- Email: [email protected]
The role of the personal digital assistant (PDA) in chiropractic practice
Clinical Chiropractic (2006) 9, 119—128
intl.elsevierhealth.com/journals/clch
SYSTEMATIC REVIEW
The role of the personal digital assistant (PDA) in chiropractic practice Rosie Kitchiner * Private Practice, 19 Whetstone Close, Milton Keynes, Heelands, Buckinghamshire MK13 7PP, UK Received 17 July 2005; received in revised form 12 April 2006; accepted 26 April 2006
KEYWORDS Chiropractic; Information technology; Personal digital assistant; PDA
Summary This is a review of the research into various uses and acceptance of personal digital assistants (PDAs) in the health industry. As technology becomes more powerful and intuitive to use, the speed of uptake in hospitals and clinics by clinicians, nurses and many varied health practitioner roles will, no doubt, increase. Over 200 applications in the medical field are currently available. It is an area that can no longer be ignored. This article attempts to throw some light on how PDAs are being used today and how chiropractors in the UK can jump on the bandwagon without too much pain! A number of patterns are described for putting a PDA to use in the chiropractic clinic, each of which may be undertaken individually, to gradually allow users to become confident in their use. # 2006 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction The term personal digital assistant (PDA) is used in this paper to describe a variety of handheld devices, all of which have the following characteristics. PDA is a term for any small mobile hand-held device that provides computing and information storage and retrieval capabilities for personal or business use. PDAs are always battery powered, with most incorporating rechargeable batteries. Unlike laptops, which typically have a maximum useful battery life of a few hours, the low power needs of PDAs mean that they can be used throughout an entire day without recharging. The device is * Tel.: +44 7812124076; fax: +44 1908311918. E-mail address: [email protected].
usually of a size that can easily be held in one hand, with a small screen, usually no more than 4-in, with resolution up to 320 480 pixels. A typical PDA is shown in Fig. 1. PDAs come with applications and data stored in a combination of ROM and RAM memory, such that the programs are immediately available for use once the PDA is switched on. Fig. 2 shows an example of the eMedicine library application. Typical built-in memory capacities are 64—128 Mbytes. Memory can be further increased through the use of a variety of add-on hardware such as SD (Secure Digital), CF (Compact Flash) or MS (Memory Stick) memory cards, which are now available with capacities up to 4 Gbytes, which provides space for high-quality graphics display. Fig. 3 shows an example of a detailed diagram of a skull being displayed on a PDA.
1479-2354/$32.00 # 2006 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2006.04.003
120
R. Kitchiner
Figure 1
Typical PDA in use. Figure 3
Figure 2
PDA showing example library application.
PDA showing graphical display of skull.
The vast majority of PDAs utilise either the Palm1 operating system or Windows1 Pocket PC. In both cases, pre-loaded software includes at least a name and address database, to-do list and note taker, with the ability to add further applications via synchronisation with a desktop PC. PDAs are pen based and use a stylus to tap selections on menus and to enter printed characters. The unit may also include a small on-screen keyboard, which is tapped with the pen. In some devices, an external wireless keyboard may be used. PDAs are usually synchronised with desktop computers to ensure data archiving should the PDA lose power or otherwise fail. They may also be combined with cell phones and other wireless technologies such as WiFi or Bluetooth to provide access to other computers and the Internet. One of the main problems with adopting new technology is ‘‘where to start?’’ With more than 200 applications to choose from, this is fast become a mature technology and evermore confusing for those putting off that day when they take the plunge! This paper reviews how other health care professionals have started to utilise personal digital assistants (PDAs) in their practice or in a hospital environment. The paper goes on to introduce the concept of patterns to document the discrete usage
Role of the personal digital assistant of common functions and their transposition to the PDA. PDA functionality is broken down into these discrete patterns, which can be adopted independently to gradually gain expertise in the use of a PDA without compromising the efficiency of the clinic.
Summary of the literature A survey by PriceWaterhouseCoopers during 2001, on information technology in medical practices, found that 60% of responders said their physicians used PDAs compared with 26% in an earlier survey of 2000. Five categories of healthcare software were identified: reference/text book; calculator; patient management/log book; personal clinical/study notebook and utility software.1 There have been a number of published articles evaluating the use of PDAs in the medical arena since their mainstream launch, starting with the PalmPilot1 in 1994. For example, their feasibility in supporting computed tomography (CT) scan interpretation has been studied.2 This study concluded that the quality of radiographic images transferred to the PDA was of a high or excellent quality in 90% of cases, very good on the remaining 10%, with the PDA considered a robust medium for radiological purposes. One article describes the PDA as a ‘walking library’,3 others see it as a useful tool in promoting patient safety. This would be achieved via informatics-based nursing education. A two-pronged approach was envisaged, the first by using a PDA ‘‘to document clinical encounters and to retrieve patient safety-related information at the point of care’’; the second was the ‘‘enhancement of informatics competencies of students and faculty’’.4 PDAs have been used to record patient information such as weight, medications or vascular lines, where previously there had been 60% discrepancies in the information taken at point-of-care. The study looked at reducing these discrepancies in a neonatal intensive care unit (NICU), using a PDA-based patient record and charting system. However, only a modest decrease in discrepancies was shown.5 There are articles comparing the environmental impact of using PDAs and wireless technologies with conventional methods of achieving the same effect, such as reading a newspaper, or teleconferencing compared to conventional travelling. In these comparisons, technology impact was favourable.6 It may be that the infrastructure has a negative environmental effect, e.g. cell phone masts, but an individual’s usage compares favourably to conventional methods. This particular study looked at gaseous emissions and not wave emissions.
