Handheld Computing in Medicine What works today.


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  • This presentation will focus on actual uses of PDA in clinical situations. Everything shown is available right now, and works at this time.
  • Currently the trend is that Pocket PC operating system machines are increasing in market share, by 2005 they should have nearly half the projected market. However, the discussion between Palm and Pocket PC, like Macintosh vs. Windows, will not be held in this forum.
  • Nearly all medical students and Residents now carry some form of PDA, and these handhelds are entering the pockets of Attendings, Solo practitioners and physicians around the country at a great rate.
  • I will show you just a few of the various hardware pieces currently available, there are 29 licensed Pocket PC manufacturers and at least half a dozen for the Palm OS at this time.
  • The Palm m515 is a very standard machine, that along with most other Palm OS machines, has only a 160 x 160 pixel screen. Sony’s Palm offerings, however, do have a beautiful 320 x 480 pixel screen, though most Palm software is still formatted for the 160 x 160 screen. While nearly all Palm machines on sale are now color, the Palm Zire, just released this week, is a basic $99 black and white handheld with only 2 MB of memory. I doubt any physician would waste their money on this very limited machine.
  • The Toshiba and Razor shown here both work on the new 400 megahertz Xscale technology recently released. While this faster chip does not make a significant difference in running most programs that we use today, it will undoubtedly help in the near future as software is optimized for this new chip. The Toshiba also has integrated wireless built-in, useful if you have a wireless network already set up in your practice setting.
  • This iPaq has an add-on sleeve allowing in addition to the standard SD memory card, an additional Compact Flash memory card as well as a wireless card on top. While it is nice to have so much memory and power, this small brick does NOT fit easily into your pocket.
  • Many memory card options exist, with compact flash being the biggest but also cheapest. These cards are also used in many digital cameras, and you may be able to get away with using the same memory card in both your PDA and camera… and then easily swap back and forth.
  • These first-generation Phone/PDAs allow for convergence of two important pieces of hardware that we tend to carry. However, as the first generation, they still have kinks to work out, and if you lose this device, you would be without two critical devices, your phone AND your organizer. If not an absolute necessity, I would wait on purchasing such a combination device. The Toshiba and Treo are from Sprint PCS, the T-mobile PPC from, obviously, T-mobile (formerly Voicestream).
  • While some of the newest handhelds integrate wireless networking on-board, many machines require add-on wireless networking. 802.11b is a standard which is more useful for constant connectivity, such as for surfing the internet. It has longer range, and is found in many coffeehouses. Bluetooth devices work on a shorter range and automatically “recognize” each other when within range. This type of technology is more useful for such applications as printing from a handheld wirelessly to a bluetooth-enabled printer. Both standards have their appropriate uses.
  • While handwriting recognition on PDAs has come a long way, its still not perfect. To quickly add patient clinic notes and such, I use a keyboard with my PDA. Here are some interesting solutions. The keyboard in the top left is flexible and can roll up, and the one depicted on the right is a “virtual keyboard”. No extra hardware is required, only a flat surface in front of the PDA.
  • Some of the most common uses of PDAs today include those listed on this slide.
  • Here are some actual screen shots from software as it looks on the Pocket PC on the left, the Palm on the right.
  • Most reference texts contain numerous monographs, as the listing from the Washington Manual shows on the left. A selection from the 5 Minute Clinical Consult on Crohns Disease is shown on the left. As you can see, a drop-down menu allows you to pick out various aspects of the disease, including Basics, Diagnosis, Treatment, Medications, Follow-up and Misc. A nice feature of many of these books is they are hyperlinked. You can select, for example, an item from one text (e.g. from the 5MCC) and then select a search for that same work in, for example, the Drug Reference guide or other book you have installed on your PDA. This allows you to study a topic from various approaches at the simple tap of a stylus.
