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.
Personal digital assistant; PDA; handheld computers; wireless networks
Over the past decade, handheld computers (or personal digital assistants [PDAs]) have become a popular tool among medical trainees and physicians. Few comprehensive reviews of PDA use in medicine have been published.
We systematically reviewed the literature to (1) describe medical trainees' use of PDAs for education or patient care, (2) catalog popular software applications, and (3) evaluate the impact of PDA use on patient care.
MEDLINE (1993 to 2004), medical education-related conference proceedings, and hand search of article bibliographies.
We identified articles and abstracts that described the use of PDAs in medical education by trainees or educators. Reports presenting a qualitative or quantitative evaluation were included.
Sixty-seven studies met inclusion criteria. Approximately 60% to 70% of medical students and residents use PDAs for educational purposes or patient care. Satisfaction was generally high and correlated with the level of handheld computer experience. Most of the studies included described PDA use for patient tracking and documentation. By contrast, trainees rated medical textbooks, medication references, and medical calculators as the most useful applications. Only 1 randomized trial with educational outcomes was found, demonstrating improved learning and application of evidence-based medicine with use of PDA-based decision support software. No articles reported the impact of PDA use on patient outcomes.
Most medical trainees find handhelds useful in their medical education and patient care. Further studies are needed to evaluate how PDAs impact learning and clinical outcomes.
handhelds; personal digital assistants (PDAs); medical trainees; medical education
Handheld computers are commonly used in clinical practice and often considered invaluable by physicians. Though full of promise, the technology is still costly and literature assessing its real use in clinical practice remains scarce. In an effort to better understand how Personal Digital Assistants (PDA) can be utilized as clinical tools, we designed a study that closely monitored the use of a selection of handheld applications by a cohort of interns in a service of Internal Medicine. Information gathered about actual use of the mobile applications offer valuable insights on usage patterns of tools that promise to be become an important part of our clinical practice in the years to come, and will hopefully help guide future developments.
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.
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.
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.
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.
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.
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.
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.
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
Residents in internal medicine training programs spend an increasing amount of time in the outpatient setting, creating the potential for substantial variability in educational experiences among residents. We developed a data management system (On Track) that combines information on clinical experiences collected from an electronic medical record (EMR) and handheld personal data assistants (PDA). This information is translated into easily interpretable graphics and reports that provide insight into the overall residency curriculum as well as the experiences of individual residents.
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.
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.
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.
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.
clinical; computer; critical care; decision support systems; handheld; internet; point-of-care systems; practice guidelines; simulation
Handheld devices such as mobile phones and tablet computers have become widespread with thousands of available software applications. Recently, handhelds are being proposed as part of medical imaging solutions, especially in emergency medicine, where immediate consultation is required. However, handheld devices differ significantly from medical workstation displays in terms of display characteristics. Moreover, the characteristics vary significantly among device types. We investigate the image quality characteristics of various handheld devices with respect to luminance response, spatial resolution, spatial noise, and reflectance. We show that the luminance characteristics of the handheld displays are different from those of workstation displays complying with grayscale standard target response suggesting that luminance calibration might be needed. Our results also demonstrate that the spatial characteristics of handhelds can surpass those of medical workstation displays particularly for recent generation devices. While a 5 mega-pixel monochrome workstation display has horizontal and vertical modulation transfer factors of 0.52 and 0.47 at the Nyquist frequency, the handheld displays released after 2011 can have values higher than 0.63 at the respective Nyquist frequencies. The noise power spectra for workstation displays are higher than 1.2×10−5 mm2 at 1 mm−1, while handheld displays have values lower than 3.7×10−6 mm2. Reflectance measurements on some of the handheld displays are consistent with measurements for workstation displays with, in some cases, low specular and diffuse reflectance coefficients. The variability of the characterization results among devices due to the different technological features indicates that image quality varies greatly among handheld display devices.
Medical care at mass casualty incidents and disasters requires rapid patient triage and assessment, acute care and disposition often in the setting of overwhelming numbers of victims, limited time, and little resources. Current systems rely on a paper triage tag on which rescuers and medical providers mark the patient’s triage status and record limited information on injuries and treatments administered in the field. In this manuscript, we describe the design, development and deployment of a wireless handheld device with an electronic medical record (EMR) for use by rescuers responding to mass casualty incidents (MCIs) and disasters. The components of this device, the WIISARD First Responder (WFR), includes a personal digital assistant (PDA) with 802.11 wireless transmission capabilities, microprocessor and non-volatile memory, and a unique EMR software that replicates the rapidity and ease of use of the standard paper triage tag. WFR also expands its functionality by recording real-time medical data electronically for simultaneous access by rescuers, mid-level providers and incident commanders on and off the disaster site. WFR is a part of the Wireless Information System for Medical Response in Disasters (WIISARD) architecture.