121 In the area of roentgenology, a Boston Department of Radiology used a seamless PDA-to-intranet connection to feed departmental and educational information to their residents. Feedback was positive.7 The Medical Informatics Group at the Bioinformatics Institute, Singapore, has developed a tool with enormous potential. It is a web-based application called the CAT Crawler; ‘CAT’ being short for ‘Critically Appraised Topics’. Its purpose is to make use of Evidence Based Medicine to speed up the clinical decision making process. It has been shown that an in-patient typically asks five questions about aetiology, diagnosis, prognosis or therapy, and three outpatients generate two such questions. Typically, of the five questions asked only one is answerable. Physicians were dissatisfied with: ‘‘outdated texts; poorly organized journals; their lack of knowledge about searching and critical appraisal; lack of time to spend on tracking the best evidence needed to solve patient-problems’’.8—10 The CAT Crawler application allows search parameters to be entered and then searches an integrated database. This database takes update information regularly and automatically from a number of source databases. Information extracted is checked for uniqueness and availability.11 The source databases are currently: CATbank-Oxford, UK, the Centre for Evidence-Based Medicine–—69 CATs; Critically Appraised Topics, University of Rochester Medical Centre–—109 CATs; EvidenceBased Pediatrics Web Site, University of Michigan– —<141 CATs (duplicated); UNC Critically Appraised Topics, University of North Carolina at Chapel Hill, School of Medicine–—69 CATs; BETs (Best Evidence Topics) in Emergency Medicine, Manchester Royal Infirmary, UK–—487 CATs.8 The resulting retrieval is a full text article which shows the questions being posed, the search strategy and a list of studies including author, date and country, patient group, study type (level of evidence), outcomes, key results, study weaknesses, comments and clinical bottom line. This text is then converted to a format suitable for downloading to a PDA.11 This strategy overcomes the limitations of individual CATs where a single piece of evidence is usually summarised and thus does not represent the entire body of evidence and may become obsolete as new evidence appears.8 The author conducted a study to evaluate the criteria chiropractors would use to measure the usefulness of a differential diagnosis ‘tool’ such as a PDA with diagnostic software, together with their attitudes towards using such a tool. The objective of
122 this study was to determine if a proposed outline for a ‘tool’ superseded the evaluated tools in this survey in aiding both the teaching of differential diagnoses, with special attention to distance-learning situations and the promotion of accurate diagnoses in a clinical setting. A ‘tool’ in this context is used as the generic term for: book, software, Internet and search engine, chart or 3D model. A study was carried out to determine selected subjects’ attitudes towards the selected tools, different tool types and the importance of different criteria in selecting tools. This study was partly an attitudinal survey, part developmental and part evaluation, using a mixed-method, primarily qualitative approach with some quantitative measurement utilising questionnaires marked by means of the Likert scale.12 This project looked at attitudes of both students of the McTimoney College of Chiropractic, Abingdon, UK and qualified practitioner/tutors, towards the use of diagnostic tools as well as their current practices in using tools day to day. This project also collected data on the importance rating of tool-related criteria from the same population. This was then matched against a sample of tools including the proposed new tool. The subjects were: 47 pre-clinic year students, and 20 clinic year students, and 14 practitioner/tutors, a total of 81 respondents. The results of this study have shown that there is a general acceptance of tool use by chiropractors across the three groups surveyed. Attitudes to tool use varied, but most respondents used at least one tool regularly. For many respondents, the book remained the tool of choice. Increasing use is being made of various tools to aid chiropractors in performing diagnosis. The results show a general acceptance of tool usage and indicate what criteria a new tool must meet in order to provide significant improvement over existing tools. However, the populations under study showed that existing newer technology tools, meeting their own criteria, were not used in preferences to books. Although, this was a very small study. However, it did indicate that, although the proposed tool meets the criteria selected by the groups, due to current methods of working it is unlikely that any new tool would be bought and used, if it became available.12 Another study examined Year 4 undergraduate medical students being given PDAs with clinical decision support software (CDSS) with a view to facilitating the adoption of evidence-based medicine at the point-of-care. Measures were of usefulness, satisfaction, functionality and utilisation. The results showed that the students found the CDSS/ PDA useful but average utilisation was low at once per week although the need for information was at
R. Kitchiner least once daily. The study concluded that improved attitudes towards the PDA, increased knowledge of evidence-based medicine and computer literacy with a CDSS interface designed for students were essential to the adoption of such a tool by students at the point-of-care.13 The Department of Psychology, Edinburgh, UK, looked at computer anxiety factors moving from a computer-based system to a pen-based PDA system. The results indicated that there were advantages using the pen-based PDA over the computer-based systems in terms of less computer anxiety on cognitive function and mood tests.14 The usefulness of the PDA in a Florida obstetrics and gynaecological residency program was assessed by survey in 2004. The survey asked how much time was perceived as saved by the use of this tool, and what aspect of the training did it most help. The perceived time saved was minimal and the tool most useful for maintaining procedural statistics logs, pharmacology reference manuals and personal clinical procedures. The study concluded that training would be useful to educate residents of the potential use of and programs available for the PDA, such as maintenance of on-call schedules, sign-out lists, statistics and procedure logs for credentialing and board certification, electronic billing and electronic prescriptions.15 A one-day trial of a PDA application called ‘MobileNurse’ was tested in Seoul, Korea using six volunteer nurses and caring-simulated patients. The PDA kept information synchronised between the PDA and the hospital information system. The volunteers found the application more helpful and convenient than other methods experienced and indicated that the most critical success factor was ease-of-use.16 A PDA data management system was evaluated for its effectiveness in saving both time and paper, in an acute pain service. Initially, the paper system was assessed using a questionnaire and then a re-assessment using the PDA. Over a three-month period, user satisfaction was the same with both systems, with the PDA slightly less easy to use. There were no missed follow-up visits using the new data store and the time taken to attend a visit was similar. The estimated savings for 177 patients with 635 acute pain follow-up visits was 650 sheets of paper and 130 man-hours. The study concluded that the PDA system could reduce time and save paper as well as missed data entry and patient follow-up.17 There have been a number of studies assessing medical residents’ usage and perceived need for PDAs. Earlier studies such as The Constellation Project found constraints such as memory limitations in particular to impede usage for anything other than holding some medical reference information and
Role of the personal digital assistant drug information. More recent concern is over catastrophic data loss and the size of the PDA.18 Drug interaction is a well-known, ever-changing hazardous area. Up-to-date information is critical with an aging population, some of whom are on many different drugs. One study looked at the accuracy, comprehensiveness and ease of use of drug interaction software used with a PDA. The conclusion was that both Lexi-Interact and iFacts excelled as PDA pharmacopoeia, but clinicians needed to remain vigilant and understand any limitations.19 At the Department of Surgery, University of Texas, the PDA has found a serious niche. Each resident carries a PDA and uses it several times a day to ascertain correct drug dosage and interactions using software such as ePocrates. Residents use ResSOLution software to enter surgical case data, to search CPT codes. Calendar and telephone files can be downloaded from the office computers and management software keeps track of patients on service and individual surgeon’s preferences.20 AnyHeart is a single-piece, implantable biventricular assist device (BVAD). Its status can be monitored via a PDA, replacing previously bulky equipment.21 Recording information from various surveys, such as quality-of-life and standardised orthopaedic clinical evaluations, was tedious, with information collected on paper-based forms with manual data entry into a database. One study showed a PDA data entry system to be easy to use, and it generated an overwhelmingly positive response from patients and physicians.22 Use of electronic diaries in suitable cases of diabetes mellitus, to aid glycaemic control, is becoming popular.23 One study utilised cell phone technology in an emergency care situation to transfer medical information to a specialist at a remote site. The PDA received both textual and image information.24 Paramedics working in rural areas in India, with little access to medical practitioners, used a PDA and a large mobile database. The paper describes the technical challenges involved.25 The US is leading the way with PDA technology in many fields, including medicine. Many products designed for the American market are applicable worldwide but some are US specific. Pharmacopoeia and drug interaction guides are country specific and the US has the most choice in this software. Australia and New Zealand follow, already having E-MIMS available for a PDA. A research paper by Australian librarian Terena Solomons surveyed the use of PDAs in the medical field in North America in 2003. The paper empha-
123 sises that librarians are the early adopters of new technologies and suggests ways in which they can learn more, such as: joining a PDA listserv, for example: http://groups.yahoo.com/group/ pdalibraries/; browsing PDA websites; communicating with friends and colleagues about their use of PDAs; purchasing PDAs for library staff and becoming familiar with their use; practising downloading of PDA software and facilitating information sharing about PDA usage via face-to-face user groups.26 The survey showed the relative use of PDAs by the different specialities. Anaesthesia had the highest usage followed in order by urology, cardiology, general surgery, orthopaedics, psychiatry, radiology, respiratory medicine, oncology, endocrinology, intensive care, ophthalmology, CCU and general medicine, with all other specialities following with the same level of use. What the PDAs were used for was also recorded. The following list, with greatest use first, shows PDAs used for personal organisers (diary, address book, etc.), medical calculators, E-MIMS, word processing, therapeutic guidelines, patient tracking and ePocrates, medical textbooks and, lastly, games.6 The paper noted the various software loaded on to the PDAs. At the OSF St Francis Medical Center Library for clinical staff, packages included Griffith’s 5 Minute Clinical Consult; ePocrates drug database; ABG Pro, an arterial blood gas analyser and MedCalc, a medical calculator.26 The Quincy Family Practice Residency Program used Archimedes, Inforetriever, Griffith’s 5 Minute Clinical Consult, ePocrates, UpToDate, Mobile PDR and Tarascon Pharmacopoeia.26 The paper concludes that the PDA is just another format for data with its own idiosyncrasies, functions and culture. A number of online categories and URLs are provided by Solomon’s paper.26 Library PDA usage can be grouped into four models: the collection and development model, which is the process of evaluation, selection, procurement and licence management of PDA resources; the instruction and advisory model, which is the provision of formal training, individual consultations, and informal advisor of PDA hardware, software and content; the facilitator and communicator model: the development of web pages with relevant links.27 A project by the Blessing Health Professions Library assessed the use of a PDA at bedside by nurses, faculty and other staff. PDAs were loaded with phone numbers, calendars and the following Skyscape packages: Davis Drug Guide for Nurses; RNLabs, a nurses manual of laboratory and diagnostic tests; RNDiseases; iFacts; Griffith’s 5 Minute
124
Table 1 Patterns for PDA usage No.
