During the 6-month study period, PDAs were used by 20 physicians (4 attending physicians, 1 research fellow, and 15 rotating medical residents) and 6 paramedical staff (3 respiratory therapists, 2 pharmacists, and 1 nurse educator). The three focus groups had a total of 19 participants. Two residents who were unable to attend participated in telephone interviews. Each focus group had six or seven participants, a number within the recommended range [11
]. Only five of the users (19%) had previous experience with the PDA computing format.
Users found the PDA to be a convenient pocket size, allowing it to be available at all times. The screen was clear and easy to read, although not ideal for long text documents or large tables. Many users became proficient in text entry using Graffiti, while others preferred to use the GoType keyboards. Of the 19 PDA units used during the 6-month study period, only one had a technical malfunction requiring replacement. Two were damaged after being dropped and needed to have their screens replaced. No other problems were encountered.
Medical reference databases
Reference databases used regularly by medical residents included the critical-care drug dosing reference, ventilator weaning protocol, and electrolyte correction application. The calculation programs (creatinine clearance, ideal body weight) were found to be useful by the pharmacist and some residents. The ventilator weaning protocol was used by medical staff, as well as respiratory therapists, allowing regular assessment of whether patients met the criteria for extubation.
Many databases were, however, not fully used. This appeared to relate more to inadequate training than to faults in the databases. In many cases, the PDA users were unaware that certain information was in their PDAs. This was because data were located on separate software programs (J-file, AvantGo, Cbas, Memopad) and may have been difficult to find. The PDA had a global 'Find' function to search for keywords, but this does not incorporate some of the added software programs, such as AvantGo. A unified database program with a search capability was suggested as a useful addition.
Patient information was managed using the text-based MemoPlus software and a customized template. This required text entry on the PDA. Several modifications to the template were made during the study period. Residents responsible for patient data entry described difficulty entering data for new patients and keeping patient information updated during busy weekends. Attending staff found the patient data useful, particularly when they were taking over care of patients at the beginning of their on-call duties. Transferring the care of critically ill patients to a new physician is time-consuming and potentially stressful. The PDA patient database improved the staff's knowledge of patients, especially of previous medical problems in patients with complex conditions who had had a long stay in hospital. It also gave staff access to patient information when they were out of the ICU, aiding decision-making. During ICU rounds, the summarized chronological information was useful to find out how long intravenous lines had been in place and to review antibiotic therapy. Less benefit was noted in short-term patients. During night call, the patient summaries were of value when residents were called to see patients with whom they were not very familiar.
In our ICU, a daily physician note is written in the patient record. The print function to create a daily note reduced duplication of work, but the process for entering patient data was found to be time-consuming initially. While residents did not feel that the patient-management application (MemoPlus) improved efficiency, it did increase their knowledge of the patients.
During the study period, other commercially available patient-management software systems were evaluated. These had the advantage of easy data input using single keystrokes for date entry and 'pop-up' lists of drugs and diagnoses. While this simplified data inputting, no system was found to be ideal for the ICU. Many of these systems did not support the infrared data transfer or printing functions.
Other uses of the software
Study participants used a variety of other applications on a regular basis. Having the call and teaching schedules easily accessible was considered a benefit. The telephone list of hospital numbers was found to be valuable and the To Do list was used by most users to keep track of their work. Teaching rounds and morbidity and mortality rounds were facilitated by using archived patient data. Many participants used the Memopad to take notes in teaching seminars.
Suggestions for change
The focus-group discussions generated a number of suggestions for improvement. The hardware unit was considered suitable, but a more robust one may be needed in view of the two damaged screens. Because most of the users had had no previous experience with the PDA, additional teaching sessions and follow-up training were suggested to make optimal use of the technology. This would have helped users to become more aware of the many databases available on their PDA. In this regard, the medical information on the PDA would clearly benefit from integration into a single, searchable program.
The patient-management software would be more user-friendly if the data could be entered with minimal effort, using customized pull-down lists of drugs, diagnoses, and procedures. The demographic data could be entered and updated daily by a ward clerk. Alarms were suggested - for example, to warn of prolonged intravenous line duration or the end of a course of antibiotic therapy. While transmission of data between staff by infrared was found to be useful, synchronization with the hospital electronic patient record was considered the optimal situation.
Two groups of four trainees took part in each crossover study. Half of the residents had prior experience with PDAs. No difference was noted in their subjective preference for the PDA or printed copy of the handbook, and the individual's preference did not correlate with previous PDA experience. Comparison of the test scores revealed no difference between the scores in the PDA-assisted test and the paper-assisted test, analyzed after correction for difficulty using the control mean and standard deviation.