Practice Management

When Gordon R. Kelley, MD, was called to the ICU in Kansas City, Mo, to evaluate a deteriorating patient who had apparently overdosed on methadone, he was puzzled. CT and MRI scans revealed an obstructive hydrocephalus associated with abnormal signals throughout the cerebellum, basal ganglia, and hippocampi. He knew that these findings were not consistent with a typical cerebrovascular injury, but he and other treating physicians were unsure of the cause of the findings. Reaching for his handheld computer, he entered several key words into his favorite program, NERVLINE: cerebellum . . . heroin . . . leukoencephalopathy.

Within seconds he found the first of a series of papers describing symmetric lesions in the cerebellar and cerebral hemispheres of illicit drug users who heat heroin on tinfoil and inhale the thick white smoke, a technique dubbed "chasing the dragon." Kelley read that the syndrome was first described in 1982 as an epidemic of 47 patients in Amsterdam, and that the prognosis was poor for advanced cases.¹ Although the syndrome has been reported sporadically since 1982, Kelley found a report published in Neurology in 1999 that described 3 cases that occurred in New York.² The report suggested a link between the toxicity and mitochondrial dysfunction. The authors, who included Arnold R. Kriegstein, MD, PhD (currently director of the Program in Development and Stem Cell Biology at the University of California, San Francisco, School of Medicine) and a team from Columbia University in New York City, reported treating 2 patients successfully with antioxidants, including coenzyme Q. So, when Kelley's patient awoke and admitted to smoking heroin, he was treated with the same regimen and made a remarkably good recovery.

Kelley raved, "NERVLINE helped me rapidly recognize and successfully treat a typical presentation of a rare disease that had previously been unknown to me. It was fast, slick, and nothing short of remarkable." NERVLINE, one of a variety of digital reference tools available today, performs searches of 25,000 core clinical neurology articles to form diagnostic relationships between key words and produce relevant citations and abstracts. For many clinicians seeking help at the bedside, handheld references have replaced manuals, textbooks, and a variety of written note systems.

Personal digital assistants (PDAs) have given us the ability to get the information needed to provide patient care at virtually any time or place. As we purchase more devices, our demand for applications is growing. Traditional texts and reference materials are being ported to platforms that can be used as handheld references and are capable of being searched rapidly. Skyscape, for example, offers 270 references for handheld devices and segregates medical content by specialty. It transforms text, tables, and algorithms into formats that are easy to read and scroll through. Its smARTlink feature cross-indexes material in a logical manner that allows users to search multiple sources easily.

For Steven A. Reid, MD, a neurosurgeon in Gainesville, Fla, the reference source of choice for the past 3 years has been Epocrates, a provider of drug and clinical information. He uses the handheld version and pulls up the system an average of 5 times a day on his Sony Clie. "It saves me a lot of time confirming medication dosage regimens and identifying potential adverse interactions," he said. "I've noticed a trend recently, disturbing actually, for primary care physicians to prescribe a panoply of medications. Some of my patients routinely take 15 or 20 meds daily. Epocrates helps me sort these out, and educates me on unfamiliar meds. I am also able to screen all my post-op orders on the polypharmacy patients."

Many physicians who have become accustomed to Epocrates feel much like Jan H. Mashman, MD, a neurologist in Danbury, Conn, who said, "I can't live without it. It provides me with the ability to list the various medications the patient is taking, run a check of interactions, see which are acceptable in pregnancy, and get details such as dosages of drugs that I use rarely." He added, "Like most practices, our providers have a wide range of technical skills, so we consider the use of PDAs a key step in getting all our providers more comfortable and proficient with technology as we progress toward an electronic medical record [EMR]."

Reid and Mashman are 2 of approximately 170,000 active physician users of Epocrates in the United States; an estimated 4000 are neurologists. In a January 2005 survey sent to 250 neurologists who were active users, 40% responded within 36 hours and 91% of them agreed that the program helps them avoid 1 or 2 adverse drug events per week. Similar estimates were obtained from 1240 responders across 13 specialties. All responders also believed that Epocrates saved them time; 43% estimated daily time savings of between 11 and 30 minutes, and 25% estimated daily time savings of between 31 and 60 minutes.

HARDWARE PREFERENCES

Not only do software preferences vary; hardware preferences differ as well. The gamut of mobile computing devices ranges from large laptop computers to tablet PCs, ultraportable sub-notebooks, handheld computers, and mobile phones with additional capabilities (so-called smart phones). As these appliances shrink in size, the processor power, screen size, and the ability to support traditional desktop PC business applications decreases. All current mobile computing technologies have advantages and disadvantages. Some physicians dislike the limitations of the smaller handheld devices: small screen size, short battery life, slow or clumsy writing capabilities, low processing power, and operating systems in which the applications that can be used are limited. Others prefer the more capable laptops and tablet PCs, but they are bigger, heavier, more expensive, and more fragile.