Pattern name
Problem
Solution
Constraints
1.
Nested Index
Human memory is fallible and as professionals it is good to have confirmation of information we are using and advice we are giving at the point-of-care
Using a nested index, often referred to as a directed acyclic graph or ‘DAG’, the chiropractor or assistant can be directed through the tree-like structure to increasingly more detailed information on a chosen topic
2.
Mind Map
Text alone cannot always convey the big picture
3.
Extended Memory
4.
Daily News Update
5.
Patient Educator
If books weighed nothing and took up no space which ones would be always carried? Keeping up to date is time-consuming and difficult to measure Describing and sketching out details to patients can often leave them confused
6.
Records Storage
7.
Differential Diagnosis
8.
Imaging store and analysis
9.
Diary and Schedule
Imaging media such as X-rays are cumbersome to carry and store and require a lightbox for accurate viewing What’s happening and when?
10.
Contact Details
What’s that number?
11.
Phone
Carrying a cell phone in addition to a PDA is one more thing to carry or lose
This is similar to the concept of the use of DAGs, but uses ‘Mind Maps’ and their associated tools.28 Colour coding can also be of use with the mind map Library books can be loaded as extra memory cards. Many books are currently available for PDAs Downloading and categorizing information from designated web sites Vast amounts of patient information can be stored on the PDA, with diagrams, plus a facility for freehand sketches Password protected patient records downloadable on to a PDA Select from a list or mind map of possible symptoms; be advised on what tests to do and what the signs mean. Enter your own presumptive diagnosis and be advised on the differentials, symptoms, tests and signs X-rays and other images are now frequently held and delivered digitally and can easily be downloaded to a PDA A feature of the personal organiser is a diary, memo pad and alarms As part of a personal organiser, contact information is vital to have secure and to hand. The address book can easily be linked to patient records and vice versa The phone/PDA can be effective when used with a Bluetooth earpiece, so that the user can type or view other items simultaneously with the phone usage
The usefulness of the tool is not only based on accurate and detailed information but how it is structured and linked in the DAG High-quality graphics PDA display required
Secure filing and transportation of patient records Too much information. Have you forgotten something?
Extra memory cards for the PDA may need to be purchased Regular synchronisation required High-quality graphics PDA display required Regular synchronisation required Extra memory cards for the PDA may need to be purchased
High-quality graphics PDA display required Synchronisation with other clinic practitioners None
R. Kitchiner
The PDA must incorporate a phone
GPS
Getting lost on home visits is not difficult
13.
Legal Adviser
Not sure of the finer point of the law?
14.
Stock Control
15.
Automatic Re-order
If you stock and sell rehabilitation items, supplements or other items, it can be extra work to keep track of your stock and current prices Running out of supplies, when you most need them
16.
Chart Generator
Outcome measurement and developmental charts take time to keep up-to-date
17.
Alarm Clock, Reminder
Need to do something at a particular time?
18.
Warning System
A warning sign can easily be messed in a busy clinic
19.
CAT Crawler
20.
Patient Reminder
Working in an evidence based way. For every paper reporting something is good there is a good chance of there being one that says it is bad. It is not a simple task to plough through papers on every topic you come across in order to work in an evidence based way Is your next patient stuck in traffic or has he or she forgotten the appointment
Your PDA could plug into your car and become a GPS navigation system, with the appropriate software Your PDA can become your legal advisor, holding details on the law, statistics, precedents and recent updates Use a stock control application
As part of your stock control application or system, use an automatic re-order to stop stock running out. This mechanism can send a text message or call your supplier Record values directly onto your PDA and have it automatically update the relevant charts Use your PDA to remind you or even do it for you As data is entered directly into the PDA, problem chart plots, for example, could be automatically spotted generating alarms CAT Crawlers can do this for you 8
Use your PDA to send an automated reminder to patients who tend to forget, or ring to remind them if they haven’t arrived
GPS function is normally an add-on Ensuring that the details reflect current legal opinion Requires frequent synchronisation with main computer Requires frequent synchronisation with main computer
Role of the personal digital assistant
12.
High-quality graphics PDA display required None Limitations of red-flag algorithms
The search engine needs to be as good as Google
Ability to connect to a network while out of the office
125
126 Clinical Consult and Nursing Care Plans software. Results from the survey showed 86% of respondents endorsed PDAs in the library on a lending timetable; 77% endorsed senior nursing students using PDAs at bedside; 86% endorsed the project replication at other levels of nursing students and 77% endorsed recommendation to the hospital administration for use by nursing staff.
R. Kitchiner Research (collecting data, statistical work, memos) CAT Crawlers (analysing clinical trials, current research, utilising evidence-based medicine (EBM), downloading from Medline and other databases) All of these can be used at the point-of-care. Typical patterns for use are indicated in Table 1.
