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1.  Prospective evaluation of an internet-linked handheld computer critical care knowledge access system 
Critical Care  2004;8(6):R414-R421.
Introduction
Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs.
Methods
Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators.
Results
Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3–126.8), with medical software accessed less often (median 9/month, IQR 3.7–13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15–40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified.
Conclusion
An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.
doi:10.1186/cc2967
PMCID: PMC1065064  PMID: 15566586
clinical; computer; critical care; decision support systems; handheld; internet; point-of-care systems; practice guidelines; simulation
2.  Using Wireless Handheld Computers to Seek Information at the Point of Care: An Evaluation by Clinicians 
Objective
To evaluate: (1) the effectiveness of wireless handheld computers for online information retrieval in clinical settings; (2) the role of MEDLINE® in answering clinical questions raised at the point of care.
Design
A prospective single-cohort study: accompanying medical teams on teaching rounds, five internal medicine residents used and evaluated MD on Tap, an application for handheld computers, to seek answers in real time to clinical questions arising at the point of care.
Measurements
All transactions were stored by an intermediate server. Evaluators recorded clinical scenarios and questions, identified MEDLINE citations that answered the questions, and submitted daily and summative reports of their experience. A senior medical librarian corroborated the relevance of the selected citation to each scenario and question.
Results
Evaluators answered 68% of 363 background and foreground clinical questions during rounding sessions using a variety of MD on Tap features in an average session length of less than four minutes. The evaluator, the number and quality of query terms, the total number of citations found for a query, and the use of auto-spellcheck significantly contributed to the probability of query success.
Conclusion
Handheld computers with Internet access are useful tools for healthcare providers to access MEDLINE in real time. MEDLINE citations can answer specific clinical questions when several medical terms are used to form a query. The MD on Tap application is an effective interface to MEDLINE in clinical settings, allowing clinicians to quickly find relevant citations.
doi:10.1197/jamia.M2424
PMCID: PMC2213482  PMID: 17712085
3.  Critical care procedure logging using handheld computers 
Critical Care  2004;8(5):R336-R342.
Introduction
We conducted this study to evaluate the feasibility of implementing an internet-linked handheld computer procedure logging system in a critical care training program.
Methods
Subspecialty trainees in the Interdepartmental Division of Critical Care at the University of Toronto received and were trained in the use of Palm handheld computers loaded with a customized program for logging critical care procedures. The procedures were entered into the handheld device using checkboxes and drop-down lists, and data were uploaded to a central database via the internet. To evaluate the feasibility of this system, we tracked the utilization of this data collection system. Benefits and disadvantages were assessed through surveys.
Results
All 11 trainees successfully uploaded data to the central database, but only six (55%) continued to upload data on a regular basis. The most common reason cited for not using the system pertained to initial technical problems with data uploading. From 1 July 2002 to 30 June 2003, a total of 914 procedures were logged. Significant variability was noted in the number of procedures logged by individual trainees (range 13–242). The database generated by regular users provided potentially useful information to the training program director regarding the scope and location of procedural training among the different rotations and hospitals.
Conclusion
A handheld computer procedure logging system can be effectively used in a critical care training program. However, user acceptance was not uniform, and continued training and support are required to increase user acceptance. Such a procedure database may provide valuable information that may be used to optimize trainees' educational experience and to document clinical training experience for licensing and accreditation.
doi:10.1186/cc2921
PMCID: PMC1065023  PMID: 15469577
critical care; handheld computers; internet; procedure logging; training program
4.  Basic Microbiologic and Infection Control Information to Reduce the Potential Transmission of Pathogens to Patients via Computer Hardware 
Computer technology from the management of individual patient medical records to the tracking of epidemiologic trends has become an essential part of all aspects of modern medicine. Consequently, computers, including bedside components, point-of-care testing equipment, and handheld computer devices, are increasingly present in patients’ rooms. Recent articles have indicated that computer hardware, just as other medical equipment, may act as a reservoir for microorganisms and contribute to the transfer of pathogens to patients. This article presents basic microbiological concepts relative to infection, reviews the present literature concerning possible links between computer contamination and nosocomial colonizations and infections, discusses basic principles for the control of contamination, and provides guidelines for reducing the risk of transfer of microorganisms to susceptible patient populations.
doi:10.1197/jamia.M1082
PMCID: PMC346637  PMID: 12223502
5.  Introducing handheld computing into a residency program: preliminary results from qualitative and quantitative inquiry. 
