Utility of Palmtop Computers in a Residency Program: A Pilot Study.

ABSTRACT

Background. With advancing technology and flourishing medical information on the Internet, we studied the use of palmtop (handheld) computers by internal medicine residents.

Methods. At a university-community hospital consortium, nine internal medicine residents and their program director participated in an 8-month cohort pilot study using palmtop computers with desktop synchronization and Internet access capabilities.

Results. After 2 months of use, the residents had found a variety of uses for palmtop computers, such as the calendar, downloading residency-provided medical information, taking lecture notes, using a spreadsheet for common formulas, Internet/MEDLINE searching with modem access, infrared file transfer, downloading call schedules, and patient tracking. At 8 months, the residents were comfortable using palmtops on a daily basis. Technical difficulties included cumbersome modem cords, incompatible platforms and difficult Internet access at times, finding analog telephone lines in the hospital, and synchronization with home computers.

Conclusion. Palmtop computers are useful in the residency setting, and residents are capable of devising ways to use palmtops to suit their individual needs.

THE ACCREDITATION COUNCIL for Graduate Medical Education requires residency programs to provide instruction in basic computer skills, and specifies that "instruction should include an introduction to computer capabilities and medical applications, basic techniques for electronic retrieval of medical literature, computer-assisted medical instruction, and electronic information networks." (1) Although palmtop (handheld) computing devices have been introduced into several residency programs, (2) literature is sparse on their utilization and effectiveness.

In 1999, the internal medicine residency program at the University of Kansas School of Medicine in Wichita embarked on a pilot project to incorporate palmtop computers into the daily patient care and educational activities of the residents. The objectives of this article are to describe (1) the pilot project and its implementation, (2) the utilization of the palmtop computers by the residents, (3) technical difficulties encountered, and (4) intended future development of the project.

MATERIAL AND METHODS

The internal medicine residency program at the University of Kansas School of Medicine in Wichita is a university-community hospital consortium with a total complement of 40 categorical, preliminary, and medicine-pediatric residency positions. In April 1998, the internal medicine department convened a meeting to discuss the optimal use of funds received from an endowment for informatics enrichment. The committee was composed of an informatics faculty member, two residents, the department chair, the program director, the program administrator, and three technical support personnel. The committee created a list of desirable resident capabilities that could be aided by obtaining palmtop computers, including Internet access to medical guidelines, MEDLINE, and journals; access to electronic mail (e-mail) from the residency office; formula calculations; calendar functions; procedure tracking; electronic forms submission (eg, vacation requests) to the residency office; and storage of medical texts.

The committee determined that the Hewlitt Packard 600 series palmtop with a Windows CE platform and a fax/modem card best matched the projected needs of the residents and the residency office while maintaining affordability (around $750). The committee decided to conduct a several-month pilot study involving nine residents plus the program director to determine the future use of palmtop computers in the residency program. Since the purpose of the project was to explore the potential uses of palmtop computers during residency, we set out to recruit residents who were computer-literate. Residents who had a home personal computer (to facilitate the synchronization function of the palmtops) and agreed to pay a monthly fee (which could be taken from the resident's educational account) for the school's dial-in Internet service were eligible to volunteer for the program.

Volunteers were solicited through a residency memorandum. Eleven residents volunteered, and all met the eligibility criteria. The first nine volunteers were selected. The 10 palmtop computers were distributed to the program director and the nine residents in November 1998. Our technical support personnel coached the residents in the proper use of the device and synchronization with their home computer.

The residency office provided resident and medical information in a format (hypertext mark-up language) that could be downloaded from the department's Web site to the new palmtops. This information included conference and meeting schedules, hospital and resident call schedules, clinic assignments, residency forms, and educational tools. This information was updated monthly. The educational tools included links to online texts and journals provided free of charge by our school library system (eg, Cochrane Library, Harrison Harrison's Textbook of Medicine, MD Consult), PubMed, and a compilation of medical tables used in our internship preparation curriculum.

Two months after the residents received palmtops, we met with them as a group to record their experiences. In a roundtable discussion, the residents described the variety of ways they found to utilize the palmtops. These responses were collated into common themes.

After 8 months, we surveyed the participants to determine if they continued to use the palmtops and to discover if they had any further technical difficulties or needs.

RESULTS

2-Month Follow-up

In January 1999, residents participating in the pilot study gathered for an in-depth, focus-group analysis of the anticipated and unanticipated use of the palmtops, difficulties they encountered, and future directions of the project. One resident was unable to be in attendance.

