Clinical and educational uses of handheld computers.

Abstract: Handheld computers, also known as personal digital assistants (PDAs), are becoming an increasingly valuable aid to physicians at the point of care. We review the use of handheld computers and their impact in clinical practice and medical education. Clinicians commonly use PDAs to access patient data and as a clinical reference tool. In medical education, handheld computers are most frequently used to track patient encounters and procedures done during medical school rotations and residency training. This report describes some interesting applications for present and future use of PDAs in inpatient care and medical education. Physicians and educational programs not using PDAs may wish to consider incorporating this technology.

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Personal digital assistants (PDAs) are small computers that fit in the palm of one's hand. Most current PDAs run on one of two main operating systems (Palm OS and Pocket PC; Pocket PC is an alternative solution for users of handheld and pocket PCs), which determine the software that can be used. These devices have adequate (and now expandable) memory capabilities (6-64 megabytes) and range in price from $200 to $500. (1)

PDAs have become extremely popular among physicians. In 1999, 15% of physicians used handheld computers; today the number has climbed to 26%. Experts predict that, within a few years, most doctors will use handheld computing devices. (2) The New England Journal of Medicine web site now offers its readership the ability to synchronize a PDA with the latest abstracts, editor's summaries, and table of contents of the journal. (3) At this time, handheld computers can accomplish a wide array of clinical, organizational, and educational tasks (Table 1). (4,5) Handheld computers have become a valuable tool for clinicians and educators by allowing them to have immediate access to relevant clinical facts such as checking for drug interaction, calculating important parameters (eg, creatinine clearance), or expanding the differential diagnosis.

Although portable knowledge appears to be the physician's panacea to cope with the overwhelming amount of medical information confronting physicians every day, little is known about how PDAs have been used and evaluated in patient care and medical education. Therefore, this article will report on the use of PDAs in clinical practice and medical education, providing physicians with an overview of the utility of handheld computers in medicine.

Methods

We performed an English-language literature search (1968 to May 2002) of MEDLINE, Educational Resources Information Center (ERIC), Applied Science and Technology, and American Medical Informatics Association (AMIA) proceedings for articles containing any of the following text words: "personal digital assistant," "handheld," and "palmtops." The main focus was on articles in English that aimed to evaluate the use of handheld computers in clinical practice and/or teaching, independent of medical specialty. We selected studies that had at least five participants. Excluded were articles on the use of other types of electronic devices (such as laptop computers, desktop personal computers, or palmtop computers connected to digital cellular phones). We also excluded articles in which nonphysicians were the main users of PDAs and those that reported primarily on specific software. References from all articles were examined to identify additional pertinent articles.

Results

Clinical Applications of PDAs

Clinicians are always searching for ways to become more effective and efficient. Handheld computers may be able to assist physicians in this quest in a myriad of ways (Table 2). One study of 100 physicians in a multispecialty group in Oregon evaluated the use of PDAs to record and track multiple procedures, to simultaneously access related billing codes, and to enter billing charges. (5) A before and after intervention design compared data from 11 months before to data from 3 months after the introduction of these computers. The users reported that PDAs allowed them to easily access lists of procedures, to bill more quickly and accurately, and to ultimately increase their level of administrative and professional satisfaction. Not surprisingly, the use of such devices increased capture of charges. (5)

PDAs have also been studied as guideline-based decision support tools for office management of asthma in a randomized prospective trial, with 2 years of follow-up. (6) While PDA use in the intervention group was associated with increased physician adherence to asthma guidelines recommended by the American Academy of Pediatrics, there were also prolonged visits and higher fees. No differences in clinical outcomes between the two groups were observed. (6) In another study, (7) a survey of 250 primary care physicians about their preference for various types of decision support information tools discovered great interest in and keenness for handheld computers as decision support devices containing drug information and treatment recommendations.

Handheld computers have been evaluated as tools to manage and access patient data and medical references in intensive care units. Twenty ICU physicians (including attending physicians and residents) participated in a 6-month study. (8) Residents primarily used reference databases such as critical care drug dosing references, ventilator weaning protocol, and electrolyte correction applications. They were satisfied with the size and capabilities of the PDAs, but they described the need for additional training in database searching strategies and patient data entry. Both the attending physicians and residents found the patient data particularly useful in that PDAs seemed to enhance clinicians' Knowledge about their patients (especially for nighttime coverage and for the care of patients with complex conditions at the beginning of a new rotation). PDAs provided easy access to accurate chronologic information about IV lines, antibiotic therapy, and helped house staff to rapidly retrieve and review patients' records when they were to be transferred out of the intensive care unit.