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.
Entering data on case report forms and subsequently digitizing them in electronic media is the traditional way to maintain a record keeping system in field studies. Direct data entry using an electronic device avoids this two-step process. It is gaining in popularity and has replaced the paper-based data entry system in many studies. We report our experiences with paper- and PDA-based data collection during a fever surveillance study in Pemba Island, Zanzibar, Tanzania.
Data were collected on a 14-page case report paper form in the first period of the study. The case report paper forms were then replaced with handheld computers (personal digital assistants or PDAs). The PDAs were used for screening and clinical data collection, including a rapid assessment of patient eligibility, real time errors, and inconsistency checking.
A comparison of paper-based data collection with PDA data collection showed that direct data entry via PDA was faster and 25% cheaper. Data was more accurate (7% versus 1% erroneous data) and omission did not occur with electronic data collection. Delayed data turnaround times and late error detections in the paper-based system which made error corrections difficult were avoided using electronic data collection.
Electronic data collection offers direct data entry at the initial point of contact. It has numerous advantages and has the potential to replace paper-based data collection in the field. The availability of information and communication technologies for direct data transfer has the potential to improve the conduct of public health research in resource-poor settings.
Bacteraemia; Handheld computers; Personal digital assistants
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.
Computing technology has the potential to improve health care management but is often underutilized. Handheld computers are versatile and relatively inexpensive, bringing the benefits of computers to the bedside. We evaluated the role of this technology for managing patient data and accessing medical reference information, in an academic intensive-care unit (ICU).
Palm III series handheld devices were given to the ICU team, each installed with medical reference information, schedules, and contact numbers. Users underwent a 1-hour training session introducing the hardware and software. Various patient data management applications were assessed during the study period. Qualitative assessment of the benefits, drawbacks, and suggestions was performed by an independent company, using focus groups. An objective comparison between a paper and electronic handheld textbook was achieved using clinical scenario tests.
During the 6-month study period, the 20 physicians and 6 paramedical staff who used the handheld devices found them convenient and functional but suggested more comprehensive training and improved search facilities. Comparison of the handheld computer with the conventional paper text revealed equivalence. Access to computerized patient information improved communication, particularly with regard to long-stay patients, but changes to the software and the process were suggested.
The introduction of this technology was well received despite differences in users' familiarity with the devices. Handheld computers have potential in the ICU, but systems need to be developed specifically for the critical-care environment.
computer communication networks; medical informatics; medical technology; microcomputers; point-of-care technology
Orthopedic injury and intracranial hemorrhage are commonly encountered in emergency radiology, and accurate and timely diagnosis is important. The purpose of this study was to determine whether the diagnostic accuracy of handheld computing devices is comparable to that of monitors that might be used in emergency teleconsultation.
Materials and Methods
Two handheld devices, a Dell Axim personal digital assistant (PDA) and an Apple iPod Touch device, were studied. The diagnostic efficacy of each device was tested against that of secondary-class monitors (primary class being clinical workstation display) for each of two image types—posteroanterior wrist radiographs and slices from CT of the brain—yielding four separate observer performance studies. Participants read a bank of 30 wrist or brain images searching for a specific abnormality (distal radial fracture, fresh intracranial bleed) and rated their confidence in their decisions. A total of 168 readings by examining radiologists of the American Board of Radiology were gathered, and the results were subjected to receiver operating characteristics analysis.
In the PDA - CT brain study, the scores from PDA readings were significantly higher than those from the monitor readings for all observers (p≤0.01) and for radiologists who were not neuroradiology specialists (p≤0.05). No statistically significant differences were noted for the wrist images or in the iPod Touch studies, although some comparisons approached significance.
Handheld devices show promise in the field of emergency teleconsultation for detection of basic orthopaedic injuries and intracranial haemorrhage, although further investigation is warranted.
Recent advances in mobile computing technologies have made electronic medical
records (EMRs) on handheld devices an attractive possibility. However, data
entry paradigms popular on desktop machines do not translate
well to mobile devices1,2. Based on a review of the literature on mobile device usability1–4, we built a prototype user interface for mobile EMRs and held focus groups
with clinician users whose feedback provided useful insight about
design choices, functionality and optimal workflow integration.
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.