Table 1 provides a summary of the comments obtained during this session. Six of the residents found that it was convenient to use the calendar function for their personal calendar, including their call schedule. Four downloaded the residency schedule, as well as the tables of medical information we provided from our Web page. Since the palmtop we selected came with a spreadsheet program, three residents had begun to develop spreadsheets to calculate commonly encountered formulas, such as those for total parenteral nutrition needs and creatinine clearance. The other residents were excited by this use and asked to receive the spreadsheets at the end of the meeting. The program director had also been using the spreadsheet function to calculate posttest probabilities for diseases based on the likelihood ratios for common tests. Although three residents said that they routinely used their palmtop to search the Internet, the group complained that the modem cords were too cumbersome to carry every day. One resident ruined her modem in the hospital during the first week of use by using a digital rather than an analog telephone line. Several residents mentioned they encountered difficulty synchronizing with their home computer but that the technical support personnel helped to resolve the problems.

The limited capabilities of the browser on the palmtop operating system led to problems accessing some Web sites, particularly the school's Web mail system and certain online journals. Also, the residents had difficulty accessing Internet medical information for immediate use in patient care because of difficulty locating compatible telephone lines, slow modem and browser time, and encumbrance accessing medical information quickly. One Web site the residents found particularly helpful was MD Consult. (3)

During the next few months, two residents returned their palmtop computers. These two residents were interviewed about their experiences. The first returned the computer when transferring to a different residency program. She liked being able to take and store notes on the palmtop. She also used the calendar function regularly. She had never attempted to connect to the Internet via the modem and was unable to comment on this function.

The second resident returned the computer because she had encountered several difficulties that made its use discouraging. She had been using the calendar function regularly. However, she had failed to continue synchronizing the palmtop with her desktop computer. When she lost her calendar information after a operating system failure, she believed the amount of time it would take to reload the information would be too great. She also found that carrying the palmtop in her laboratory coat caused neck aches because of its weight. Additionally, she had left it behind when leaving an area several times and was concerned that she would lose it. On a positive note, she found its Internet connectivity easy to use and was able to find the medical information she desired.

8-Month Follow-up

In July 1999, the residency office sent a questionnaire to the remaining study group of seven residents. The seven who responded all used their palmtop in patient care on a daily basis (Table 2). The residents had a high degree of comfort using their palmtops to keep a daily calendar, to connect to the Internet, and to find medical information and practice guidelines. Four of seven respondents continued to have difficulty using palmtops to access the Internet at one of the area hospitals. Residents stated that they needed improved access to analog telephone lines in the call rooms, medical texts for the Windows CE format, and additional training in using the devices.

The program director's experiences were not dissimilar to those of the residents. Additionally, the program director loaded teaching files for use in small group didactic sessions, such as teaching rounds and pre-clinic conferences. He found demonstrating MEDLINE searching during management rounds to be difficult because of the time required to locate a compatible telephone jack, to connect to the Internet, and to await Web pages to be downloaded on the browser.

DISCUSSION

Our pilot study demonstrated the power of providing residents with a highly usable and versatile "blank slate." The palmtop devices we purchased were not specifically designed for the medical environment and initially contained no medical software programs. Yet, because of the burgeoning amount of information and programming obtainable through the Internet, our residents were able to develop a tool utilized as often as their stethoscopes. Although the pilot study was not controlled, it would be difficult to envision a study design that would capture the range of possible uses residents would discover.

Fishman et al (4,5) reported their experience with residents using early palmtop devices to store and access medical information while on the hospital wards in 1992. The original devices had a limited memory (up to 1 MB of random access memory and up to 4 MB of read-only memory). Some had spreadsheet capabilities and optional modems. At that time, Franklin Electronic Publishers (Burlington, NJ) began to provide cartridges containing medical texts (including the Physician's Desk Reference annotated version, The Medical Letter Handbook of Adverse Drug Interactions, The Washington Manual of Medical Therapeutics, and Harrison s Principles of Internal Medicine: Companion Handbook) that could be plugged in to a palmtop device. (6)

With the advent of a user-friendly Internet and the proliferation of medical database search engines (eg, PubMed, Cochrane Library), as well as the availability of expanded computer memory, residents and physicians are learning to access and retrieve dozens of megabytes of information from palm tops. The diversity of information available on the Internet, from practice guidelines provided by the Agency for Health Care Policy and Research and related organizations to the numbers-needed-to-treat for various therapies found on evidence-based medicine, Web sites, leaves today's palmtop users able to meet their individual practice and learning needs.

