How Technology Will Affect Your Practice

Technology has become an essential component in the practice of medicine, largely due to high information demand. The information and computing needs of the physician are tremendous, especially in light of newer federal regulations regarding security and confidentiality. Information management for the busy physician involves storage, retrieval and speedy access at the point of care. In the last several years, personal digital assistants (PDAs) or handheld computers have become an essential information tool to meet this information need.

Many articles in both health care and technology magazines have been written regarding the use of PDAs in medicine, with diverse topics such as prescription ordering (Hicks, 2001), reference tools (Kelly, 2001) and charge capture (Terry, 2001). Even magazines devoted to handheld computing have had articles specific to the field of medicine (Johnson, 2002). The journal Psychiatric Services has already published three articles regarding PDA use (Grasso and Genest, 2001; Luo et al., 2002; Luo et al., 2001). Clearly, PDAs have become a topic of interest.

The issue of PDAs has also piqued the interest of many health care organizations. The California Healthcare Foundation published a report last October on wireless and mobile computing, examining how soon and to what extent these applications might be integrated into standard health care practice (Turisco and Case, 2001). The Agency for Healthcare Research and Quality has funded four research projects involving personal digital assistants to prevent medical errors <www.ahrq.org/qual/ newgrants/it.htm>. This interest demonstrates how PDA use has become more of an enterprise and systems issue.

In addition to the numerous articles that have been written on PDAs, there are several books (Table) and over 1,000 Web sites devoted to PDAs according to Google <directory.google.com/Top/Computers/Systems/
Handhelds/?tc=1>. Organizations such as the Michigan State Medical Society (Chin, 2001) and the American Psychiatric Association <www.psych.org/sched_events/ ann_mtg_02/
brochure02.pdf> have offered classes to teach physicians how to use their PDAs. Given the tremendous amount of information available, this article will introduce essential concepts and serve as the portal to the wealth of information relating to PDAs in psychiatry.

Most people know that PDAs started as electronic counterparts to their cousins, paper-based organizers. The standard PDA features include a date book, an address book, a to-do list and a memo area for notes. These features function similarly to paper-based organizers but have significant additional capabilities. An obvious advantage is that the entries are made in machine text, which can then be exchanged with other electronic media or devices. What sets these devices apart from paper organizers is their capability to run medical applications or programs.

There are many other advantages to using a PDA. A key element involves their size, which ranges from a pack of cards to a thick checkbook. For the busy physician moving from office to office, a PDA is portable and unobtrusive. Almost all PDAs provide some linkage to information on desktop computers. This allows for the synchronization of data between the PDA and the desktop computer to keep information current. In addition, this synchronization process serves as a handy backup feature when data are lost.

Although the various models and manufacturers make the decision appear difficult, choosing a PDA is really a simple matter. One key concept to keep in mind is that technology improves and changes rather quickly. Within one year, newer models may offer additional features or capabilities that are desirable. Although a wait-and-see approach may mitigate your anxiety that your PDA is obsolete, it will also mean that you will not benefit from using a PDA as efficiently. A good plan of action is to consider keeping your PDA for at least one year, then upgrade only when new features are compelling, such as more memory or wireless capability.

Which PDA to purchase should be first determined based on its operating system (OS). Currently, there are four main operating systems available. Palm OS-based PDAs are currently the most popular, EPOC OS-based devices are more popular in Europe, Pocket PC-based PDAs are becoming more popular, and Linux OS-based PDAs have just begun to enter the market. Generally, all PDAs have similar basic capabilities, but what set them apart are their available software and hardware options.

Currently, Palm OS <www.palmos.com> PDAs are quite quick and portable. They are generally smaller than their counterparts and are noted for an "instant-on" capability, intuitive user interface and good battery life. They have the most medical software available. In addition, many hardware accessories are available such as modems, keyboards and wireless local area network (LAN) adapters. Manufacturers to consider include Palm, IBM, Sony, HandEra and Handspring.

Pocket PC-based PDAs are considered the powerhouses of the PDA market with more memory and a faster central processing unit (CPU) <www.pocketpc.com>. These devices are noted for enterprise-level capability but are notorious for poor battery life. Although the number of software developers for the Pocket PC is significantly smaller than the number of Palm OS developers, this trend is slowly beginning to change. Manufacturers include Toshiba, Compaq, Hewlett-Packard, Casio, Audiovox and NEC <www.microsoft.com/mobile/pocketpc/
hardware/default.asp>.

The EPOC OS PDAs and Linux OS PDAs are both quite versatile. However, both lack a significant software developer base. Psion <www.psion.com>, one of the primary manufacturers of EPOC OS PDAs, has withdrawn from the consumer market to focus on enterprise and vertical markets. Linux OS PDAs by Agenda <www.agendacomputing.com> and Sharp <www.sharpusa.com/products/ModelLanding/
0,1058,698,00.html> are quite feature-rich, but should only be used by those comfortable with the Linux OS.