  • The most frequent use of PDAs in hospitals today is probably for the drug references. The most widely known of these is ePocrates, a free drug guide for Palm machines. Currently there are a number of commercial and free drug references available on the internet. These are popular because drugs are constantly being added to our therapeutic regimen, and it is impossible to know about each and every one unless you stopped practicing medicine and only read about drugs all day. One interesting thought is that when you update the free references, its probable that the company providing the update (such as ePocrates or PDR.net) downloads information from your handheld on which drugs you looked up and so on. I am not sure what the privacy implications of this two-way exchange of data comes down to, but there may be some questions on this asked by advocacy groups in the future.
  • Similar to the reference texts I showed earlier, here’s a screen shot from DrDrugs, a commerically available drug reference from Skyscape. As you can see, there’s an immense amount of information available at your fingertips. You can learn a lot about a drug from such a look-up, and may even learn pricing information which could be critical if your patient is uninsured or doesn’t have prescription drug coverage.
  • Another nice feature of several drug references, here is the new Tarascon Pharmacopea, is the ability to look up drug interactions. In this program, drug interaction information is in the form of monographs from The Medical Letter®.
  • Medical calculators are great for the reasons listed above. To have this ability in the same small pocket-sized device makes such a machine even more useful.
  • Formulary software allows one to know what drugs (and doses) may be available in certain insurance plans. They also allow for automatic, rapid transmission of a prescription to a pharmacy and saves on errors based on a doctors bad handwriting.
  • Here is a sample of how a prescription or clinical notes can be taken from a handheld, via a local server through a central server to a pharmacy or transcription company. It is a simple enough model, and actually works with existing technology and networks.
  • Billing and coding software can be implemented on a handheld. The major advantages include the ability to improve accuracy and compliance with ICD-9 regulations. Also, such software may help you bill-up by assuring you include sufficient data from history and exam at the point-of-care. Such software can allow for more rapid turn-around on billing when coding is done at the patient visit rather than later.
  • Further, future uses include the ability for patients to carry their own medical records on a secure memory card chip which they can hand to the doctor at the time of the visit. As long as they authorize it, the doctor then can view and add to that record in real-time, through the use of her handheld. As all physicians have some Continuing Medical Education requirements from their institutions, associations, etc., a handheld could be a very good medium for such education. For example, on my daily subway commute in New York city, I would pull out my Pocket PC and read the Prescriber’s letter (shown in the next slide) as well as the New York times and other items. Why not get credit for appropriate time spent? Its easy to envision you downloading a CME module of 20 - 30 minutes duration in the morning, getting through it some time during the day, taking a test on the handheld, sync your machine in the evening and receiving credit for that CME via e-mail later that night or the next day. Delivery of multimedia content to pocket pcs and palms is already available through services such as that provided by Mazingo.net.
  • Here are screen shots of my Mazingo.net account and how the Prescribers Letter looks on my handheld.
  • A screen shot of my Weather.com page from Mazingo. I can click on “video” and get full color, full screen video of my 5 day forecast and color doppler maps for my region, just like surfing on the internet, but here in the palm of my hand!
  • Some useful links. Infosync.no is a norwegian site (in English) for technology/gadget junkies who want to know the latest in handheld and cellular technology. MedicalPocketPC.com is the number one free resource on the internet for those interested in improving patient care through the use of handheld technology. Skyscape is a major developer of reference texts for Palm and Pocket PCs.
  • Thanks especially to my patients, who have had the patience to deal with me as I struggle with hardware and software in clinic to record their clinical data in my Pocket PC.
  • Handheld Computing in Medicine What works today.