Although published reports describe specific handheld computer applications in medical training, we know very little yet about how, and how well, handheld computing fits into the spectrum of information resources available for patient care and physician training. This paper reports preliminary quantitative and qualitative results from an evaluation study designed to track changes in computer usage patterns and computer-related attitudes before and after introduction of handheld computing. Pre-implementation differences between residents and faculty s usage patterns are interpreted in terms of a "work role" construct. We hypothesize that over time residents and faculty will adopt, adapt, or abandon handheld computing according to how, and how well, this technology supports their successful completion of work role-related tasks. This hypothesis will be tested in the second phase of this pre- and post-implementation study.
PMCID: PMC2243603  PMID: 11825224
6.  A Palm OS Peripheral Brain Program for Use by Clinicians 
Physicians and medical students are increasingly turning to handheld computers to serve their point-of-care information needs. Although many reference texts are available for handhelds, these references may not have all the answers a clinician needs. A complimentary source of information is a personal listing of “pearls,” small pieces of clinical information that a clinician wants to remember. We created a Palm OS pearl program to study the pearl concept, and point-of-care information retrieval by medical students and clinicians. We report on preliminary findings confirming the perceived usefulness of the pearl concept and user beliefs that it would aid in learning.
PMCID: PMC2244378
7.  Clinician Use of a Palmtop Drug Reference Guide 
Objective: Problems involving drug knowledge are one of the most common causes of serious medication errors. Although the information that clinicians need is often available somewhere, retrieving it expeditiously has been problematic. At the same time, clinicians are faced with an ever-expanding pharmacology knowledge base. Recently, point-of-care technology has become more widely available and more practical with the advent of handheld, or palmtop, computing. Therefore, the authors evaluated the clinical contribution of a drug database developed for the handheld computer. ePocrates Rx (formerly known as qRx; ePocrates, San Carlos, California) is a comprehensive drug information guide that is downloadable free from the Internet and designed for the Palm OS platform align="right".
Design: A seven-day online survey of 3,000 randomly selected ePocrates Rx users was conducted during March 2000.
Measurements: User technology experience, product evaluation and usage patterns, and the effects of the drug reference database on information-seeking behavior, practice efficiency, decision making, and patient care.
Results: The survey response rate was 32 percent (n=946). Physicians reported that ePocrates Rx saves time during information retrieval, is easily incorporated into their usual workflow, and improves drug-related decision making. They also felt that it reduced the rate of preventable adverse drug events.
Conclusions: Self-reported perceptions by responding clinicians endorse improved access to drug information and improved practice efficiency associated with the use of handheld devices. The clinical and practical value of using these devices in clinical settings will clearly grow further as wireless communication becomes more ubiquitous and as more applications become available.
doi:10.1197/jamia.M1001
PMCID: PMC344582  PMID: 11971883
8.  Barriers to Acceptance of Personal Digital Assistants for HIV/AIDS Data Collection in Angola 
Purpose
Handheld computers have potential to improve HIV/AIDS programs in healthcare settings in low-resource countries, by improving the speed and accuracy of collecting data. However, the acceptability of the technology (i.e., user attitude and reaction) is critical for its successful implementation. Acceptability is particularly critical for HIV/AIDS behavioral data, as it depends on respondents giving accurate information about a highly sensitive topic – sexual behavior.
Methods
To explore the acceptability of handheld computers for HIV/AIDS data collection and to identify potential barriers to acceptance, five focus groups of 8–10 participants each were conducted in Luanda, Angola. Facilitators presented Palm Tungsten E handhelds to the focus groups, probed participants’ perceptions of the handheld computer, and asked how they felt about disclosing intimate sexual behavior to an interviewer using a handheld computer. Discussions were conducted in Portuguese, the official language of Angola, and audio-taped. They were then transcribed and translated into English for analysis.
Results
In total, 49 people participated in the focus groups. PDAs were understood through the lens of social and cultural beliefs. Themes that emerged were suspicion of outsiders, concern with longevity, views on progress and development, and concern about social status.
