Personal digital assistant use in Florida obstetrics and gynecology residency programs.
Methods: The authors conducted a statewide survey addressing the general question: is the PDA useful in an obstetrics and gynecology residency training program? Specifically, the authors asked residents how much time was perceived to be saved weekly with the use of this tool, and in what aspect of their training use of this tool was most helpful.
Results: At the survey's close, five of seven programs had returned the survey for evaluation. These five institutions included both university- and community-based residency programs. Forty percent of obstetrics and gynecology residents at these programs responded to this questionnaire. Resident responses to the survey revealed that most of the perceived benefit was in maintaining procedural statistics logs, pharmacology reference manuals, and personal clinical protocols. Most responses revealed that only minimal time savings (<2 h/wk) were gained with using this tool. However, many residents felt they were not using this tool to its maximum potential. Nearly 90% of those who responded felt that the PDA should be available at residency programs and anticipated using it after completing residency.
Conclusions: This study posed the question of PDA usefulness at obstetric and gynecology residency programs in the state of Florida. Although not all programs provided their residents with a PDA, 95% of the respondents revealed that they owned one of these tools. Experience at the authors' institution revealed high expectations for the potential uses of a PDA. Although many residents were not using this tool to its full potential, a PDA tutorial session could educate residents on the many applications available for PDAs, including applications to maintain on-call schedules and sign-out lists, statistics and procedure logs for credentialing and board certification, electronic billing, and electronic prescriptions.
Key Words: obstetrics and gynecology, personal digital assistant, residency training
Clinical medicine in the 21st century demands that the physician become more efficient yet maintain thoroughness. One approach to meeting these demands is better use of available technologies. Although the computer revolution continues to impact all professions, the medical profession remains reactive rather than proactive. For example, only 1 to 2% of a typical health care operating budget is spent on information technology, as opposed to 4 to 10% in other industries. (1) Trends in medical applications that have only slowly elicited a reaction include electronic medical records and the paperless office. Other industries, such as banking and the service sectors, have welcomed this revolution.
The most recent addition to this arena is the personal digital assistant (PDA), also known as a handheld computer. The advantages of a PDA include mobility and instant availability of data. (2) Physicians need a mobile instrument that can provide access to evidence-based medicine and other clinical data resources at the point of care. (3) Malan et al (4) found handheld computers increasingly useful in the daily practice of clinical and academic medicine. However, a 2002 survey reveals that only 28% of Canadian physicians are currently using the PDA in clinical practice. (5)
Our institutional experience (6) gave us mixed findings as to the residents' satisfaction in using these PDAs. This article samples a larger population representing both university- and community-based residency programs in the state of Florida, and specifically addresses whether a PDA is helpful in an obstetrics and gynecology residency training program.
Materials and Methods
In Florida, there are four university-based obstetrics and gynecology residency programs (located in Gainesville, Jacksonville, Miami, and Tampa) and three community-based residency programs (located in Orlando, Pensacola, and St. Petersburg). A survey (Fig. 1) was sent to the chairs of each of the Florida obstetrics and gynecology residency programs, and their assistance in disseminating the surveys to their residents was requested. On completion of the surveys, all responses were to be returned to the program coordinator at the University of Florida Health Science Center, Jacksonville. All queries maintained residents' anonymity, with the only identifying questions asking for residency institution and postgraduate year (PGY) level. Statistical analysis was performed using StatView for Windows (SAS Institute Inc., Cary, NC). A Student t test was used to compare dichotomous variables.
The survey included several quantitative components (Fig. 1), combined to assign a daily value to having a PDA. These measures included resident perception of usefulness of the PDA for clinical practice protocols, sign-out sheets while on call, drug reference manuals, personal organizer, procedure log, and so forth. A numeric score ranging from 1 (PDA not useful at all) to 5 (very useful) was then assigned to resident responses. If no response was given, a score of 0 was assigned. The respondent's score could thus range from 0 to 50. The mean for each PGY level was compared. Additional evaluation included comparing university- to community-based residency programs.
[FIGURE 1 OMITTED]
Additional questions included whether residents would recommend PDA use at other residency programs, and whether respondents anticipated using PDAs on completion of residency (ie, in private practice or fellowship). A final evaluation was of the time respondents perceived they saved weekly by using the PDA: less than 2 hours, 2 to 5 hours, 5 to 9 hours, or greater than 9 hours.
Five of the seven obstetrics and gynecology residency programs that received the survey had returned it at the time of our study's close. Although there are 140 obstetrics and gynecology residents in Florida programs, nearly 70% are at university-based programs. There were 54 responses (16 of 40 from community programs and 38 of 100 from university programs), for a nearly 40% response rate. Of those institutions that returned the surveys, the response rate varied from 25 to 92% of residents at each institution. The percentage of nonresponders was nearly equal.