Patterns of usage Discussion This paper puts forward 20 usage patterns for a PDA which maybe suitable for the chiropractor’s office. Pattern descriptions have been developed over the last 20 years to provide a framework that encapsulates knowledge of working within a specific field. The following patterns follow a simple consistent template: Name of the pattern: a simple descriptive name. Problem: a concise statement of the generic issue that this pattern addresses. Solution: the concise description of possible solutions to the stated problem. Constraints: any limiting factors acting on the solution, such as PDA screen resolution. This paper proposes the following categories: Personal Organiser (address book, diary, memo pad, etc.) Patient Education and Compliance (instructions to patients, medication reminders, general information, daily logs and charts) Practice Management (accounting, billing, stock control, scheduling) Formal Practitioner Education (CME/CPD) Electronic Medical Record Keeping (EMR, including camera device and imaging, digital prescriptions using secure digital signatures) Specialist Applications (e.g. X-ray scanning and editing; ECG storage) Pharmacopoeia (drugs, dosage and drug interaction analysers) Clinical Consults (differential diagnostic assistance, medical dictionaries, lab and diagnostic tests) Library (Harrison’s Internal Medicine, Oxford Book of Clinical Medicine, library loans systems, codes and standards of practice and other legal issues) Supporting Tasks and Communication (language translators, phone devices, bleepers, navigation on home visits or new clinics for example)
All clinicians fulfilling the role of primary care practitioners have much in common, whether chiropractors or medical doctors. Many of the packages developed for medical doctors and physiotherapists can be utilised effectively by chiropractors. The US has generated packages for PDAs, many of which are country-independent; some however, such as pharmacopoeia, are countryspecific. Where practice administration is concerned, the PDA can be thought of as an extension to the main computer, but as a screen, rather than a computer in its own right. The data is secured on the main computer or server and synchronised with the PDA at relevant times, such as daily in a busy clinic or weekly, maybe, in a smaller clinic. There is a risk of losing any data not synchronised and this risk must be weighed against the task and scheduling of synchronisation. Synchronisation is not necessary for read-only reference material. This function can be thought of as ‘ectopic memory’. It is still necessary to keep this information up-to-date and add in any important bulletins and news. This is more a one-way synchronisation, from source to PDA, often via the main office computer. Becoming acquainted with your PDA can be threatening and time-consuming. One way to start is by downloading a medical dictionary and maybe some reference material, such as the e-medicine books. The drug libraries are also useful as is drug interaction information. Everyone has favourite books, but they are heavy to carry around and take up space. Much of this information can be zero weight and zero space consuming. Using a PDA at point-of-care is useful, as the patient cannot tell whether the doctor is looking something up or making a note, and therefore it can be less ‘confidence-destroying’ than reaching for a textbook. In the UK, Mims is currently under development for PDA downloading and viewing. The US, Australian and New Zealand versions of Mims are already
Role of the personal digital assistant available for PDA use. The BNF has just become available at a price. While the PDA has been used as a reference, its operation will have become familiar. The next stage is to start to enter some data. Security is now important, so keep the data safe by password or other protective mechanisms and backed-up to prevent loss. A calendar and appointment book might be the next data to move to your PDA. If you are using a diary currently it is unlikely that it is secure. Anyone can read it if it is lost, and there is probably no copy or back-up. Moving a diary to a PDA with can significantly improve security and data protection. Before going ‘live’ with real data, the process should be designed and documented. Once it has been reviewed by all potential users, one or more test runs should be designed and tried out using fictional data. Only when satisfied with this should real data be used with the process. Adding applications to your PDA is important; keeping them up-to-date even more so. Most applications include the updates as part of the package. Another way of finding out for yourself what is going on is by using ‘blogs’ (short for ‘weblogs’). A ‘blog’ is defined as ‘A frequent, chronological publication of personal thoughts and Web links’.29 The most well known of these is ‘The Palmdoc Chronicles’, which covers medical PDA news. Although blogs can keep you up-to-date, it must be remembered that these postings are not peerreviewed and therefore any information must be checked-out before being put to use. The Palmdoc site contains timely information on new software plus a variety of reviews and other information. Comments can be added at will. There are also discussion forums that PDA users can join. They serve as another method of communicating with peer groups.
Acknowledgement The author is grateful to Paul Toland for his help and support.
127
3. 4.
5.
6.
7.
8. 9.
10.
11.
12. 13.
14.
15.
16.
17.
18.
19.
20.
References [1] Gillingham W, Holt A, Gillies J. Hand-held computers in healthcare: what software programs are available? NZ Med J 2002;115(1162):U185. 2. Yaghmai V, Kuppuswami S, Berlin JW, Salehi SA. Evaluation of personal digital assistants as an interpretation medium for
21.
22.
computed tomography of patients with intracranial injury. Emerg Radiol 2003;10(2):87—9. Wiggins IIIrd RH. Personal digital assistants. J Digit Imaging 2004;17(1):5—17. Bakken S, Cook SS, Curtis L, Desjardins K, Hyun S, Jenkins M, et al. Promoting patient safety through informatics-based nursing education. Int J Med Inform 2004;73(7—8):581—9. Carroll AE, Tarczy-Hornoch P, O’reilly E, Christakis Da. The effect of point-of-care personal digital assistant use on resident documentation discrepancies. Pediatrics 2004;113(3 Pt 1):450—4. Toffel MW, Horvath A. Environmental implications of wireless technologies: news delivery and business meetings. Environ Sci Technol 2004;38(11):2961—70. Busch JM, Barbaras L, Wei J, Nishino M, Yam CS, Hatabu H. A mobile solution: PDA-based platform for radiology information management. AJR Am J Roentgenol 2004;183(1):237— 42. ZHU AL. Critically appraised topics. 2002. online at http:// www.bii.a-star.edu.sg/docs/mig/cats.pdf. Osheroff JA, Forsythe DE, Buchanan BG, Bankowitz RA, Blumenfeld BH, Miller RA. Physicians’ information needs: analysis of questions posed during clinical teaching. Ann Intern Med 1991;114(7):576—81. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985;103(4): 596—9. Dong P, Mondry A. Enhanced quality and quantity of retrieval of Critically Appraised Topics using the CAT Crawler. Med Inform Internet Med 2004;29(1):43—55. Kitchiner RF. Final Year Project. Abingdon, UK: McTimoney College of Chiropractic; 2003. Johnston JM, Leung GM, Tin KY, Ho LM, Lam W, Fielding R. Evaluation of a handheld clinical decision support tool for evidence-based learning and practice in medical undergraduates. Med Educ 2004;38(6):628—37. Tseng HM, Tiplady B, Macleod HA, Wright P. Computer anxiety: a comparison of pen-based personal digital assistants, conventional computer and paper assessment of mood and performance. Br J Psychol 1998;89(Pt 4):599—610. Joy S, Benrubi G. Personal digital assistant use in Florida obstetrics and gynecology residency programs. South Med J 2004;97(5):430—3. Choi J, Chun J, Lee K, Lee S, Shin D, Hyun S, et al. MobileNurse: hand-held information system for point of nursing care. Comput Methods Programs Biomed 2004;74(3):245— 54. Chan SS, Chu CP, Cheng BC, Chen PP. Data management using the personal digital assistant in an acute pain service. Anaesth Intensive Care 2004;32(1):81—6. Barrett JR, Strayer SM, Schubart JR. Assessing medical residents’ usage and perceived needs for personal digital assistants. Int J Med Inform 2004;73(1):25—34. Barrons R. Evaluation of personal digital assistant software for drug interactions. Am J Health Syst Pharm 2004;61(4): 380—5. Suliburk J. Handheld medicine–—handheld software to ease the day and improve patient care. Curr Surg 2003;60(2): 176—7. Park JW, Choi J, Lee JJ, Nam K, Chung J, Park SK, et al. AnyHeart: a single-piece heart-saving implantable artificial heart (BVAD)–—monitoring and estimation. Int J Artif Organs 2003;26(5):406—10. Giammattei FP. Implementing a total joint registry using personal digital assistants. A proof of concept. Orthop Nurs 2003;22(4):284—8.