Conclusions
The findings from this study suggest that personal and cultural beliefs influence participant acceptance of PDAs in Angola. While PDAs provide great advantages in terms of speed and efficiency of data collection, these barriers, if left unaddressed, may lead to biased reporting of HIV/AIDS risk data. An understanding of the barriers and why they are relevant in Angola may help researchers and practitioners to reduce the impact of these barriers on HIV/AIDS data collection.
doi:10.1016/j.ijmedinf.2011.04.004
PMCID: PMC3152252  PMID: 21622022
Computers; Handheld; Data Collection; HIV; Sexual Behavior; Africa South of the Sahara
9.  Design and evaluation of a wireless electronic health records system for field care in mass casualty settings 
Background
There is growing interest in the use of technology to enhance the tracking and quality of clinical information available for patients in disaster settings. This paper describes the design and evaluation of the Wireless Internet Information System for Medical Response in Disasters (WIISARD).
Materials and methods
WIISARD combined advanced networking technology with electronic triage tags that reported victims' position and recorded medical information, with wireless pulse-oximeters that monitored patient vital signs, and a wireless electronic medical record (EMR) for disaster care. The EMR system included WiFi handheld devices with barcode scanners (used by front-line responders) and computer tablets with role-tailored software (used by managers of the triage, treatment, transport and medical communications teams). An additional software system provided situational awareness for the incident commander. The WIISARD system was evaluated in a large-scale simulation exercise designed for training first responders. A randomized trial was overlaid on this exercise with 100 simulated victims, 50 in a control pathway (paper-based), and 50 in completely electronic WIISARD pathway. All patients in the electronic pathway were cared for within the WIISARD system without paper-based workarounds.
Results
WIISARD reduced the rate of the missing and/or duplicated patient identifiers (0% vs 47%, p<0.001). The total time of the field was nearly identical (38:20 vs 38:23, IQR 26:53–1:05:32 vs 18:55–57:22).
Conclusion
Overall, the results of WIISARD show that wireless EMR systems for care of the victims of disasters would be complex to develop but potentially feasible to build and deploy, and likely to improve the quality of information available for the delivery of care during disasters.
doi:10.1136/amiajnl-2011-000229
PMCID: PMC3198000  PMID: 21709162
Electronic Health records; disasters; wireless; mobile computing
10.  Hand-held Computer Use in Third-year Medical Clerkships 
Handheld computers (PDA's, palm-tops, etc.) are increasingly popular in medicine. We analyzed a class of medical students to identify and categorize the differences between handheld computer owners vs. non-owners. Medical students were surveyed in several third year clinical rotations regarding demographics, technology use, barriers to ownership and perceived educational advantage. These data provide a profile of the typical medical handheld computer user, useful for institutions seeking to successfully integrate handheld computers into their programs.
PMCID: PMC2243663
11.  Handheld Computing in Medicine 
Handheld computers have become a valuable and popular tool in various fields of medicine. A systematic review of articles was undertaken to summarize the current literature regarding the use of handheld devices in medicine. A variety of articles were identified, and relevant information for various medical fields was summarized. The literature search covered general information about handheld devices, the use of these devices to access medical literature, electronic pharmacopoeias, patient tracking, medical education, research, business management, e-prescribing, patient confidentiality, and costs as well as specialty-specific uses for personal digital assistants (PDAs).
The authors concluded that only a small number of articles provide evidence-based information about the use of PDAs in medicine. The majority of articles provide descriptive information, which is nevertheless of value. This article aims to increase the awareness among physicians about the potential roles for handheld computers in medicine and to encourage the further evaluation of their use.
doi:10.1197/jamia.M1180
PMCID: PMC150367  PMID: 12595403
12.  Techniques for identifying the applicability of new information management technologies in the clinical setting: an example focusing on handheld computers. 
This article describes techniques and strategies used to judge the potential applicability of new information management technologies in the clinical setting and to develop specific design recommendations for new features and services. We focus on a project carried out to identify the potential uses of handheld computers (i.e., the Palm Pilot or a small WinCE-based device) in the ambulatory practice setting. We found that the potential for a robust handheld computing device to positively affect the outpatient ambulatory clinical setting is enormous, and that the information derived from the exploratory research project is useful in creating specific design recommendations for further development.