When comparing the mean response score for each PGY level, the only statistically significant result was for the PGY-1 class compared with the PGY-3 class (mean difference = -7.09, t value = -2.59, P = 0.03). When comparing other PGY levels (PGY-1 versus PGY-2, PGY-1 versus PGY-4. etc.), none of the mean differences were statistically significant. Table 1 lists the mean score and standard error for each PGY level.
When comparing a summation of the resident scores at university-based programs to those at community-based programs, a statistically significant difference favoring community-based programs was noted (mean difference = 4.75, t value = 2.22, P = 0.04). Table 1 lists the mean score and standard error for community- versus university-based programs. However, when comparing each residency program to the other programs individually, no statistically significant differences were noted.
Sixty percent of respondents had used their PDA for more than 12 months, 12% for 6 to 12 months, and 28% for less than 2 months. With regard to time saved by using this tool, in 64% of responses, the residents felt that less than 2 hours were being saved by having the PDA. In an additional 32% of responses, the residents felt they saved or could save 2 to 5 hours weekly. The remaining 4% felt that they could save more than 5 hours a week using the PDA.
Comments from residents as to their satisfaction with the PDA related to maintaining on-call schedules and pharmacologic reference manuals, keeping procedural statistics, decreasing the number of books kept in the laboratory coat, and improving organization with to-do and contact lists. Complaints from respondents included difficulty using the PDA, difficulty transcribing data into the PDA, and insufficient time to learn software applications.
Our institutional experience (6) has shown that resident expectations are high when PDAs are made available. However, residency requirements for obstetrics and gynecology are very time intensive, and the necessary investment of time makes learning how to use a new tool a daunting task for the resident, especially in a voluntary setting. As a result, the introduction of new technologies can be associated with a degree of resistance. (7) Therefore, resident comments such as "have not used the PDA in 4 months" and "not taken the time to learn how to use it but plan to learn" are not surprising.
One of the limitations of this study is selection bias. We limited our survey to obstetrics and gynecology residents within Florida programs. In addition, we relied on program directors and their staff to distribute and collect the survey. We suspect that this method of survey dissemination contributed to our nonresponder bias. In nearly 95% of responses, the respondents stated they owned or had access to a PDA. We suspect that our findings might have been different had all residents responded. Those residents who either did not own a PDA or had a negative opinion of the PDA may not have taken the time to complete the survey.
In addition, in an effort to maintain anonymity, identifiers of gender, race, and age were omitted from the survey. We recognize that these identifiers are independent variables that may have helped in distinguishing nonresponders from responders, but maintaining simplicity was a key component of this survey. Furthermore, regarding accessibility to software applications, we did not explicitly ask, but relied on respondents to provide such information.
We do not suspect a bias in our comparison of university- to community-based training programs; however, statistically, there was a greater perceived usefulness at community programs. Of the two programs for which survey responses were not available, one program was university-based and the other community-based. Therefore, there was a balance of responding programs, and the number of responses from community programs was 16 (40% of all potential responses) compared with 38 (38% of all potential responses) at the university programs.
The generalizability of our findings must be confirmed with larger studies, due to the limited number of residents that were evaluated in this survey. One hundred forty obstetrics and gynecology residents were available to asses the experience of using a PDA within Florida residency programs. We could increase the sample size by obtaining a higher response rate from the current programs or sampling additional programs throughout the country. An increase in the sample size could impact the initial findings of our study.
The 2002 Canadian Medical Association Physician Resource Questionnaire revealed that there has been a 47% increase in PDA use since 2001. (5) This increased PDA use by clinicians complements our finding in that nearly 90% of our responders recommended the PDA to other residency programs and for use after residency. This can be interpreted as indicating that residents recognize the potential value of this tool and continue to anticipate time-saving rewards in the future.