128 23. Kerkenbush NL, Lasome CE. The emerging role of electronic diaries in the management of diabetes mellitus. AACN Clin Issues 2003;14(3):371—8. 24. Kondo Y. Medical image transfer for emergency care utilizing Internet and mobile phone. Nippon Hoshasen Gijutsu Gakkai Zasshi 2002;58(10):1393—401. 25. Anantharaman V, Lim SH. Hospital and emergency ambulance link: using IT to enhance emergency pre-hospital care. Int J Med Inform 2001;61(2—3):147—61. 26. Solomons T. Beam me up! Supporting PDAs (Personal Digital Assistants) in medical libraries: new technology, or just
R. Kitchiner another format?; 2003, online at http://www.vala.org.au/ vala2004/2004pdfs/57Solom.PDF. 27. Dorsch J, Burnett P, Heskett K. PDA medical applications and content for librarians. San Diego: MLA Continuing Education; 2003 . online at http://www.uic.edu/depts/lib/lhsp/temp/ roles_files/frame.htm. 28. Buzan T. The mind map book. BBC Publications; 1993 0563363738. 29. Online at http://www.marketingterms.com/dictionary/ blog/.
intl.elsevierhealth.com/journals/clch
SYSTEMATIC REVIEW
The role of the personal digital assistant (PDA) in chiropractic practice Rosie Kitchiner * Private Practice, 19 Whetstone Close, Milton Keynes, Heelands, Buckinghamshire MK13 7PP, UK Received 17 July 2005; received in revised form 12 April 2006; accepted 26 April 2006
KEYWORDS Chiropractic; Information technology; Personal digital assistant; PDA
Summary This is a review of the research into various uses and acceptance of personal digital assistants (PDAs) in the health industry. As technology becomes more powerful and intuitive to use, the speed of uptake in hospitals and clinics by clinicians, nurses and many varied health practitioner roles will, no doubt, increase. Over 200 applications in the medical field are currently available. It is an area that can no longer be ignored. This article attempts to throw some light on how PDAs are being used today and how chiropractors in the UK can jump on the bandwagon without too much pain! A number of patterns are described for putting a PDA to use in the chiropractic clinic, each of which may be undertaken individually, to gradually allow users to become confident in their use. # 2006 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction The term personal digital assistant (PDA) is used in this paper to describe a variety of handheld devices, all of which have the following characteristics. PDA is a term for any small mobile hand-held device that provides computing and information storage and retrieval capabilities for personal or business use. PDAs are always battery powered, with most incorporating rechargeable batteries. Unlike laptops, which typically have a maximum useful battery life of a few hours, the low power needs of PDAs mean that they can be used throughout an entire day without recharging. The device is * Tel.: +44 7812124076; fax: +44 1908311918. E-mail address: [email protected].
usually of a size that can easily be held in one hand, with a small screen, usually no more than 4-in, with resolution up to 320 480 pixels. A typical PDA is shown in Fig. 1. PDAs come with applications and data stored in a combination of ROM and RAM memory, such that the programs are immediately available for use once the PDA is switched on. Fig. 2 shows an example of the eMedicine library application. Typical built-in memory capacities are 64—128 Mbytes. Memory can be further increased through the use of a variety of add-on hardware such as SD (Secure Digital), CF (Compact Flash) or MS (Memory Stick) memory cards, which are now available with capacities up to 4 Gbytes, which provides space for high-quality graphics display. Fig. 3 shows an example of a detailed diagram of a skull being displayed on a PDA.
1479-2354/$32.00 # 2006 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2006.04.003
120
R. Kitchiner
Figure 1
Typical PDA in use. Figure 3
Figure 2
PDA showing example library application.
PDA showing graphical display of skull.
The vast majority of PDAs utilise either the Palm1 operating system or Windows1 Pocket PC. In both cases, pre-loaded software includes at least a name and address database, to-do list and note taker, with the ability to add further applications via synchronisation with a desktop PC. PDAs are pen based and use a stylus to tap selections on menus and to enter printed characters. The unit may also include a small on-screen keyboard, which is tapped with the pen. In some devices, an external wireless keyboard may be used. PDAs are usually synchronised with desktop computers to ensure data archiving should the PDA lose power or otherwise fail. They may also be combined with cell phones and other wireless technologies such as WiFi or Bluetooth to provide access to other computers and the Internet. One of the main problems with adopting new technology is ‘‘where to start?’’ With more than 200 applications to choose from, this is fast become a mature technology and evermore confusing for those putting off that day when they take the plunge! This paper reviews how other health care professionals have started to utilise personal digital assistants (PDAs) in their practice or in a hospital environment. The paper goes on to introduce the concept of patterns to document the discrete usage
Role of the personal digital assistant of common functions and their transposition to the PDA. PDA functionality is broken down into these discrete patterns, which can be adopted independently to gradually gain expertise in the use of a PDA without compromising the efficiency of the clinic.
Summary of the literature A survey by PriceWaterhouseCoopers during 2001, on information technology in medical practices, found that 60% of responders said their physicians used PDAs compared with 26% in an earlier survey of 2000. Five categories of healthcare software were identified: reference/text book; calculator; patient management/log book; personal clinical/study notebook and utility software.1 There have been a number of published articles evaluating the use of PDAs in the medical arena since their mainstream launch, starting with the PalmPilot1 in 1994. For example, their feasibility in supporting computed tomography (CT) scan interpretation has been studied.2 This study concluded that the quality of radiographic images transferred to the PDA was of a high or excellent quality in 90% of cases, very good on the remaining 10%, with the PDA considered a robust medium for radiological purposes. One article describes the PDA as a ‘walking library’,3 others see it as a useful tool in promoting patient safety. This would be achieved via informatics-based nursing education. A two-pronged approach was envisaged, the first by using a PDA ‘‘to document clinical encounters and to retrieve patient safety-related information at the point of care’’; the second was the ‘‘enhancement of informatics competencies of students and faculty’’.4 PDAs have been used to record patient information such as weight, medications or vascular lines, where previously there had been 60% discrepancies in the information taken at point-of-care. The study looked at reducing these discrepancies in a neonatal intensive care unit (NICU), using a PDA-based patient record and charting system. However, only a modest decrease in discrepancies was shown.5 There are articles comparing the environmental impact of using PDAs and wireless technologies with conventional methods of achieving the same effect, such as reading a newspaper, or teleconferencing compared to conventional travelling. In these comparisons, technology impact was favourable.6 It may be that the infrastructure has a negative environmental effect, e.g. cell phone masts, but an individual’s usage compares favourably to conventional methods. This particular study looked at gaseous emissions and not wave emissions.