PMCID: PMC2243837  PMID: 11079995
13.  The Impact of Mobile Handheld Technology on Hospital Physicians' Work Practices and Patient Care: A Systematic Review 
The substantial growth in mobile handheld technologies has heralded the opportunity to provide physicians with access to information, resources, and people at the right time and place. But is this technology delivering the benefits to workflow and patient care promised by increased mobility? The authors conducted a systematic review to examine evidence regarding the impact of mobile handheld technology on hospital physicians' work practices and patient care, focusing on quantification of the espoused virtues of mobile technologies. The authors identified thirteen studies that demonstrated the ability of personal digital assistants (PDAs) to positively impact on areas of rapid response, error prevention, and data management and accessibility. The use of PDAs demonstrates the greatest benefits in contexts where time is a critical factor and a rapid response crucial. However, the extent to which these devices improved outcomes and workflow efficiencies because of their mobility was largely absent from the literature. The paucity of evidence calls for much needed future research that asks explicit questions about the impact the mobility of devices has on work practices and outcomes.
doi:10.1197/jamia.M3215
PMCID: PMC3002124  PMID: 19717793
14.  An integrated platform for portable clinical data, collaboration, and interactive education 
We describe Apprentice, an innovative web-based patient record that combines clinical data, tools for collaborative task-management, and an integrated, interactive educational platform. The system makes this information available to providers in a handheld format to bring knowledge and education to the bedside. Apprentice is incorporated into preexisting clinical and educational computer systems within a large academic medical center.
PMCID: PMC1839459  PMID: 17238474
15.  Personal Digital Assistants 
Journal of Digital Imaging  2004;17(1):5-17.
Personal digital assistant sales are growing exponentially, and as medical technology advances the amount of information available becomes staggering, making a handheld device, with the ability to store a great amount of information, progressively more valuable to health care providers. Mobile computing allows for a great deal of knowledge in a small package, creating a “walking library” with a mobile collection of data always accessible. There are many diverse types of PDAs, and this article discusses the history of PDAs, general purchasing issues, general PDA features, and the most significant differences between the Palm and the Windows CE operating systems.
doi:10.1007/s10278-003-1665-8
PMCID: PMC3043961  PMID: 15255514
Personal digital assistant; PDA; handheld computers; wireless networks
16.  The feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance - ‘a remote virtual mentor’ 
Background
Point-of-care ultrasound (POC-US) use is increasingly common as equipment costs decrease and availability increases. Despite the utility of POC-US in trained hands, there are many situations wherein patients could benefit from the added safety of POC-US guidance, yet trained users are unavailable. We therefore hypothesized that currently available and economic ‘off-the-shelf’ technologies could facilitate remote mentoring of a nurse practitioner (NP) to assess for recurrent pneumothoraces (PTXs) after chest tube removal.
Methods
The simple remote telementored ultrasound system consisted of a handheld ultrasound machine, head-mounted video camera, microphone, and software on a laptop computer. The video output of the handheld ultrasound machine and a macroscopic view of the NP's hands were displayed to a remote trauma surgeon mentor. The mentor instructed the NP on probe position and US machine settings and provided real-time guidance and image interpretation via encrypted video conferencing software using an Internet service provider. Thirteen pleural exams after chest tube removal were conducted.
Results
Thirteen patients (26 lung fields) were examined. The remote exam was possible in all cases with good connectivity including one trans-Atlantic interpretation. Compared to the subsequent upright chest radiograph, there were 4 true-positive remotely diagnosed PTXs, 2 false-negative diagnoses, and 20 true-negative diagnoses for 66% sensitivity, 100% specificity, and 92% accuracy for remotely guided chest examination.
Conclusions
Remotely guiding a NP to perform thoracic ultrasound examinations after tube thoracostomy removal can be simply and effectively performed over encrypted commercial software using low-cost hardware. As informatics constantly improves, mentored remote examinations may further empower clinical care providers in austere settings.
doi:10.1186/2036-7902-5-5
PMCID: PMC3735420  PMID: 23805869
Pneumothorax; Remote medicine; Tele-ultrasound; Education; Global health
17.  The Use of Wireless E-Mail to Improve Healthcare Team Communication 
Objective
To assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU).