Our survey has demonstrated that just providing the tools is inadequate. Given the demands of residency training, an additional tool can be considered an extra burden to the resident. Although most residents feel that this tool will be useful in their future, the initial time necessary to learn the PDA alphabetic character recognition system and additional applications is a drawback. Only those who are motivated or interested in this new technology will use these tools unless there are imposed requirements from the department or national accreditation committees. Constant technical support and problem solving will be necessary to optimize user acceptance. (7)
There are immediate and future rewards to the obstetrics and gynecology resident who becomes proficient with these technologically advanced tools. For example, resident procedure tracking is an onerous task required for residency accreditation and for future hospital privilege applications by the resident. With the PDA and a patient-data tracking application, not only can residents have access to their procedural statistics, they can also use them for the case list submitted for the oral examination for licensure. Furthermore, it is now possible to achieve wireless entry and retrieval of data using a PDA, with potential advantages being the collection and entry of data at the same time, easy entry of data from multiple sites, and retrieval of data at the patient's bedside. (8)
In future practice, the obstetrics and gynecology resident could do billing on the PDA using a data capture program, whereby the billing would be more accurate, and there would be no hard copy to misplace, forget, or have incorrectly prepared by billing personnel. Some charge-capture programs automatically generate codes based on Medicare guidelines, and the clinician can earn an extra 5% per year while seeing the same number of patients. (8) In addition, in today's highly litigious environment, with national attention focused on medical errors, complications, and deaths, the objective measure of a physician's skills will become important in licensing, hiring, privileging, and promotion processes. (9) Using an electronic prescribing application has the potential to improve work flow, reduce prescription fraud, provide formulary and copay information, and reduce medication errors. (10, 11) Prescriptions can be electronically transmitted to the pharmacy by means of fax or a hard copy provided to the patient.
In the near future, many doctors will find their PDA to be an essential medical instrument, as indispensable as their stethoscope. (3) We suggest implementing information technology tutorial sessions into the didactic sessions for all residency programs. Our institution incorporated a PDA tutorial, and found residents receptive to this educational program. This tutorial not only introduced, but also encouraged the use of clinical applications for the PDA. Consequently, we anticipate that providing both opportunity and education will motivate residents to integrate the infinite computer resources available through the World Wide Web and the mobility of the PDA into their clinical practice.
Table 1. Resident survey response scores at different intervals (a,b) PDA usefulness No. of score respondents All PGY-1 31.7 [+ or -] 2.04 11 All PGY-2 31.9 [+ or -] 2.38 14 All PGY-3 38.5 [+ or -] 1.93 16 All PGY-4 33.4 [+ or -] 2.52 13 University-based programs 33.7 [+ or -] 1.39 38 Community-based programs 35.3 [+ or -] 2.11 16 (a) PDA, personal digital assistant; PGY, postgraduate year resident. (b) Score reported as mean [+ or -] standard error. Score: minimum = 0, maximum = 50. Two respondents, who did not own a PDA, did not provide a usefulness score.
Accepted December 8, 2003.
Copyright [c] 2004 by The Southern Medical Association
1. Peters S. "Paperless" offices assist compliance, efficiency. Obstet Gynecol News Feb 1, 2002:33.
2. Fowler DL, Hogle NJ, Martini F, Roh MS. The use of a personal digital assistant for wireless entry of data into a database via the internet. Surg Endosc 2002;16:221-223.
3. Wilcox RA, La Tella RR. The personal digital assistant, a new medical instrument for the exchange of clinical information at the point of care. Med J Aust 2001;175:659-662.
4. Malan TK. Haffner WHJ, Armstrong AY, Satin AJ. Hand-held computer operating system program for collection of resident experience data. Obstet Gynecol 2000;96:792-794.
5. Martin S. MD's computer, PDA use on the upswing. CMAJ 2002;167:794.
6. Joy S, Benrubi G. The personal digital assistant in an obstetrics and gynecology residency program. Prim Care Update Obstet Gynecol 2002;9:238-242.
7. Fischer S, Lapinsky SE, Weshler J, et al. Surgical procedure logging with use of a hand-held computer. Can J Surg 2002;45:345-350.
8. Terry K. How the device in your hand can put more money in your pocket. Med Econom 2002;78:34-41.
9. Bird SB, Zarum RS, Renzi FP. Emergency medicine resident patient pare documentation using a hand-held computerized device. Acad Emerg Med 2001;8:1200-1203.
10. McNamara D. Handheld electronic prescribing can save time, reduce errors. Obstet Gynecol News Feb 1, 2002:33.
11. Grasso BC, Genest R, Yung K, Arnold C. Reducing errors in discharge medication lists by using personal digital assistants. Psychiatr Serv 2002;53:1325-1326.
RELATED ARTICLE: Key Points
* Many residents felt they were not using the personal digital assistant (PDA) to its maximum potential.
* Nearly 90% of those who responded felt that the PDA should be available at residency programs.
* Nearly 90% anticipated using the PDA after completing residency.
Saju Joy, MD, and Guy Benrubi, MD
From the Department of Obstetrics and Gynecology, University of Florida Health Science Center Jacksonville, Jacksonville, FL.
Reprint requests to Saju Joy, MD, Department Obstetrics and Gynecology, 561 Means Hall, 1654 Upham Drive, Columbus, OH 43210. Email: email@example.com