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).
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.
Electronic Health records; disasters; wireless; mobile computing
Personal Digital Assistants (PDAs), also known as handheld computers, are being increasingly adopted by physicians, many of whom find the PDA to be an indispensable part of their medical practice. With limited time and expense, an interested physician can choose and purchase a PDA, connect it to a computer, and fill it with useful medical software, much of which is available at little or no cost on the Internet. At its most basic, the PDA allows for the access of medical reference material at the point of care. Physicians interested in going to the next level can use the PDA for electronic prescribing, charge capture, or to customize documents or databases to meet the specific needs of their practice.
Advanced mobile communications and portable computation are now combined in handheld devices called “smartphones”, which are also capable of running third-party software. The number of smartphone users is growing rapidly, including among healthcare professionals. The purpose of this study was to classify smartphone-based healthcare technologies as discussed in academic literature according to their functionalities, and summarize articles in each category.
In April 2011, MEDLINE was searched to identify articles that discussed the design, development, evaluation, or use of smartphone-based software for healthcare professionals, medical or nursing students, or patients. A total of 55 articles discussing 83 applications were selected for this study from 2,894 articles initially obtained from the MEDLINE searches.
A total of 83 applications were documented: 57 applications for healthcare professionals focusing on disease diagnosis (21), drug reference (6), medical calculators (8), literature search (6), clinical communication (3), Hospital Information System (HIS) client applications (4), medical training (2) and general healthcare applications (7); 11 applications for medical or nursing students focusing on medical education; and 15 applications for patients focusing on disease management with chronic illness (6), ENT-related (4), fall-related (3), and two other conditions (2). The disease diagnosis, drug reference, and medical calculator applications were reported as most useful by healthcare professionals and medical or nursing students.
Many medical applications for smartphones have been developed and widely used by health professionals and patients. The use of smartphones is getting more attention in healthcare day by day. Medical applications make smartphones useful tools in the practice of evidence-based medicine at the point of care, in addition to their use in mobile clinical communication. Also, smartphones can play a very important role in patient education, disease self-management, and remote monitoring of patients.
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.
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.
incident reporting; medication errors; computers; handheld
Medical imaging is commonly used to diagnose many emergent conditions, as well as plan treatment. Digital images can be reviewed on almost any computing platform. Modern mobile phones and handheld devices are portable computing platforms with robust software programming interfaces, powerful processors, and high-resolution displays. OsiriX mobile, a new Digital Imaging and Communications in Medicine viewing program, is available for the iPhone/iPod touch platform. This raises the possibility of mobile review of diagnostic medical images to expedite diagnosis and treatment planning using a commercial off the shelf solution, facilitating communication among radiologists and referring clinicians.
Radiology; PACS; informatics; teleradiology; mobile phone; iPhone; PDA; medical images; health care; DICOM; smartphone
Handheld computers are now a common sight in medicine, but there are scarce data on who actually uses them and what functions are found to be most useful. This is the first study of handheld computer use in a British hospital, and shows that there is already considerable use and acceptance of the technology, with 22 of 55 (40%) physicians possessing and using such a device. Doctors in training grades are more likely to make use of medical software, particularly textbooks, calculators, and formularies. The main barriers to greater use of this technology were cost of software and poor applicability to UK practice.
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.
Kampo medicine has been the primary medical model in Japan until the mid 1800s, regained a prominent role in today's Japanese medical system. Today, 148 herbal Kampo formulas can be prescribed under the national health insurance system, allowing physicians to integrate Kampo in their daily practice. This article aims to provide information about the extent to which Kampo is now used in clinics throughout Japan and about physician's current attitudes toward Kampo. We used the results of a 2008 survey that was administered to physicians throughout Japan (n = 684). The data showed that 83.5% of physicians currently use Kampo in the clinic, although the distribution of physicians who use Kampo differ widely depending on the specialty and provided a breakdown of Kampo usage by specialty. It will be interesting to see how each specialty incorporates Kampo into its respective field as Kampo continues to play a pertinent role in Japanese medical system.
Handheld computing has had many applications in medicine, but relatively few in pathology. Most reported uses of handhelds in pathology have been limited to experimental endeavors in telemedicine or education. With recent advances in handheld hardware and software, along with concurrent advances in whole-slide imaging (WSI), new opportunities and challenges have presented themselves. This review addresses the current state of handheld hardware and software, provides a history of handheld devices in medicine focusing on pathology, and presents future use cases for such handhelds in pathology.
Education; handhelds; smartphones; tablets; WSI