Design
The authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact.
Measurements
The survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7.
Results
Staff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices.
Conclusions
Interdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.
doi:10.1197/jamia.M2299
PMCID: PMC2744721  PMID: 19567803
18.  Use and Perceived Benefits of Handheld Computer-based Clinical References 
Objective
Clinicians are increasingly using handheld computers (HC) during patient care. We sought to assess the role of HC-based clinical reference software in medical practice by conducting a survey and assessing actual usage behavior.
Design
During a 2-week period in February 2005, 3600 users of a HC-based clinical reference application were asked by e-mail to complete a survey and permit analysis of their usage patterns. The software includes a pharmacopeia, an infectious disease reference, a medical diagnostic and therapeutic reference and transmits medical alerts and other notifications during HC synchronizations. Software usage data were captured during HC synchronization for the 4 weeks prior to survey completion.
Measurements
Survey responses and software usage data.
Results
The survey response rate was 42% (n = 1501). Physicians reported using the clinical reference software for a mean of 4 years and 39% reported using the software during more than half of patient encounters. Physicians who synchronized their HC during the data collection period (n = 1249; 83%) used the pharmacopeia for unique drug lookups a mean of 6.3 times per day (SD 12.4). The majority of users (61%) believed that in the prior 4 weeks, use of the clinical reference prevented adverse drug events or medication errors 3 or more times. Physicians also believed that alerts and other notifications improved patient care if they were public health warnings (e.g. about influenza), new immunization guidelines or drug alert warnings (e.g. rofecoxib withdrawal).
Conclusion
Current adopters of HC-based medical references use these tools frequently, and found them to improve patient care and be valuable in learning of recent alerts and warnings.
doi:10.1197/jamia.M2103
PMCID: PMC1656968  PMID: 16929041
19.  MEDLINE as a Source of Just-in-Time Answers to Clinical Questions 
Clinicians increasingly use handheld devices to support evidence-based practice and for clinical decision support. However, support of clinical decisions through information retrieval from MEDLINE® and other databases lags behind popular daily activities such as patient information or drug formulary look-up. The objective of the current study is to determine whether relevant information can be retrieved from MEDLINE to answer clinical questions using a handheld device at the point of care. Analysis of search and retrieval results for 108 clinical questions asked by members of clinical teams during 28 daily rounds in a 12-bed intensive care unit confirm MEDLINE as a potentially valuable resource for just-in-time answers to clinical questions. Answers to 93 (86%) questions were found in MEDLINE by two resident physicians using handheld devices. The majority of answers, 88.9% and 97.7% respectively, were found during rounds. Strategies that facilitated timely retrieval of results include using PubMed® Clinical Queries and Related Articles, spell check, and organizing retrieval results into topical clusters. Further possible improvements in organization of retrieval results such as automatic semantic clustering and providing patient outcome information along with the titles of the retrieved articles are discussed.
PMCID: PMC1839449  PMID: 17238329
20.  Validation of electronic student encounter logs in an emergency medicine clerkship. 
Handheld electronic patient encounter logs offer opportunities to understand and enhance medical students' clinical experiences. Before using the data, the reliability of log entries needs to be verified. We assessed the sensitivity and specificity of handheld patient encounter logs by comparing documented entries with reliable external data sources. During an Emergency Medicine clerkship, medical students voluntarily recorded their patients' diagnoses in an Electronic Student Encounter Log (E-SEL) on handheld computers. We used patient demographics to match anonymous log entries with medical charts. Most students recorded 60% or more of their patient encounters and on average 60% of their patients' medical problems in the log. The false positive rate was 26% for patient encounters and 19% for patient problems. In general, students recorded more diagnoses in more detail than was available in the patient's ED chart. Improvements in the log's interface and documentation incentives should enhance the log's accuracy and utility.
PMCID: PMC2244433  PMID: 12463859
21.  Handheld Technology to Improve Patient Care 
Objective: Despite an increasing movement toward shared decision making and the incorporation of patients' preferences into health care decision making, little research has been done on the development and evaluation of support systems that help clinicians elicit and integrate patients' preferences into patient care. This study evaluates nurses' use of choice, a handheld-computer–based support system for preference-based care planning, which assists nurses in eliciting patients' preferences for functional performance at the bedside. Specifically, it evaluates the effects of system use on nurses' care priorities, preference achievement, and patients' satisfaction.
