purpose of PDAs. Some experts, for example, say that PDAs don't need the computing power and functionality of the Windows operating system. Michael McGuire, a senior industry analyst for mobile computing at Dataquest, said that many people don't need a mini-computer, but prefer to have a simple device to store personal information. "You don't use the [palmtops] the way you use a computer," he said. "You use it for your calendar and contacts, not to grab data from the Web."

But the decision to go with a Windows CE device or other PDAs, such as the PalmPilot, also has practical implications: Not all types of machines can run all types of software.

Most experts say that the 3Com PalmPilot has the edge right now because it is easy to use, and there is a treasure trove of compatible software. Dr. Thompson, for example, is a supporter of the PalmPilot and its sister product, IBM's WorkPad. He acknowledged, however, that devices with the Windows CE platform will eventually win over many physician users, particularly once more medical software becomes available.

Experts have also complained, however, that the keyboards on most Windows CE devices are too small. (See "What to look for in a PDA—and when to buy one ".) But because of support from Microsoft, Windows CE devices are bound to grow in popularity, particularly for users who want the same operating system on their PDAs and their desktop machines.

For Dr. Kramer, the decision to remain with the Velo handheld is relatively simple: It allows him to use programs and to accomplish tasks that are simply not possible with the PalmPilot.

"I have a second peripheral memory that exists in my coat pocket," he explained. "It is hard to match the robustness and flexibility of a Windows CE handheld," he said. "Few technologies will change your work style more than an electronic organizer. [It's] your daily planner on steroids."

Howard Wolinsky is a Chicago-based freelance medicine and technology writer.


What to look for in a PDA—and when to buy one

If you're thinking about making the leap to personal digital assistants (PDAs), you should first ensure that you're ready for one of these devices. Some experts caution that for many people, paper may still suffice.

Greg Shirai, a product manager with 3Com Corp., maker of the PalmPilot, said that many people are getting by just fine with old-fashioned paper: "The biggest competition we have in some ways is paper," he said. "There is a whole world of people using DayTimers and paper organizers, and they haven't seen a compelling reason to switch."

If you think the time is right to go digital, however, here are some factors to consider:

  • Cost. The new Palm III and competing palm-size PCs using Windows CE go for between $300 and $500 while the Windows CE handhelds cost between $600 and $1,000. A great deal of free software is available, but more sophisticated programs can cost more than the device itself. Pocketchart, patient note software for Windows CE machines, for example, costs about $1,000.
  • Portabilitys. Palmtop PCs will fit in a shirt or pants pocket and can be worn on a belt. Handhelds can't squeeze in the shirt or pant, but they can fit into a lab coat pocket or hip bag.
  • Data. If you want to input large amounts of data, you may want to get a device with a keyboard. Keyboards are available for small devices like PalmPilots, but the keyboards are separate items and can be bulky to carry around. While some larger handheld devices offer built-in keyboards, the tiny keys can make typing difficult.
  • Software. Are you partial to a personal information manager program in your desktop or laptop computer? If you use, for example, Lotus Organizer, Microsoft's Outlook or Symantec ACT! to manage your calendar, check to see which device is compatible with the software.

How some physicians are using and creating PalmPilot software

By Chris Dwyer

While vendors are busy developing medical software for 3Com's PalmPilot family of products, physicians have already figured out ways to use the PalmPilot's basic functions and free software available on the Internet to organize clinical information.

Gary N. Greenberg, FACP, assistant clinical professor at Duke University Medical Center's Division of Occupational and Environmental Medicine, uses the PalmPilot's basic features to keep a list of his rounding team's patients and their chart and room numbers, as well as important hospital phone numbers and staff lists for the wards. Dr. Greenberg also uses the PalmPilot's basic features to refer to notes for teaching rounds, ACLS protocols, the mini-mental status exam and formal criteria for Chronic Fatigue Syndrome.

Other internists use the PalmPilot's basic features to store items like patient questionnaires, EKG axis information, end-of-life guidelines, endocarditis guidelines and HMO formulary information. Physicians often share these text files, which are known as "docs," on Internet sites like PalmCentral (www.palmcentral.com).

Physicians are also creating their own software by using scientific calculators such as SynCalc (800-210-5293) to write medicine-specific modules to manage complex medical data. (Physicians often offer these modules on the Web for free or for a small charge.)

Dr. Greenberg, for example, uses such tools to determine creatinine clearance, A-Aa gradient, body mass index and aminoglycoside intervals. Physicians are also using database programs like JFile (www.land-j.com) and HanDbase (www.ddhsoftware.com) to track this type of information. Palm Central and the online store PilotGear (www.pilotgear.com) both feature a wide selection of free and inexpensive PalmPilot software for physicians.

Some commercial medical software is also available for the PalmPilot, but these applications typically cost hundreds of dollars. Raphael (www.pdamed.com) is a patient information management system, Lexi-Comp's Drug Information Handbook (www.skyscape.com/k2) covers more than 5,000 drugs commonly used by internists, and Mobile MedData (www.medcomsys.com) is an electronic medical record system that helps physicians centralize their medical records.

Physicians are also finding that both free and commercial applications are making the PalmPilot so useful that several organizations are studying how the device can be used to help groups of clinicians collaborate more effectively. At Massachussetts General Hospital, for example, incoming neurology residents received PalmPilots this year to manage patient information. And this June, Case Western Reserve University School of Medicine began a one-year trial involving 12 third-year medical students to measure whether the devices improve productivity and health care delivery.

Chris Dwyer is Medical Informatics Programs Associate in ACP-ASIM's Education Division. He can be reached at medinfo@acponline.org.


PDA resources

There is a growing number of online resources for users of palmtop and handheld computers. Here are some starting points, some of which offer information on medical software available.

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