121 In the area of roentgenology, a Boston Department of Radiology used a seamless PDA-to-intranet connection to feed departmental and educational information to their residents. Feedback was positive.7 The Medical Informatics Group at the Bioinformatics Institute, Singapore, has developed a tool with enormous potential. It is a web-based application called the CAT Crawler; ‘CAT’ being short for ‘Critically Appraised Topics’. Its purpose is to make use of Evidence Based Medicine to speed up the clinical decision making process. It has been shown that an in-patient typically asks five questions about aetiology, diagnosis, prognosis or therapy, and three outpatients generate two such questions. Typically, of the five questions asked only one is answerable. Physicians were dissatisfied with: ‘‘outdated texts; poorly organized journals; their lack of knowledge about searching and critical appraisal; lack of time to spend on tracking the best evidence needed to solve patient-problems’’.8—10 The CAT Crawler application allows search parameters to be entered and then searches an integrated database. This database takes update information regularly and automatically from a number of source databases. Information extracted is checked for uniqueness and availability.11 The source databases are currently: CATbank-Oxford, UK, the Centre for Evidence-Based Medicine–—69 CATs; Critically Appraised Topics, University of Rochester Medical Centre–—109 CATs; EvidenceBased Pediatrics Web Site, University of Michigan– —<141 CATs (duplicated); UNC Critically Appraised Topics, University of North Carolina at Chapel Hill, School of Medicine–—69 CATs; BETs (Best Evidence Topics) in Emergency Medicine, Manchester Royal Infirmary, UK–—487 CATs.8 The resulting retrieval is a full text article which shows the questions being posed, the search strategy and a list of studies including author, date and country, patient group, study type (level of evidence), outcomes, key results, study weaknesses, comments and clinical bottom line. This text is then converted to a format suitable for downloading to a PDA.11 This strategy overcomes the limitations of individual CATs where a single piece of evidence is usually summarised and thus does not represent the entire body of evidence and may become obsolete as new evidence appears.8 The author conducted a study to evaluate the criteria chiropractors would use to measure the usefulness of a differential diagnosis ‘tool’ such as a PDA with diagnostic software, together with their attitudes towards using such a tool. The objective of
122 this study was to determine if a proposed outline for a ‘tool’ superseded the evaluated tools in this survey in aiding both the teaching of differential diagnoses, with special attention to distance-learning situations and the promotion of accurate diagnoses in a clinical setting. A ‘tool’ in this context is used as the generic term for: book, software, Internet and search engine, chart or 3D model. A study was carried out to determine selected subjects’ attitudes towards the selected tools, different tool types and the importance of different criteria in selecting tools. This study was partly an attitudinal survey, part developmental and part evaluation, using a mixed-method, primarily qualitative approach with some quantitative measurement utilising questionnaires marked by means of the Likert scale.12 This project looked at attitudes of both students of the McTimoney College of Chiropractic, Abingdon, UK and qualified practitioner/tutors, towards the use of diagnostic tools as well as their current practices in using tools day to day. This project also collected data on the importance rating of tool-related criteria from the same population. This was then matched against a sample of tools including the proposed new tool. The subjects were: 47 pre-clinic year students, and 20 clinic year students, and 14 practitioner/tutors, a total of 81 respondents. The results of this study have shown that there is a general acceptance of tool use by chiropractors across the three groups surveyed. Attitudes to tool use varied, but most respondents used at least one tool regularly. For many respondents, the book remained the tool of choice. Increasing use is being made of various tools to aid chiropractors in performing diagnosis. The results show a general acceptance of tool usage and indicate what criteria a new tool must meet in order to provide significant improvement over existing tools. However, the populations under study showed that existing newer technology tools, meeting their own criteria, were not used in preferences to books. Although, this was a very small study. However, it did indicate that, although the proposed tool meets the criteria selected by the groups, due to current methods of working it is unlikely that any new tool would be bought and used, if it became available.12 Another study examined Year 4 undergraduate medical students being given PDAs with clinical decision support software (CDSS) with a view to facilitating the adoption of evidence-based medicine at the point-of-care. Measures were of usefulness, satisfaction, functionality and utilisation. The results showed that the students found the CDSS/ PDA useful but average utilisation was low at once per week although the need for information was at
R. Kitchiner least once daily. The study concluded that improved attitudes towards the PDA, increased knowledge of evidence-based medicine and computer literacy with a CDSS interface designed for students were essential to the adoption of such a tool by students at the point-of-care.13 The Department of Psychology, Edinburgh, UK, looked at computer anxiety factors moving from a computer-based system to a pen-based PDA system. The results indicated that there were advantages using the pen-based PDA over the computer-based systems in terms of less computer anxiety on cognitive function and mood tests.14 The usefulness of the PDA in a Florida obstetrics and gynaecological residency program was assessed by survey in 2004. The survey asked how much time was perceived as saved by the use of this tool, and what aspect of the training did it most help. The perceived time saved was minimal and the tool most useful for maintaining procedural statistics logs, pharmacology reference manuals and personal clinical procedures. The study concluded that training would be useful to educate residents of the potential use of and programs available for the PDA, such as maintenance of on-call schedules, sign-out lists, statistics and procedure logs for credentialing and board certification, electronic billing and electronic prescriptions.15 A one-day trial of a PDA application called ‘MobileNurse’ was tested in Seoul, Korea using six volunteer nurses and caring-simulated patients. The PDA kept information synchronised between the PDA and the hospital information system. The volunteers found the application more helpful and convenient than other methods experienced and indicated that the most critical success factor was ease-of-use.16 A PDA data management system was evaluated for its effectiveness in saving both time and paper, in an acute pain service. Initially, the paper system was assessed using a questionnaire and then a re-assessment using the PDA. Over a three-month period, user satisfaction was the same with both systems, with the PDA slightly less easy to use. There were no missed follow-up visits using the new data store and the time taken to attend a visit was similar. The estimated savings for 177 patients with 635 acute pain follow-up visits was 650 sheets of paper and 130 man-hours. The study concluded that the PDA system could reduce time and save paper as well as missed data entry and patient follow-up.17 There have been a number of studies assessing medical residents’ usage and perceived need for PDAs. Earlier studies such as The Constellation Project found constraints such as memory limitations in particular to impede usage for anything other than holding some medical reference information and
Role of the personal digital assistant drug information. More recent concern is over catastrophic data loss and the size of the PDA.18 Drug interaction is a well-known, ever-changing hazardous area. Up-to-date information is critical with an aging population, some of whom are on many different drugs. One study looked at the accuracy, comprehensiveness and ease of use of drug interaction software used with a PDA. The conclusion was that both Lexi-Interact and iFacts excelled as PDA pharmacopoeia, but clinicians needed to remain vigilant and understand any limitations.19 At the Department of Surgery, University of Texas, the PDA has found a serious niche. Each resident carries a PDA and uses it several times a day to ascertain correct drug dosage and interactions using software such as ePocrates. Residents use ResSOLution software to enter surgical case data, to search CPT codes. Calendar and telephone files can be downloaded from the office computers and management software keeps track of patients on service and individual surgeon’s preferences.20 AnyHeart is a single-piece, implantable biventricular assist device (BVAD). Its status can be monitored via a PDA, replacing previously bulky equipment.21 Recording information from various surveys, such as quality-of-life and standardised orthopaedic clinical evaluations, was tedious, with information collected on paper-based forms with manual data entry into a database. One study showed a PDA data entry system to be easy to use, and it generated an overwhelmingly positive response from patients and physicians.22 Use of electronic diaries in suitable cases of diabetes mellitus, to aid glycaemic control, is becoming popular.23 One study utilised cell phone technology in an emergency care situation to transfer medical information to a specialist at a remote site. The PDA received both textual and image information.24 Paramedics working in rural areas in India, with little access to medical practitioners, used a PDA and a large mobile database. The paper describes the technical challenges involved.25 The US is leading the way with PDA technology in many fields, including medicine. Many products designed for the American market are applicable worldwide but some are US specific. Pharmacopoeia and drug interaction guides are country specific and the US has the most choice in this software. Australia and New Zealand follow, already having E-MIMS available for a PDA. A research paper by Australian librarian Terena Solomons surveyed the use of PDAs in the medical field in North America in 2003. The paper empha-
123 sises that librarians are the early adopters of new technologies and suggests ways in which they can learn more, such as: joining a PDA listserv, for example: http://groups.yahoo.com/group/ pdalibraries/; browsing PDA websites; communicating with friends and colleagues about their use of PDAs; purchasing PDAs for library staff and becoming familiar with their use; practising downloading of PDA software and facilitating information sharing about PDA usage via face-to-face user groups.26 The survey showed the relative use of PDAs by the different specialities. Anaesthesia had the highest usage followed in order by urology, cardiology, general surgery, orthopaedics, psychiatry, radiology, respiratory medicine, oncology, endocrinology, intensive care, ophthalmology, CCU and general medicine, with all other specialities following with the same level of use. What the PDAs were used for was also recorded. The following list, with greatest use first, shows PDAs used for personal organisers (diary, address book, etc.), medical calculators, E-MIMS, word processing, therapeutic guidelines, patient tracking and ePocrates, medical textbooks and, lastly, games.6 The paper noted the various software loaded on to the PDAs. At the OSF St Francis Medical Center Library for clinical staff, packages included Griffith’s 5 Minute Clinical Consult; ePocrates drug database; ABG Pro, an arterial blood gas analyser and MedCalc, a medical calculator.26 The Quincy Family Practice Residency Program used Archimedes, Inforetriever, Griffith’s 5 Minute Clinical Consult, ePocrates, UpToDate, Mobile PDR and Tarascon Pharmacopoeia.26 The paper concludes that the PDA is just another format for data with its own idiosyncrasies, functions and culture. A number of online categories and URLs are provided by Solomon’s paper.26 Library PDA usage can be grouped into four models: the collection and development model, which is the process of evaluation, selection, procurement and licence management of PDA resources; the instruction and advisory model, which is the provision of formal training, individual consultations, and informal advisor of PDA hardware, software and content; the facilitator and communicator model: the development of web pages with relevant links.27 A project by the Blessing Health Professions Library assessed the use of a PDA at bedside by nurses, faculty and other staff. PDAs were loaded with phone numbers, calendars and the following Skyscape packages: Davis Drug Guide for Nurses; RNLabs, a nurses manual of laboratory and diagnostic tests; RNDiseases; iFacts; Griffith’s 5 Minute
124
Table 1 Patterns for PDA usage No.