Design: Three-group sequential design with one intervention and two control groups (N=155). In the intervention group, nurses elicited patients' preferences for functional performance with the handheld-computer–based choice application as part of their regular admission interview; preference information was added to patients' charts and used in subsequent care planning.
Results: Nurses' use of choice made nursing care more consistent with patient preferences (F=11.4; P<0.001) and improved patients' preference achievement (F=4.9; P<0.05). Furthermore, higher consistency between patients' preferences and nurses' care priorities was associated with higher preference achievement (r=0.49; P<0.001).
Conclusion: In this study, the use of a handheld-computer–based support system for preference-based care planning improved patient-centered care and patient outcomes. The technique has potential to be included in clinical practice as part of nurses' routine care planning.
doi:10.1197/jamia.M0891
PMCID: PMC344576  PMID: 11861634
22.  Evidence of Effectiveness of Health Care Professionals Using Handheld Computers: A Scoping Review of Systematic Reviews 
Background
Handheld computers and mobile devices provide instant access to vast amounts and types of useful information for health care professionals. Their reduced size and increased processing speed has led to rapid adoption in health care. Thus, it is important to identify whether handheld computers are actually effective in clinical practice.
Objective
A scoping review of systematic reviews was designed to provide a quick overview of the documented evidence of effectiveness for health care professionals using handheld computers in their clinical work.
Methods
A detailed search, sensitive for systematic reviews was applied for Cochrane, Medline, EMBASE, PsycINFO, Allied and Complementary Medicine Database (AMED), Global Health, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. All outcomes that demonstrated effectiveness in clinical practice were included. Classroom learning and patient use of handheld computers were excluded. Quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. A previously published conceptual framework was used as the basis for dual data extraction. Reported outcomes were summarized according to the primary function of the handheld computer.
Results
Five systematic reviews met the inclusion and quality criteria. Together, they reviewed 138 unique primary studies. Most reviewed descriptive intervention studies, where physicians, pharmacists, or medical students used personal digital assistants. Effectiveness was demonstrated across four distinct functions of handheld computers: patient documentation, patient care, information seeking, and professional work patterns. Within each of these functions, a range of positive outcomes were reported using both objective and self-report measures. The use of handheld computers improved patient documentation through more complete recording, fewer documentation errors, and increased efficiency. Handheld computers provided easy access to clinical decision support systems and patient management systems, which improved decision making for patient care. Handheld computers saved time and gave earlier access to new information. There were also reports that handheld computers enhanced work patterns and efficiency.
Conclusions
This scoping review summarizes the secondary evidence for effectiveness of handheld computers and mhealth. It provides a snapshot of effective use by health care professionals across four key functions. We identified evidence to suggest that handheld computers provide easy and timely access to information and enable accurate and complete documentation. Further, they can give health care professionals instant access to evidence-based decision support and patient management systems to improve clinical decision making. Finally, there is evidence that handheld computers allow health professionals to be more efficient in their work practices. It is anticipated that this evidence will guide clinicians and managers in implementing handheld computers in clinical practice and in designing future research.
doi:10.2196/jmir.2530
PMCID: PMC3841346  PMID: 24165786
handheld computers; mobile devices; mhealth; PDA; information seeking behavior; evidence-based practice; delivery of health care; clinical practice; health technology adoption; diffusion of innovation; systematic review; evidence synthesis; documentation
23.  Delirium and Sedation Recognition Using Validated Instruments: Reliability of Bedside ICU Nursing Assessments from 2007 to 2010 
Journal of the American Geriatrics Society  2011;59(Suppl 2):S249-S255.
OBJECTIVES
The aim of this study was to describe the reliability and sustainability of delirium and sedation measurements by bedside intensive care unit (ICU) nurses.
DESIGN
Prospective cohort study.
SETTING
A tertiary care academic medical center.
