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Palmtops today do more than check your prescriptions

Drug reference software is still hot, but a boom in new titles for handhelds is changing physician routines

From the April ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

A patient was having cardiac arrest induced by ventricular fibrillation. Ebben Smith, MD, an internal medicine resident at the University of Pennsylvania Medical Center in Philadelphia, was following the advanced cardiac life support algorithm when he came across an indication for amiodarone. Because the drug had recently been added to the algorithm, however, no one knew the appropriate dose.

Fortunately, Dr. Smith had downloaded information about the drug onto his handheld computer and had easy access to dosage information and indications for the drug. "I pulled it up at the patient's bedside in a matter of seconds," he recalled. "It was there when I needed it, when the patient was dying. It was a lifesaver, literally."

Dr. Smith's experience illustrates the convenience that palmtop computers offer physicians, particularly when they need information quickly. And while handheld computers have been popular with younger generations of physicians for years—many residency programs now equip housestaff with the devices—they are finally catching on with physicians of all ages.

If you don't already use a palmtop, also known as personal digital assistants (PDAs), you've probably seen a colleague toting one around the office or hospital wards. Surveys show that about 20% of physicians say they use the tiny devices. (A survey conducted by the College last fall found that 47% of respondents said they use handheld computers.)

Why are palmtops suddenly catching on with physicians? In short, because of a boom in software designed specifically for doctors. While drug reference programs for palmtops have been available for years, there are now all kinds of products for physicians on today's market. You can use handheld computers to peruse medical textbooks, write and send prescriptions, and even code patient visits.

Drug information

For now, however, the most popular physician software still focuses on drugs. Many physicians use ePocrates Rx, a drug reference that they can download from the Web free of charge.

Jerome K. Wang, ACP-ASIM Member, assistant director of the med-peds residency program at Cedars-Sinai Medical Center in Los Angeles, uses the software to get more information on medicines. He said that the software, which runs on handhelds that use the Palm operating system, is easy to operate. He simply enters the first few letters of the medication name into his handheld computer and the software shows him the dosing, frequency, route, proper dosage forms, interactions and contraindications.

To update the drug information in his software, Dr. Wang simply logs onto the ePocrates Web site, downloads a new version of the software onto his desktop computer and transfers this information to his handheld.

Physicians like Dr. Wang have found software for their PDAs not only easy to use, but also fairly affordable. While programs from vendors like ePocrates are free, products such as LexiDrugs, MosbyDrugs and iFacts are available for under $75.

Daniel Z. Sands, ACP-ASIM Member, clinical director of electronic patient records and communication at Beth Israel Deaconess Medical Center in Boston, noted that the PDA's ability to make drug reference information portable is probably its most useful feature for physicians.

"If I'm called in the middle of the night, rather than get out of bed and wander over to my computer," he said, "I can get drug information quickly from my handheld. If you're paged while at a restaurant, you can look up things on your handheld device."

Frederick E. Turton, FACP, a general internist in Sarasota, Fla., and Governor for the College's Florida Chapter, tested the program iScribe, which is designed to help physicians print prescriptions. (Other e-prescription applications include Touch-Works by Allscripts and ePhysician's ePad.) The company gave him a PDA and a printer and connected both devices to his office computer.

Dr. Turton said the software allowed him to produce a script that was legible and contained all necessary information. The software also alerted him to adverse drug interactions and screened out medications that the patient's insurance company doesn't cover.

While he liked the system, he found one major downside. Because his office computer doesn't list the medications his patients take, he had to enter his patients' drug lists into the PDA by hand. This ate up so much time that he eventually stopped using the software. (A pharmacy benefit management company recently bought iScribe and plans to relaunch it.)

Formulas

After drug referencing, crunching equations and formulas is probably the most common task doctors perform with their PDAs. Software like Archimedes, MedCalc and MedMath provide the formulas and do the complex calculations you need to solve everyday problems in your practice.

Dr. Smith from the University of Pennsylvania Medical Center regularly uses MedMath to calculate appropriate respiratory compensation on blood gases in a patient with metabolic acidosis. And when a patient presented with hypernatremia, he used MedCalc to quickly calculate the free water deficit so he could initiate proper hydration therapy.

"If I get some lab data, I plug it into the formula calculator and it helps me with the diagnosis," Dr. Smith said. "I use Archimedes fairly often, especially in the more data-driven units, such as the ICU, where we rely heavily on lab tests and data."

Howard Steiner, MD, a pulmonologist and critical care specialist at Good Samaritan Hospital in Baltimore, said he has used MedRules software to calculate acute physiology and chronic health evaluation scores for indicating illness levels.