Trade-offs exist in the methods of getting the information to and from the device. Wireless local area networks and the Internet have become more readily available but typically suffer from slow data transfer, poor security, competing standards, and in some cases, electromagnetic interference with medical equipment. Data synchronization through cradle and cable is simple and secure, but it is hardware-specific and can only perform batch data updates.

Most handheld devices run on the Palm OS or Pocket PC operating systems. Until relatively recently, most Palm OS devices were smaller and cheaper, had a longer battery life, had more applications, required less memory, and were easier to use, whereas Pocket PC devices had better integration with enterprise applications (such as Microsoft Office), more security, more computing power, bigger screens with nicer displays, and more standardization. Much of this is changing now, and more devices are being seen that have similar desired features.

Given all the available choices, what is the best device for today's practicing physician? "As with any technology purchase, the answer is, 'It depends on what problems you are trying to solve,'" advises Neil A. Busis, MD, a neurologist in Pittsburgh, who teaches about handheld devices and other technologies at medical society meetings, including the annual meeting of the American Academy of Neurology. "The hardware that offers the features and applications that best address each individual's greatest needs is the best one to buy." He continued, "For example, if a physician's most indispensable desktop software can only link with Pocket PC but not with Palm OS devices, the Pocket PC would be the mobile platform to select. If e-mail or Web brows-ing is a user's top priority, a smart phone may be the best solution."

In fact, many experts are tout-ing these latest gadgets--smart phones--as the devices most suitable for physicians. In addition to the standard functions, the Treo 650, for example, has a digital camera that captures video, Bluetooth technology that allows the user to connect wirelessly to printers and desktop computers, and even an MP3 player. Moreover, when convergence devices are combined with greater bandwidth, such as Cingular's high-speed data network EDGE, the user is able to experience faster synchronization times and handle more robust applications. For example, such a device can accommodate the PatientKeeper clinical application suite, test results, drug databases, and reference material. With a smart phone, a physician can be out at a ball game and answer a patient's telephone call, pull up a medicine list, retrieve up-to-date laboratory reports, or look at references.

"My Treo 650 takes all the pressure off being on call," said Alida F. Griffith, MD, a movement disorder specialist and solo neurologist for a hospital practice in Woodinville, Wash. She explained, "I use it in lieu of my pager, because I don't see the point of carrying both a pager and a cell phone. It accepts text messages from my answering service and holds all of my essential information, such as business addresses and my DEA number. It also weighs far, far less than the smallest laptop, so is a pleasure to bring on business trips. I can be out biking in the middle of nowhere and yet easily look up medication doses or even search PubMed."

Indeed,PubMed, the Internet site perhaps most widely visited by physicians, is now available for Web-enabled handheld devices. It allows users to search medical literature, browse journal abstracts, and compare different forms of treatment and desired outcomes through a new feature called Patient, Intervention, Comparison, Outcome. The developers also are creating other enhancements, such as a spell checker and a query tool called askMedline through which health care providers can ask natural-language, free-text questions.

INDISPENSaBLE TECHNOLOGY?

Some veteran users find it inconceivable to practice without mobile computing. Randy M. Rosenberg, MD, a neurologist in group practice in Huntington Valley, Pa, uses a Dell Axim v50 with wireless capabilities that operates on the Pocket PC system. He depends on a wide variety of resources from his handheld, including Mobile MerckMedicus, which provides him with free journals; several drug databases, including Epocrates; MedCalc 3000, a clinical calculator; Pocket Consult, a mobile version of MD Consult; and Medformulas, to calculate medication dosing.

He reflected, "I first came to realize the power of having information at my fingertips several years ago when I was called by a remote hospital to provide urgent orders on a potential tPA [tissue plasminogen activator] patient. I connected my handheld to the telephone using it as a dial-up modem and faxed an order set to the ER within the 3-hour window." Rosenberg believes that Palm OS systems eventually will become obsolete, however. He explained, "The nature of medicine will require a Windows-based environment that does not have to use third-party software to go back and forth between handheld and PC."

At the Neurosurgical Intensive Care Unit of the 800-bed Hartford Hospital, director Marc D. Palter, MD, also relies on a Dell Axim v50. "Most physicians prescribe about 200 drugs; the problem is that we all use a different 200 drugs," he said. "My drug database, Lexi-Comp, allows me to do quick checks for drug interactions and look up less familiar meds. Furthermore, the material gets updated right away so, unlike the paper counterparts, they are always current. For instance, the minute that Vioxx was taken off the market, it was no longer available on the handheld."

He continued, "Our ICU, like many others, often has to accommodate medical boarders with problems that are not typically neurosurgical. Mobile references become truly useful in taking care of patients that are not our native population. For example, we recently admitted a patient with sudden dyspnea who was found to have methemoglobinemia. We looked it up on the handheld Washington Manual and found a relationship to hurricaine spray [a local anesthetic] and indeed, it turned out that the patient had self-administered so much that this potentially lethal condition had developed."