The basic features of PDAs serve the psychiatrist well. One of the advantages of the calendar program is the ability to set repeating appointments, such as therapy sessions or meetings, which prevents double-booking of appointments. The address book program is quite versatile in storing information, such as demographics, preferred pharmacy and so on. The To-Do program keeps track of activities such as returned calls and prescription refills. Document editing is done via the memo or note program in the PDA, which is very useful for entering short notes such as drug information.

In the Palm OS PDAs, only short notes can be entered due to the 4 kilobyte file size limit, which represents less than one full page. More extensive text editing is available on Palm OS PDAs with software such as QuickWord <www.cesinc.com> or Wordsmith <www.bluenomad.com>. These pro-grams offer conversions between Microsoft Word and the Palm PDA versions of the document. On Pocket PC devices, there is no size limit, since Pocket Word is a standard application with linked conversion to documents on the desktop. Documents can be printed with the use of additional infrared printing software specific for the PDA.

E-mail is a popular form of communication, and more physicians are using this medium specifically to communicate with patients. Screen size and ability to work with attachments limit e-mail on the PDA. E-mail can be handled either with a direct PDA-Internet connection or upon synchronization with an Internet-connected computer. An extensive list of Palm OS e-mail software can be found on Handheld Computing magazine's Web site <www.hhcmag.com> by searching the links for e-mail software. Although the Pocket PC provides Pocket Outlook for e-mail, PocketGear <www.pocketgear.com> has additional related software.

Pharmaceutical information at the point of care is one of the most valuable uses of a PDA. These programs cannot replace resources such as the Physician's Desk Reference, but they do provide portable versions. One of the more popular Palm OS clinical drug databases is qRx from ePocrates <www.epocrates.com>. Many of these programs have the capability to check for drug-drug interactions or will link to other programs that do. This is particularly important to psychiatrists due to the inhibition of the cytochrome P450 enzyme system by numerous psychotropic drugs.

Prescriptions that are more legible, thus decreasing potential transcription errors at the pharmacy, can be written with PDAs. These prescriptions are printed directly on specialized paper in standard printers or via specialized printers. Another advantage of handheld prescription writing is that the software can check for availability of the medication on the health plan formulary.

Psychiatrists rely upon reference texts such as DSM-IV-TR or Kaplan and Saddock's Comprehensive Textbook of Psychiatry. Only a few reference texts for psychiatry are now available in electronic form for review on the PDA; see <www.handheldmed.com>, <www.pdamed.com>. Many people have taken electronic versions and ported the codes and criteria into a variety of formats. Good resources for Palm OS DSM-IV software are at PocketPsych <www.pocketpsych.com/Resources/dowloads.htm> and Memoware <www.memoware.com>.

Patient tracking can be done on the PDA using the To-Do feature or specific software. Although many programs exist, even for mental health purposes, organization of patient care information is a matter of preference. Some programs have integrated features such as charge capture and coding.

Use of the PDA must take into account security measures due to its portability, especially in light of sensitive mental health information. The Health Information Portability and Accountability Act (HIPAA) of 1996 was developed to improve the efficiency and effectiveness of electronic information. It mandates that all providers who conduct electronic billing directly or via clearinghouses implement security in these transactions to maintain the privacy of an individual's medical record. Information in electronic form on the PDA is quite vulnerable to theft. Although HIPAA does not specify the security mechanism to be used, the best mechanism for security on the PDA is to use encryption software (Brown, 2002).

As briefly outlined here, the PDA has many capabilities that make it an attractive information tool in the practice of medicine. Hardware peripherals, such as the ActiveECG <www.activecenter.com> for monitoring electrocardiograms, add amazing but real capabilities to these powerful devices. Most of the software mentioned is focused on the individual PDA user. As PDAs have gained popularity, an emerging trend has been for manufacturers and software developers to focus on enterprise level capability. Companies such as Oracle and Sybase have developed PDA clients to allow access in real time to main databases. With time, there will be more integration and seamless exchange of information across various computing platforms and health systems.

The PDAs are not replacements for desktop and notebook computers but should be considered in terms of how they extend desktop computing capabilities. Mobility is a clear strength, keeping in mind the drawback of limited memory and small screen size. There needs to be seamless and effortless integration of information flow with desktop and mainframe computers as part of the pervasive computing presence. Technology should adapt to fit physicians' work needs instead of physicians adapting to new technology. In this manner, the future will be in the palm of our hands (Briggs, 2002).

References:

References

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