For example, he once used MedRules to look up Ranson's criteria for pancreatitis severity. "It's a huge convenience," he said. "This really does make it easier to take care of multisystem illness in the ICU."

Textbooks

Physicians are also discovering the benefits of old standards that have been adapted for handheld computers. PDA versions of "Five Minute Clinical Consult," "The Merck Manual," "Harrison's Principles of Internal Medicine," and others make the PDA a virtual medical library in your pocket. (For more titles, see the College's PDA Portal at www.acponline.org/pda/index.html.)

Cedars-Sinai's Dr. Wang recently saved himself a trip back to his office by looking up anemia in the digital version of the "Merck Manual" stored on his PDA. He wanted to make sure that he had done all the proper tests and evaluations indicated for the condition. Although Dr. Wang had followed the indications properly, he found that being able to easily double-check his work is a powerful way to eliminate errors.

You can freely download some reference materials, such as ventilator management guidelines, a seizure log database and a diabetic blood glucose and medication tracker—all in document forms accessible to your document readers—-from Web sites like PalmGear.com and Memoware.com. Other sites, such as handheldmed.com, CollectiveMed.com and skyscape.com, sell handheld versions of medical reference books, often for less than their printed counterparts.

The handheld versions of these materials offer a big advantage: You can search them more quickly than the print version by using a search engine. Instead of consulting a table of contents or an index, you enter keywords and hit the search button.

The screens on most palmtops are small, forcing users to constantly scroll down to see new text. As a result, most users say that reading on PDAs can be tedious and that the devices are best used to rapidly search for specific facts, not extensive reading and research.

William R. Hersh, FACP, a member of the College's Medical Informatics Subcommittee, said that large diagrams and graphics, particularly those that contain important information in color, don't translate very well to handheld screens.

In addition, PDAs' scant storage capacity can limit their ability to serve as reference libraries. Typically, doctors can store only two or three large reference works on their palmtops. (That difficulty, however, is fading with increased built-in storage and easily changed memory cartridges.)

Patient information

While storing patient information on PDAs may be one goal, so far users say it is still fairly difficult to track patient information using handheld computers. Many programs, however, do a better job when it comes to note-taking.

Dr. Smith, for example, uses Patient Tracker, a program that is available free from handheldmed.com. The software provides templates that he can use to enter vitals, medications and clinical problems.

"I can use it to track some of my outpatients' ongoing issues or to remind myself of lab tests that I need to follow up on or radiology studies that I want to keep track of," Dr. Smith said. The software also provides a to-do list for each patient, which helps him stay organized.

Coding

When it comes to coding patient visits, physician users say that PDAs offer more promise than functionality. Many hope that PDAs will free them from bulky printed coding manuals that are difficult to navigate. Nirav Shah, ACP-ASIM Associate, a Robert Wood Johnson Scholar at the University of California, Los Angeles, and a member of the College's Medical Informatics Subcommittee, stores a list of ICD-9 codes on his PDA—lightening his burden of paper and books. Digital versions of these code lists are easy to keep current.

Dr. Turton from Florida enters the details of his patient encounters in a database on his handheld. He then prints the information and has his staff code the visits later, he said.

While you can purchase software to help code patient visits from vendors like MDeverywhere, PatientKeeper and ePhysician, they all require that you make dozens of choices to work through the patient interaction. The process is often too slow to be helpful, many physicians said.

Experts point out that better networking capabilities will probably be required before the PDA can help you code patient visits faster than the system you presently use. In order to speed the process and preclude retyping information, you have to be able to download information from electronic medical records directly into your handheld's software.

Security

Putting that much information on palmtop computers, however, raises some thorny issues about information security. Imagine the confidentiality issues that would arise if the wrong person found a handheld that contained a list of your HIV patients.

Medical administrators are addressing confidentiality issues in some environments by allowing users to log on to hospital-based repositories and view data on a temporary basis, much like viewing a Web page. The information is not permanently stored on your device, giving you only temporary access after you've entered a password.

Linking palmtops to larger information systems not only goes a long way toward addressing confidentiality issues, but also gives physicians access to a full spectrum of information, not just data they've downloaded or typed in themselves.

Some hospitals, including Good Samaritan Hospital in Baltimore, Cedars-Sinai in Los Angeles and Integris Health in Oklahoma City, have implemented systems that allow doctors to access patient electronic records on their handheld computers. Physicians can retrieve information about X-rays, ECGs and vital signs recorded by nurses, as well as hospital room numbers and locations, demographics, emergency contact information, medication lists and results of almost any test that is run in the hospital.

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