PARTICIPANTS
510 ICU patients from 2007 to 2010. 627 bedside nurses.
MEASUREMENTS
Delirium and sedation levels were independently measured in routine care by bedside nurses and well-trained reference-rater research nurses. Bedside nurses were instructed to use the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) every 12 hours and the Richmond Agitation-Sedation Scale (RASS) every 4 hours to measure delirium and sedation, respectively. CAM-ICU and RASS assessment agreement were computed using weighted kappa statistics across the entire population and subgroups (e.g., ICU type). Sensitivity and specificity of bedside nurse identification of delirium were calculated to understand sources of discordance.
RESULTS
6198 CAM-ICU and 6880 RASS measurement pairs obtained on 3846 patient-days. For CAM-ICU measurements, agreement between bedside and research nurses was substantial (weighted kappa = 0.67, 95% CI 0.66 to 0.70) and stable over 3 years of data collection. RASS measures also demonstrated substantial agreement (weighted kappa = 0.66, 95% CI 0.64 to 0.68), which was stable across all years of data collection. The sensitivity and specificity of delirium nurse assessments was 0.81 (95% CI 0.78 to 0.83) and 0.81 (95% CI 0.78 to 0.85), respectively.
CONCLUSION
Bedside nurse measurements of delirium and sedation are sustainable and reliable sources of information. These measures can be used for clinical decision making, quality improvement and measurement activities.
doi:10.1111/j.1532-5415.2011.03673.x
PMCID: PMC3233973  PMID: 22091569
Delirium; Sedation; Measurement; Critical Care; Nursing
24.  Handheld Optical Coherence Tomography Scanner for Primary Care Diagnostics 
The goal of this study is to develop an advanced point-of-care diagnostic instrument for use in a primary care office using handheld optical coherence tomography (OCT). This system has the potential to enable earlier detection of diseases and accurate image-based diagnostics. Our system was designed to be compact, portable, user-friendly, and fast, making it well suited for the primary care office setting. The unique feature of our system is a versatile handheld OCT imaging scanner which consists of a pair of computer-controlled galvanometer-mounted mirrors, interchangeable lens mounts, and miniaturized video camera. This handheld scanner has the capability to guide the physician in real time for finding suspicious regions to be imaged by OCT. In order to evaluate the performance and use of the handheld OCT scanner, the anterior chamber of a rat eye and in vivo human retina, cornea, skin, and tympanic membrane were imaged. Based on this feasibility study, we believe that this new type of handheld OCT device and system has the potential to be an efficient point-of-care imaging tool in primary care medicine.
doi:10.1109/TBME.2010.2096816
PMCID: PMC3214662  PMID: 21134801
Handheld imaging scanner; optical coherence tomography (OCT); primary care medicine
25.  Use of a Handheld Computer Application for Voluntary Medication Event Reporting by Inpatient Nurses and Physicians 
OBJECTIVE
To determine the feasibility of capturing self-reported medication events using a handheld computer-based Medication Event Reporting Tool (MERT).
DESIGN AND PARTICIPANTS
Handheld computers operating the MERT software application were deployed among volunteer physician (n = 185) and nurse (n = 119) participants on the medical wards of four university-affiliated teaching hospitals. Participants were encouraged to complete confidential reports on the handheld computers for medication events observed during the study period.
MEASUREMENTS AND MAIN RESULTS
Demographic variables including age, gender, education level, and clinical experience were recorded for all participants. Each MERT report included details on the provider, location, timing and type of medication event recorded. Over the course of 2,311 days of clinician participation, 76 events were reported; the median time for report completion was 231 seconds. The average event reporting rate for all participants was 0.033 reports per clinician shift. Nurses had a significantly higher reporting rate compared to physicians (0.045 vs 0.026 reports/shift, p = .02). Subgroup analysis revealed that attending physicians reported events more frequently than resident physicians (0.042 vs 0.021 reports/shift, p = .03), and at a rate similar to that of nurses (p = .80). Only 5% of MERT medication events were reported to require increased monitoring or treatment.
CONCLUSIONS
A handheld-based event reporting tool is a feasible method to record medication events in inpatient hospital care units. Handheld reporting tools may hold promise to augment existing hospital reporting systems.
doi:10.1007/s11606-007-0404-0
PMCID: PMC2359505  PMID: 18373139
incident reporting; medication errors; computers; handheld

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