Pattern name
Problem
Solution
Constraints
1.
Nested Index
Human memory is fallible and as professionals it is good to have confirmation of information we are using and advice we are giving at the point-of-care
Using a nested index, often referred to as a directed acyclic graph or ‘DAG’, the chiropractor or assistant can be directed through the tree-like structure to increasingly more detailed information on a chosen topic
2.
Mind Map
Text alone cannot always convey the big picture
3.
Extended Memory
4.
Daily News Update
5.
Patient Educator
If books weighed nothing and took up no space which ones would be always carried? Keeping up to date is time-consuming and difficult to measure Describing and sketching out details to patients can often leave them confused
6.
Records Storage
7.
Differential Diagnosis
8.
Imaging store and analysis
9.
Diary and Schedule
Imaging media such as X-rays are cumbersome to carry and store and require a lightbox for accurate viewing What’s happening and when?
10.
Contact Details
What’s that number?
11.
Phone
Carrying a cell phone in addition to a PDA is one more thing to carry or lose
This is similar to the concept of the use of DAGs, but uses ‘Mind Maps’ and their associated tools.28 Colour coding can also be of use with the mind map Library books can be loaded as extra memory cards. Many books are currently available for PDAs Downloading and categorizing information from designated web sites Vast amounts of patient information can be stored on the PDA, with diagrams, plus a facility for freehand sketches Password protected patient records downloadable on to a PDA Select from a list or mind map of possible symptoms; be advised on what tests to do and what the signs mean. Enter your own presumptive diagnosis and be advised on the differentials, symptoms, tests and signs X-rays and other images are now frequently held and delivered digitally and can easily be downloaded to a PDA A feature of the personal organiser is a diary, memo pad and alarms As part of a personal organiser, contact information is vital to have secure and to hand. The address book can easily be linked to patient records and vice versa The phone/PDA can be effective when used with a Bluetooth earpiece, so that the user can type or view other items simultaneously with the phone usage
The usefulness of the tool is not only based on accurate and detailed information but how it is structured and linked in the DAG High-quality graphics PDA display required
Secure filing and transportation of patient records Too much information. Have you forgotten something?
Extra memory cards for the PDA may need to be purchased Regular synchronisation required High-quality graphics PDA display required Regular synchronisation required Extra memory cards for the PDA may need to be purchased
High-quality graphics PDA display required Synchronisation with other clinic practitioners None
R. Kitchiner
The PDA must incorporate a phone
GPS
Getting lost on home visits is not difficult
13.
Legal Adviser
Not sure of the finer point of the law?
14.
Stock Control
15.
Automatic Re-order
If you stock and sell rehabilitation items, supplements or other items, it can be extra work to keep track of your stock and current prices Running out of supplies, when you most need them
16.
Chart Generator
Outcome measurement and developmental charts take time to keep up-to-date
17.
Alarm Clock, Reminder
Need to do something at a particular time?
18.
Warning System
A warning sign can easily be messed in a busy clinic
19.
CAT Crawler
20.
Patient Reminder
Working in an evidence based way. For every paper reporting something is good there is a good chance of there being one that says it is bad. It is not a simple task to plough through papers on every topic you come across in order to work in an evidence based way Is your next patient stuck in traffic or has he or she forgotten the appointment
Your PDA could plug into your car and become a GPS navigation system, with the appropriate software Your PDA can become your legal advisor, holding details on the law, statistics, precedents and recent updates Use a stock control application
As part of your stock control application or system, use an automatic re-order to stop stock running out. This mechanism can send a text message or call your supplier Record values directly onto your PDA and have it automatically update the relevant charts Use your PDA to remind you or even do it for you As data is entered directly into the PDA, problem chart plots, for example, could be automatically spotted generating alarms CAT Crawlers can do this for you 8
Use your PDA to send an automated reminder to patients who tend to forget, or ring to remind them if they haven’t arrived
GPS function is normally an add-on Ensuring that the details reflect current legal opinion Requires frequent synchronisation with main computer Requires frequent synchronisation with main computer
Role of the personal digital assistant
12.
High-quality graphics PDA display required None Limitations of red-flag algorithms
The search engine needs to be as good as Google
Ability to connect to a network while out of the office
125
126 Clinical Consult and Nursing Care Plans software. Results from the survey showed 86% of respondents endorsed PDAs in the library on a lending timetable; 77% endorsed senior nursing students using PDAs at bedside; 86% endorsed the project replication at other levels of nursing students and 77% endorsed recommendation to the hospital administration for use by nursing staff.
R. Kitchiner Research (collecting data, statistical work, memos) CAT Crawlers (analysing clinical trials, current research, utilising evidence-based medicine (EBM), downloading from Medline and other databases) All of these can be used at the point-of-care. Typical patterns for use are indicated in Table 1.