Palter's device also includes Outlines in Clinical Medicine, Pocket ICU, PocketChart, PatientKeeper, and numerous other applications, such as EPERC's end-of-life care treatment guidelines. "The vast majority of practitioners at Hartford Hospital uses PDAs and, at times, there is a race for information with everyone pulling up stuff on dueling handheld devices. Partners also routinely beam sign-out lists of patients to each other. The hospital is in the process of rolling out wireless connectivity, so while walking from the ICU to the floor, I can sync and update my device. Eventually, this will be done every time I turn it on," he said.

Although desktop computing offers capabilities that far surpass those of handheld devices, even terminal-rich hospitals such as MidState Medical Center in Meriden, Conn, do not necessarily support physician use. "Firewalls so restrict access that I am unable to connect to local networks or even use the Internet," said Ron Nath, MD, a solo neurologist in Wallingford, Conn. Nath refers to his Palm Tungsten T3 to look up medical information while on rounds. He uses the 5-Minute Neurology Consult, ICD-9-CM, and Stedman's Medical Dictionary from Skyscape, as well as Epocrates. He said, "I don't like filling up my pockets with books; I even find it inconvenient in the office. There is no better tool than a handheld for when I-need-the-information-right-now."

ONE SIZE CAN'T FIT ALL

Nilay R. Shah, MD, 1 of 6 neurologists working at Crystal Run Healthcare, a large multispecialty group in Middletown, NY, believes that no single solution will appeal to every doctor. "Each physician has his or her own work style and workflow; there really is no one-size-fits-all gadget," he said. In fact, for his own computing preferences, he uses a combination of tools. He favors his HP Jornada 568 Pocket PC for mobile computing at the nursing home and hospital. The small machine with built-in Wi-Fi and Bluetooth technologies uses wireless connectivity, allowing him to incorporate parts of his in-patient records onto his Pocket PC. He prefers the larger tablet PC (about the size of a clipboard) for his office practice, which includes charting using an EMR.

Michael Segal, MD, PhD, a child neurologist and the founder of SimulConsult--a Web-based support tool that helps clinicians identify inherited and congenital neurologic diseases--also uses a tablet PC. "I have been very impressed, particularly with the dictionary-based handwriting recognition. For our software, we have a file with terms that users can add to their tablet dictionary, which then recognizes the medical terms used in the software extremely well," he said. But for the most part, the adoption of Tablet PCs has failed to meet expectations. Although screen size is larger, the current weight, fragility, and expense of these devices, as well as their awkward input methods, have been viewed as obstacles by many physicians. Newer mini-PCs--which are the size of PDAs, run on Windows XP, and easily connect to keyboards and full-size monitors--may attract some physicians, but they are still limited by short battery life and, for now, high cost.

For those physicians who are contemplating use of a PDA, many experts advise an incremental approach. "Start using it as an organizer and a date book first," said Nath. "Once you are comfortable with backing up and other basic functions, you can add medical applications."

As always, some are waiting for the ideal device that will do it all: function as a telephone, retrieve e-mail, run all necessary software, integrate seamlessly with PCs, and communicate quickly with all external sources of data. Griffith mused, "One day they will make the ultimate machine, which will consist of a heads-up display that fits into my glasses, voice-activated commands that make typing unnecessary, and is able to seamlessly transition between Wi-Fi hotspots and wireless dial-up. Until then, the Treo 650 does a pretty good job of keeping me connected." *

REFERENCES

1. Wolters EC, van Wijngaarden GK, Stam FC, et al. Leukoencephalopathy after inhaling "heroin" pyrolysate. Lancet. 1982;2:1233-1237.

2. Kriegstein AR, Shungu DC, Miller WS, et al. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation ("chasing the dragon"). Neurology. 1999;53:1765-1773.

Orly Avitzur, MD, MBA, is a practicing neurologist in Tarrytown, NY.

Neil A. Busis, MD, answers the question: What can PDAs do?

PDAs started out as simple electronic organizers with only 4 canonical functions: a calendar, address book, memo pad, and to-do list. Now they are real computers with a universe of applications and have the ability to communicate with other computers and the Internet. Three capabilities of PDAs make them ideal devices to support medical decision making: PDAs think, sync, and link.

PDAs think PDAs literally put information at your fingertips. Examples of information that can be accessed include medical references, drug information databases, and clinical calculators. Requirements:

* Handheld computer

* Operating system

* Medical software

PDAs sync PDAs synchronize their information with information on desktop or laptop computers either by wired (the PDA is placed in a cradle attached to the desktop computer) or by wireless mechanisms. Synchronization can be achieved either manually or automatically. Examples of synchronization include personal information management (calendar, address book, memos, to-do lists), charge capture, and electronic prescribing. Requirements:

* The basics (see above) plus:

* Conduit hardware/software

* Information server (desktop or laptop computer)

PDAs link With wired or wireless modems, PDAs can connect to the Internet and access e-mail and the World Wide Web. They also can connect to private networks, such as hospital networks, and access patient data in real time. Requirements:

* The basics plus:

* Internet access

* One or more Internet services