Uses for PDAs in Medical Education

PDAs are increasing in popularity among residency training programs. A recent survey of family medicine residency programs indicated that 67% of the programs use handheld computers as medication reference tools and for electronic textbook and calculator-type functions. (9) A summary of other uses related to medical education are listed in Table 3.

To ensure that students and residents get an appropriate and diverse clinical experience, it is important to collect data about their exposure to patients and specific medical conditions. In one study, 13 medical students recorded more than 4,000 patient contacts over 4 years using PDAs. Details of every encounter were recorded onto PDAs using a spreadsheet and were downloaded to a desktop computer every 2 months. Students found the recording to be fairly easy. The information collected from the handheld devices was subsequently used to improve the students' educational experience by identifying areas and topics in need of increased exposure and formal teaching. (10) Similarly, PDAs have been used to collect data about residents' experiences. Thirteen obstetrics and gynecology residents used handheld computers over a 6-month period. Residents carried PDAs and recorded all patient encounters, and the information was transferred to a central database for additional review and analysis. Residents could input patient data in less time than with conventional logs and were satisfied with the ability to easily access their patient encounters. The program director's administrative staff did not have to spend time reentering the data and were able to generate individualized reports instantaneously. (11) Such reports can be used to ensure adequate and comparable training for each resident and to allow for many other types of comparisons.

For Residency Review Committee requirements and hospital privileges, it is imperative to document residents' procedures. Twenty-six family medicine residents from the University of Washington's family medicine residency program collected procedure data on their PDAs over a 6-month period during obstetrics and gynecology rotations. Eighty-eight percent of residents collected the data using their PDA. They found the handheld computer to be a valuable tool to streamline the collection of procedural data and to assist the residency program in generating detailed reports of the residents' activity. (12) In an emergency medicine residency training program, a recent prospective study, with a retrospective cohort as a control, evaluated the documentation procedures of 12 residents using a handheld device. Mean procedure documentation was significantly increased in the PDA group for three procedures (thoracentesis, conscious sedation, and ultrasonography). (13)

The use of PDAs in an internal medicine residency program was evaluated by an 8-month cohort pilot study of nine internal medicine residents and one program director. (14) Internal medicine trainees found that the use of handheld computers was convenient for the retrieval of medical information and practice guidelines, as well as for the calculation of commonly needed formulae (such as total parenteral nutrition needs or measurement of creatinine clearance). They also found them useful for downloading call schedules and patient data. The majority of residents, however, reported access to online medical information was difficult due to cumbersome modem cords and slow modems. The program director appreciated being able to load teaching files for small group didactic sessions but noted similar barriers. (14)

Educators have also described PDAs as an enhancement to teaching. Preliminary data have shown that handheld computers can be used to prompt teachers' self-assessment about their own performance. In one study, (15) teachers were given PDAs with a list of the characteristics believed to be associated with effective clinical teaching. Teachers were then asked to record their impressions of their teaching interaction with learners on the PDAs. Subsequently, teachers compared their own assessment with the written evaluations of the learners. Physician-teachers reported that this experience promoted reflection about their effectiveness as educators. (15)

PDAs can be integrated into the process of learner evaluation. Handheld computers allow the recording of specific details about a trainee's performance in many settings, including clinical rotations and observed structured clinical evaluation (OSCE). Nine observers used PDAs to evaluate 98 medical students working through 13 stations. The evaluators reported increased speed of data gathering, and they liked the ability to generate immediate automated feedback via printouts of all incorrect or missed actions. (16)

Handheld devices have also been shown to improve students' evidence-based decision-making. (17) Five third-year medical students evaluated the use of PDAs during an ambulatory medicine rotation. The students were able to quickly access medical references about patient care problems. The most commonly reported frustration by the students, however, was that often the software used did not contain the answers to their specific questions or they could not find the relevant and appropriate medical reference. (17)

Using PDAs, medical learners can evaluate rotations on an ongoing basis and in real-time. In a family medicine clerkship, students were asked to use their handheld devices to evaluate the educational experience of the clerkship, including opinions about working with specific preceptors. (18) This led to the attainment of richer and more detailed feedback about strengths and weaknesses of the rotation.

Discussion

Although the technological development of PDAs is fairly recent, they have been shown to be a valuable resource for both practicing clinical medicine as well as for teaching and learning in medicine. As handheld computers become less expensive, easier to use, and capable of storing a greater amount of information, their diffusion will likely continue to spread in medicine. Physicians who are well versed and comfortable with current uses and applications of PDAs will be well positioned and ready to take advantage of new PDA resources as they become available.

Handheld computers can be particularly useful for medical decision-making. The ability to retrieve reliable and updated evidence-based information at the point of care should facilitate the evaluation and approach to many specific clinical situations. The ability to enter, store, and retrieve data "on the fly" makes handheld computers a valuable aid to the modern physician. Furthermore, the versatility of these devices and the ongoing development of specific medical software will likely make PDAs popular among physicians in various specialties involved in diverse types of work activity.