    1. 1. Handheld Computing in Medicine What works today… Nilay Shah, MD American College of Surgeons 88th Annual Clinical Congress October 8, 2002
    2. 2. Worldwide Handheld Sales <ul><li>Nearly 10 million PDAs sold in the last year </li></ul><ul><li>Palm OS - 50% </li></ul><ul><li>Pocket PC - 28% </li></ul><ul><li>Other (proprietary OS) - 20% </li></ul>Source: Dataquest, a member of The Gartner Group, July 2002
    3. 3. Medical Use of PDAs <ul><li>Presence in healthcare on a steep rise </li></ul><ul><li>Current major uses include: </li></ul><ul><ul><li>Peripheral brain </li></ul></ul><ul><ul><li>Patient tracking </li></ul></ul><ul><ul><li>Reduce pharmacy errors </li></ul></ul>
    4. 4. Hardware <ul><li>Palm and Pocket PC Handhelds </li></ul><ul><li>Add-on Memory Cards </li></ul><ul><li>Integrated phones </li></ul><ul><li>Wireless add-ons </li></ul><ul><li>Keyboards </li></ul>
    5. 5. Some Palm OS Machines Acer s60 Sony NX70v Palm m515
    6. 6. Some Pocket PC OS Machines Viewsonic v35 Toshiba e740 Razor Zayo a600
    7. 7. Pocket PC OS Machines Compaq iPaq
    8. 8. Flash Memory Cards Memory Type Size (mm) Price/MB Compact Flash 43 x 36 x 5 $0.43 Memory Stick 21 x 50 x 3 $0.53 Secure Digital 23 x 33 x 2 $0.84 MMC 23 x 33 x 1.5 $0.73 Source: PC World Magazine, May 2002
    9. 9. Phone/PDA Devices Toshiba 2032 Treo 300 T-Mobile PPC
    10. 10. Wireless Networking <ul><li>802.11b - aka Wi-Fi </li></ul><ul><li>“ always-on” connectivity </li></ul><ul><li>Longer range </li></ul><ul><li>Starbucks, etc. </li></ul><ul><li>Bluetooth </li></ul><ul><li>Device-to-device </li></ul><ul><li>Shorter range </li></ul><ul><li>“ secure” </li></ul>
    11. 11. Keyboards
    12. 12. Software <ul><li>Peripheral Brain - i.e. Reference Software </li></ul><ul><ul><li>Text books </li></ul></ul><ul><ul><li>Drug References </li></ul></ul><ul><ul><li>Medical Calculators </li></ul></ul><ul><li>Patient Tracking </li></ul><ul><li>Pharmacy/Formulary Software </li></ul>
    13. 13. Reference Texts
    14. 14. Reference Texts
    15. 15. Drug Reference Software <ul><li>Extremely popular use of handhelds </li></ul><ul><ul><li>E.g. ePocrates, PDR, A2Zdrugs </li></ul></ul><ul><li>Need frequent updating </li></ul><ul><li>?Tracking of our use by Pharma </li></ul>
    16. 16. Drug Reference Software
    17. 17. Drug Reference Software
    18. 18. Medical Calculators <ul><li>Allow more accurate dosing based on disease </li></ul><ul><li>Diagnostic Aid (e.g. Fractional excretion of Na+ for acute renal failure) </li></ul><ul><li>Risk stratification </li></ul><ul><li>(e.g. Ranson’s Criteria) </li></ul>
    19. 19. Formulary Software <ul><li>Reduce errors </li></ul><ul><li>What’s on insurance formulary </li></ul><ul><li>Saves time </li></ul><ul><li>Drug history tracking </li></ul>
    20. 20. Formulary Software
    21. 21. ICD-9 Coding Software
    22. 22. Further Uses <ul><li>Integrated medical systems (cross platform) </li></ul><ul><li>Continuing Medical Education </li></ul>
    23. 23. Miscellaneous Software
    24. 24. Miscellaneous Software
    25. 25. Useful Links <ul><li>www.pocketpc.com </li></ul><ul><li>www.palm.com </li></ul><ul><li>www.infosync.no </li></ul><ul><li>www.medicalpocketpc.com </li></ul><ul><li>www.skyscape.com </li></ul>
    26. 26. Thanks to… <ul><li>American College of Surgeons </li></ul><ul><li>Palm & Microsoft </li></ul><ul><li>Margi Systems </li></ul><ul><li>Countless developers </li></ul><ul><li>Dr. Muhammad Khan </li></ul><ul><li>My patients </li></ul>