Patterns of usage Discussion This paper puts forward 20 usage patterns for a PDA which maybe suitable for the chiropractor’s office. Pattern descriptions have been developed over the last 20 years to provide a framework that encapsulates knowledge of working within a specific field. The following patterns follow a simple consistent template: Name of the pattern: a simple descriptive name. Problem: a concise statement of the generic issue that this pattern addresses. Solution: the concise description of possible solutions to the stated problem. Constraints: any limiting factors acting on the solution, such as PDA screen resolution. This paper proposes the following categories: Personal Organiser (address book, diary, memo pad, etc.) Patient Education and Compliance (instructions to patients, medication reminders, general information, daily logs and charts) Practice Management (accounting, billing, stock control, scheduling) Formal Practitioner Education (CME/CPD) Electronic Medical Record Keeping (EMR, including camera device and imaging, digital prescriptions using secure digital signatures) Specialist Applications (e.g. X-ray scanning and editing; ECG storage) Pharmacopoeia (drugs, dosage and drug interaction analysers) Clinical Consults (differential diagnostic assistance, medical dictionaries, lab and diagnostic tests) Library (Harrison’s Internal Medicine, Oxford Book of Clinical Medicine, library loans systems, codes and standards of practice and other legal issues) Supporting Tasks and Communication (language translators, phone devices, bleepers, navigation on home visits or new clinics for example)
All clinicians fulfilling the role of primary care practitioners have much in common, whether chiropractors or medical doctors. Many of the packages developed for medical doctors and physiotherapists can be utilised effectively by chiropractors. The US has generated packages for PDAs, many of which are country-independent; some however, such as pharmacopoeia, are countryspecific. Where practice administration is concerned, the PDA can be thought of as an extension to the main computer, but as a screen, rather than a computer in its own right. The data is secured on the main computer or server and synchronised with the PDA at relevant times, such as daily in a busy clinic or weekly, maybe, in a smaller clinic. There is a risk of losing any data not synchronised and this risk must be weighed against the task and scheduling of synchronisation. Synchronisation is not necessary for read-only reference material. This function can be thought of as ‘ectopic memory’. It is still necessary to keep this information up-to-date and add in any important bulletins and news. This is more a one-way synchronisation, from source to PDA, often via the main office computer. Becoming acquainted with your PDA can be threatening and time-consuming. One way to start is by downloading a medical dictionary and maybe some reference material, such as the e-medicine books. The drug libraries are also useful as is drug interaction information. Everyone has favourite books, but they are heavy to carry around and take up space. Much of this information can be zero weight and zero space consuming. Using a PDA at point-of-care is useful, as the patient cannot tell whether the doctor is looking something up or making a note, and therefore it can be less ‘confidence-destroying’ than reaching for a textbook. In the UK, Mims is currently under development for PDA downloading and viewing. The US, Australian and New Zealand versions of Mims are already
Role of the personal digital assistant available for PDA use. The BNF has just become available at a price. While the PDA has been used as a reference, its operation will have become familiar. The next stage is to start to enter some data. Security is now important, so keep the data safe by password or other protective mechanisms and backed-up to prevent loss. A calendar and appointment book might be the next data to move to your PDA. If you are using a diary currently it is unlikely that it is secure. Anyone can read it if it is lost, and there is probably no copy or back-up. Moving a diary to a PDA with can significantly improve security and data protection. Before going ‘live’ with real data, the process should be designed and documented. Once it has been reviewed by all potential users, one or more test runs should be designed and tried out using fictional data. Only when satisfied with this should real data be used with the process. Adding applications to your PDA is important; keeping them up-to-date even more so. Most applications include the updates as part of the package. Another way of finding out for yourself what is going on is by using ‘blogs’ (short for ‘weblogs’). A ‘blog’ is defined as ‘A frequent, chronological publication of personal thoughts and Web links’.29 The most well known of these is ‘The Palmdoc Chronicles’, which covers medical PDA news. Although blogs can keep you up-to-date, it must be remembered that these postings are not peerreviewed and therefore any information must be checked-out before being put to use. The Palmdoc site contains timely information on new software plus a variety of reviews and other information. Comments can be added at will. There are also discussion forums that PDA users can join. They serve as another method of communicating with peer groups.
Acknowledgement The author is grateful to Paul Toland for his help and support.
127
3. 4.
5.
6.
7.
8. 9.
10.
11.
12. 13.
14.
15.
16.
17.
18.
19.
20.
References [1] Gillingham W, Holt A, Gillies J. Hand-held computers in healthcare: what software programs are available? NZ Med J 2002;115(1162):U185. 2. Yaghmai V, Kuppuswami S, Berlin JW, Salehi SA. Evaluation of personal digital assistants as an interpretation medium for
21.
22.
computed tomography of patients with intracranial injury. Emerg Radiol 2003;10(2):87—9. Wiggins IIIrd RH. Personal digital assistants. J Digit Imaging 2004;17(1):5—17. Bakken S, Cook SS, Curtis L, Desjardins K, Hyun S, Jenkins M, et al. Promoting patient safety through informatics-based nursing education. Int J Med Inform 2004;73(7—8):581—9. Carroll AE, Tarczy-Hornoch P, O’reilly E, Christakis Da. The effect of point-of-care personal digital assistant use on resident documentation discrepancies. Pediatrics 2004;113(3 Pt 1):450—4. Toffel MW, Horvath A. Environmental implications of wireless technologies: news delivery and business meetings. Environ Sci Technol 2004;38(11):2961—70. Busch JM, Barbaras L, Wei J, Nishino M, Yam CS, Hatabu H. A mobile solution: PDA-based platform for radiology information management. AJR Am J Roentgenol 2004;183(1):237— 42. ZHU AL. Critically appraised topics. 2002. online at http:// www.bii.a-star.edu.sg/docs/mig/cats.pdf. Osheroff JA, Forsythe DE, Buchanan BG, Bankowitz RA, Blumenfeld BH, Miller RA. Physicians’ information needs: analysis of questions posed during clinical teaching. Ann Intern Med 1991;114(7):576—81. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985;103(4): 596—9. Dong P, Mondry A. Enhanced quality and quantity of retrieval of Critically Appraised Topics using the CAT Crawler. Med Inform Internet Med 2004;29(1):43—55. Kitchiner RF. Final Year Project. Abingdon, UK: McTimoney College of Chiropractic; 2003. Johnston JM, Leung GM, Tin KY, Ho LM, Lam W, Fielding R. Evaluation of a handheld clinical decision support tool for evidence-based learning and practice in medical undergraduates. Med Educ 2004;38(6):628—37. Tseng HM, Tiplady B, Macleod HA, Wright P. Computer anxiety: a comparison of pen-based personal digital assistants, conventional computer and paper assessment of mood and performance. Br J Psychol 1998;89(Pt 4):599—610. Joy S, Benrubi G. Personal digital assistant use in Florida obstetrics and gynecology residency programs. South Med J 2004;97(5):430—3. Choi J, Chun J, Lee K, Lee S, Shin D, Hyun S, et al. MobileNurse: hand-held information system for point of nursing care. Comput Methods Programs Biomed 2004;74(3):245— 54. Chan SS, Chu CP, Cheng BC, Chen PP. Data management using the personal digital assistant in an acute pain service. Anaesth Intensive Care 2004;32(1):81—6. Barrett JR, Strayer SM, Schubart JR. Assessing medical residents’ usage and perceived needs for personal digital assistants. Int J Med Inform 2004;73(1):25—34. Barrons R. Evaluation of personal digital assistant software for drug interactions. Am J Health Syst Pharm 2004;61(4): 380—5. Suliburk J. Handheld medicine–—handheld software to ease the day and improve patient care. Curr Surg 2003;60(2): 176—7. Park JW, Choi J, Lee JJ, Nam K, Chung J, Park SK, et al. AnyHeart: a single-piece heart-saving implantable artificial heart (BVAD)–—monitoring and estimation. Int J Artif Organs 2003;26(5):406—10. Giammattei FP. Implementing a total joint registry using personal digital assistants. A proof of concept. Orthop Nurs 2003;22(4):284—8.
128 23. Kerkenbush NL, Lasome CE. The emerging role of electronic diaries in the management of diabetes mellitus. AACN Clin Issues 2003;14(3):371—8. 24. Kondo Y. Medical image transfer for emergency care utilizing Internet and mobile phone. Nippon Hoshasen Gijutsu Gakkai Zasshi 2002;58(10):1393—401. 25. Anantharaman V, Lim SH. Hospital and emergency ambulance link: using IT to enhance emergency pre-hospital care. Int J Med Inform 2001;61(2—3):147—61. 26. Solomons T. Beam me up! Supporting PDAs (Personal Digital Assistants) in medical libraries: new technology, or just
R. Kitchiner another format?; 2003, online at http://www.vala.org.au/ vala2004/2004pdfs/57Solom.PDF. 27. Dorsch J, Burnett P, Heskett K. PDA medical applications and content for librarians. San Diego: MLA Continuing Education; 2003 . online at http://www.uic.edu/depts/lib/lhsp/temp/ roles_files/frame.htm. 28. Buzan T. The mind map book. BBC Publications; 1993 0563363738. 29. Online at http://www.marketingterms.com/dictionary/ blog/.