At present, several issues prevent medical professionals from relying on PDAs to the same extent as they do their stethoscopes. First, how efficiently PDAs can be integrated in the patient encounter is not known, nor is the effect that they have on the doctor-patient relationship. Second, more evidence is needed to substantiate the benefits of PDAs compared with more conventional technologies or other electronic devices. A limitation of this review and the current understanding of PDAs in medicine is that most of the studies conducted have been small studies with limited power. Third, although new wireless technologies are on the horizon, (19) the ability to connect to the Internet with the same speed and capabilities as a desktop computer appears to be several years away. This feature is important for physicians who access large online databases or web-based medical references. Fourth, security concerning the potential loss of the device and patient confidentiality can be a source of great concern among both physicians and patients.

Handheld computers are here to stay. While the potential applications for clinicians and educators are vast, users will likely choose to customize PDAs to meet their selected information needs and diverse job-related goals. As this portable technology rapidly develops, the ultimate challenge will be to understand how handheld computers can best be integrated with current information systems and into the busy lives of medical trainees and health care professionals.

The Fox said to the Little Prince, "Now here's my secret: It is only with the heart that one can see rightly."

--Antoine de Saint-Exupery, The Little Prince

Table 1. General uses of personal digital assistants for health
care professionals

Store reference material
Function as specialized calculators
Aid in the billing process
Control hospital inventory
Track and collect patient data
Perform organizational tasks and scheduling
Access the Internet
Provide patient education material
Read medical journals
Transmit electronic prescriptions
Voice recording

Table 2. Select specific clinical uses of personal digital
assistants

Record and track patient procedures
Manage and access patient data
Enter billing charges
Function as a clinical decision-making support tool
Calculate common clinical parameters (eg, body mass index)

Table 3. Select specific uses of personal digital assistants in
medical education

Document patient encounters and procedures done
Retrieve medical information (practice guidelines, educational
biomedical resources)
Check residents' call schedules and patient data
Prompt teachers' self-assessment about their own performance
Record students' evaluations
Store reference material

From the Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; and the Department of Medicine, The Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD. (Dr. Wright is an Arnold P. Gold Foundation Associate Professor of Medicine.)

Reprint requests to Scott M. Wright, MD, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224. Email: [e-mail]

Accepted June 19, 2002.

Copyright [c] 2003 by The Southern Medical Association

0038-4348/03/9610-0996

References

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6. Shiffman RN, Freudigman M, Brandt CA, et al. A guideline implementation system using handheld computers for office management of asthma: Effects on adherence and patient outcomes. Pediatrics 2000;105:767-773.

7. Ebell MH, Gaspar DL, Khurana S. Family physicians' preferences for computerized decision support hardware and software. J Fam Pract 1997;45:137-141.

8. Lapinsky SE, Weshler J, Mehta S, et al. Handheld computers in critical care. Crit Care 2001;5:227-231.

9. Criswell DF, Parchman ML. Handheld computer use in US family practice residency programs. J Am Med Inform Assoc 2002;9:80-86.

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11. Malan TK, Haffner WH, Armstrong AY. Handheld computer operating system program for collection of resident experience data. Obstet Gynecol 2000;96:792-794.

12. Garvin R, Otto F, McRae D. Using handheld computers to document family practice resident procedure experience. Fam Med 2000;32:115-118.

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15. Krippendorf RL, Simpson DE, Schiedermayer D. Promoting reflective teaching with personal digital assistants. Acad Med 1999;74:577.

16. Schmidts MB. OSCE logistics: Handheld computers replace checklists and provide automated feedback-objective structured clinical examination. Med Educ 2003;34:957-958.

17. Helwig AL, Flynn C. Using palmtop computers to improve students' evidence-based decision-making. Acad Med 1998;73:603-604.

18. Sullivan L, Halbach JL, Shu T. Using personal digital assistants in a family medicine clerkship. Acad Med 2001;76:534-535.

19. Bluetooth web site. Wireless technology page. Available at http://www.bluetooth.com/tech/works.asp. Accessed February 19, 2002.

RELATED ARTICLE: Key Points

* Handheld computers, also known as personal digital assistants (PDAs), perform a variety of tasks that are practical and helpful for physicians.

* Clinicians can use PDAs to access patient data, to enter billing charges, and to check guideline-based decision support tools.

* In medical education, PDAs have been most commonly used by trainees to log patient encounters and procedures and as a pocket-sized, evidence-based reference tool.

Dario M. Torre, MD, MPH, and Scott M. Wright, MD