We were pleased to learn of the variety of information that our residents had been able to retrieve, carry, and use in clinical settings. They also began to collaborate and share information, exponentially expanding their individual discoveries. One of the requests that residents have continued to make is assistance in finding medical textbooks that can be downloaded to their palmtops. Handheldmed (7) has developed a text reader for the palmtop computers and has a variety of medical titles already available to download, including The Merck Manual, Centennial Edition, and Fauci: Harrison 's Principles of Internal Medicine 14e Companion Handbook. Franklin Electronic Publishers has recently announced a venture to begin distributing medical textbooks in the Palm OS and Windows CE formats. (8)

Our pilot study was limited by the number of participants. However, we intended to explore the possible uses that would be generated by residents, and this goal was reached. Also, by enlisting volunteers to receive a palmtop computer rather than assigning residents to receive them, those with previous knowledge and interest in computers might have been self-selected. In fact, our desire was to maximize use in this relatively expensive venture, and we foresaw a need to limit the study group to only those owning a desktop computer. We may have had different results if we had begun with computer novices. Finally, although we found our residents to be using the palmtops frequently in their daily work, technical difficulties such as those we encountered (ie, the ruined modem, technology support time) can be expensive when there are few resources at an institution to deal with them.

CONCLUSION

Our pilot study demonstrated that not only are today's palmtop computers useful in the residency setting, but also residents are capable of devising new tools for the palmtops to meet their individual needs. As further digital wireless technology develops, palmtop devices will more likely become nodes of information access rather than information databases. Rather than increased memory, the future palmtop device will focus on speed of connection and retrieval. This will only increase the physician's ability to obtain updated information for "real-time" use in patient care. With such a future, it becomes imperative that medical education programs invest in technology that will train physicians in this arena.

From the Department of Internal Medicine, University of Missouri in Kansas City.

This study was funded through a private, anonymous educational grant.

Reprint requests to Brent w. Beasley, MD, St. Luke's Hospital, Department of Medical Education, 4401 wornall Rd, Kansas City, MO 64111.

References

(1.) Program Requirements for Residency Education in Internal Medicine. Graduate Medical Education Directory. Chicago, Ill, American Medical Association, 1995

(2.) Jerant AF: Training residents in medical informatics. fam Med 1999; 31:465-472

(3.) MD Consult (Web site). St. Louis, Mo, Harcourt General Inc. Available at http://www.mdconsult.com/about/contact.html

(4.) Fishman SM: Palmtop computers on the medical wards. JAMA/Pulse 1992; 267:169

(5.) Fishman SM, Prince JB, Herman JB, et al: Pocket-sized electronic clinical referencing. MD Computing 1996; 13:310-313

(6.) Ruehlman PG: Portable information: digital book system. JAMA 1993; 270:1990-1991

(7.) Hand Medical merges with Handheldmed, the leading resource for medical handheld computing (Press release. Oklahoma City, Okla, Handheldmed LLC, June 7, 2000

(8.) Franklin and the American Society of Health-System Pharmacists agree to adapt key medical references for Palm, Windows CE, and Psion handhelds. (Press Release) Orlando, Fla, Franklin Electronic Publishers, December 6, 1999

TABLE 1

Summary of 2-Month Follow-up With Pilot Study Group (n = 9)

        Item                             No. Residents Mentioning
                                         During Evaluation Session

Palmtop Capabilities and Uses

 Calendar                                            6
 Downloading residency-provided medical              4
 information
 Taking notes in lectures                            3
 Spreadsheet used for common formulas                3
 Address book                                        3
 Internet/MEDLINE searching with modem               3
 access
 Infrared transfer of files to other                 2
 residents
 Synchronization with home computer to               2
 download Internet files/articles
 Pocket Quicken program used to track                2
 moonlighting budget
 Facsimile transmission                              1
 Infrared printing on hospital printer               1
 Downloading call schedules from Web                 1
 Patient tracking                                    1
 Self-memoranda using voice recorder                 1

Palmtop Difficulties

 Modem cords are cumbersome                          -
 Platforms for online journals and Web               -
 mail systems often not compatible
 Inconvenient to access Internet                     -
 Finding out if telephone lines are                  -
 analog
 Synchronizing with home computer                    -
Table 2

Results of 8-Month Follow-up Survey of Pilot Study (Group (n = 7)

Questionnaire Item                                Response

How often in last week palmtop
was used in patient care                          Daily
Level of comfort (*):
  Calendar function                               4.6 (0.9)
  Connecting to Internet                          3.8 (1.6)
  Finding medical information                     4.0 (0.9)
  Finding practice guidelines                     4.0 (1.1)
No. (%) of users having difficulty using palmtop  4 (57)
 to access Internet at hospital
Further Needs (Written Comments)
Access to analog lines in call rooms              --
Medical text for palmtops                         --
More training on maximizing use                   --

(*)Mean comfort level on grounded Likert scale (SD); 1 = extremely
uncomfortable, 5 = extremely comfortable.

RELATED ARTICLE: KEY POINTS

* Residents found palmtop computers useful in their daily clinical work.

* Residents were able to devise their own clinical tools using the software that was available on the palmtop computers.

* Residents found that quick access of online materials for patient care was cumbersome with palmtop modems.

* Residents downloaded and used schedules and medical information provided by the residency website to their palmtop computers.