What do drug dealers and doctors have in common? From the 1980s onwards neither could do their job without a pager. Only by carrying a pager can junior doctors leave their wards, safe in the knowledge that they would be paged about their patients’ needs. The same junior doctors also feel safer knowing that they can page their senior at any time to get advice and support. And of course the code blue message on pagers is essential to the ability of the cardiac arrest team to respond quickly wherever its individual members are dispersed in the hospital.

Handheld computers promise an even bigger qualitative contribution to clinical workflow. Not only can you use a handheld computer to do your clinical work faster and better than before, you can do some things that colleagues without these devices are simply incapable of doing.

What is a handheld computer?

A handheld computer is a computer small enough to hold in your hand or fit into your coat pocket. It is often called a ‘personal digital assistant’ (PDA). Some handheld computers also have phone features, enabling the owner to make and receive phone calls—they are called smartphones.

Of all the computer devices, handheld computers are possibly the most appropriate for clinical practice. While working with IT departments around the UK and USA we heard the same comment from puzzled computer professionals: it was so hard to convince clinicians to adopt computers. However, this changed with the arrival of handheld computers. Doctors are regularly buying them in order to improve patient care—even before their IT departments decided to make the investment. Healthcare computing professionals around the world are delighted that the clinicians now care passionately about computing resources because of PDAs and smartphones.

There are several aspects of handheld computers that make them well-suited to clinical practice.

First, of course, is the portability. The devices are small enough to carry everywhere, including from ward rounds to patients’ homes, and lecture to libraries.

Battery life makes the portability qualitatively different from laptops or tablet PCs. Most handheld computers are usable over 2 days of clinical work—few laptops or tablet PCs can last 3 hours without requiring recharging. The efficiency of the battery still supports speed. Laptops and tablet PCs preserve battery life by switching to ‘standby’ or ‘hibernation’ modes after a few minutes without use. The former means the computer will take several seconds to respond, while up to a minute is necessary to use a computer that is in hibernation mode. By contrast, a handheld computer instantly works no matter how long it has been since you last used it. This is necessary for the continuous interruption environment of ward rounds.

Every handheld computer includes a cradle for recharging. The former sits in the latter for a couple of hours to recharge completely. The cradle also allows synchronization.

Synchronization is the process of copying everything you have on your handheld computer onto your PC. This means that anything you do on your handheld computer is backed up on your PC the next time you synchronize. Compare this with backing up a paper diary.

Synchronization is a two-way process. If you type a new appointment into your PC’s diary the new appointment will appear on your handheld computer the next time you synchronize. And if you write down the details of a test for one of your patients on your handheld computer the details will appear on your PC the next time you synchronize. This is great for sharing information that you write on your handheld computer and your secretary types on your PC.

Beaming is another way to share information. Line up one handheld computer with another then beam information between the two. This means you can send details about your patients to a colleague’s device while the two of you discuss the most important points—or simply enjoy your tea.

Handheld computers allow writing. Some can recognize handwriting some of the time, and this is a tremendous achievement given the handwriting of doctors. But the fastest and most reliable way to write is using a slightly modified alphabet without joining up the letters. This may not be as fast as your writing on paper, but it will be legible and more than one doctor has noticed an improvement in their writing on paper after using a handheld computer.

The advantage of writing rather than typing is that you can enter information into your handheld computer during the ward round. For prolonged writing you may prefer to use an unfolding keyboard instead. Unfolded this is the same size and comfort of a normal PC allowing fast typing. And folded it is the same size as your other coat pocket, maintaining portability (and perhaps adding some balance to your gait).

You can enter all sorts of information in your handheld computer. The original devices were named PDAs because of the included organizer software: diary, address book, task list and simple notes. A good rule of thumb is that if you find yourself needing a piece of information more than once then you should take the trouble to enter it into your handheld computer. The date of an upcoming lecture, the phone number of your primary care trust manager, the tasks you must carry out for your patients today and notes from the lecture you attended yesterday will all be useful to refer to in the future.

Extra software allows entry of other information. For example, databases allow surgeons to keep logbooks and general practitioners to maintain their personal development plans. Reference software provides access to the British National Formulary as well as American and German formularies. You can read textbooks from around the world without the burden of bookshelves. And with the support of your hospital’s computer department doctors on the ward can read X-ray reports as soon as the radiologist types them and blood test results as soon as the pathology laboratory produces them.

In fact, computer departments of healthcare institutions around the world are making such investments.

Handheld computer use around the world

PubMed lists almost 400 papers from 2003 and 2004 that covered handheld computers and the rate for 2005 is probably accelerating. [The medical subject heading ‘computers, handheld’ is useful for finding these.] More significantly, the character of the papers is changing from anecdotal cases and reviews to quantitative trials and sophisticated projects.

At Stanford University, for example, students were provided with handheld computers and teachers used them in tutorials. The teachers would periodically ask questions and the students would select their answers on the handheld computers. The students’ aggregated choices would appear on the teacher’s computer. The anonymity gave the students the confidence to give answers based on their understanding of the topic—the results gave the instructors instant feedback about the class’s progress.

Such work is the reason for medical schools of Harvard University, the University of Cambridge and the National University of Singapore providing handheld computers to their students.

Clinical work has also benefited. At St John’s Hospital in Scotland doctors on ward rounds have access to each patient’s admission details, pathology laboratory test results and notes from previous ward rounds, as well as reference documents. Meanwhile in Lanarkshire the night-time hospital emergency care team of two nurses and five doctors uses handheld computers for triaging all patients, structured clinical assessments, prescriptions and protocols. The devices generate printed clinical assessments at the bedside and hand-over registers and reports for the morning teams.

It is such work that convinced Duke University Health System’s hospitals in the USA, St Olavs Hospital in Norway and Shin-Kong Wu Ho-Su Memorial Hospital in Taiwan to invest in handheld computers to support patient care. Even without expensive integrated electronic systems the devices have shown a return on the investment. This is why Satellife has deployed simple battery-powered handheld computers in Uganda to collect public health data.

Footnotes

This is the first of a series of extracts from a forthcoming book by A. Al-Ubaydli and C Paton [www.rsmpress.co.uk/bkpda.htm].

Clinical vignette of a Medical Digital Assistant

In doing locum work around the UK’s hospitals Dr ibn Battuta always used his handheld computer. With it he kept track of the phone numbers of his consultant and his locum agency, the shifts he was to do, the jobs for each of the patients under his care, and the directions to the different hospitals he was to practise in. On ward rounds of different specialties he referred to the British National Formulary and the 20 specialist textbooks he carried with him at all times.

Finally, for revalidation, he kept track of the lessons he learnt every day. At the end of the year he had ample proof that he was keeping up to date with the literature and improving his clinical skills.

In many of the hospitals he found colleagues who also used the devices. Those members of his team would beam him more phone numbers from the hospital directory. At the end of his shift he would beam to them jobs for the patients that had not yet been completed. He could trust that the information would be transferred accurately and comprehensively, as well as documenting the jobs that he had already completed.

In a few hospitals he was delighted to see institutional support for the devices. The IT departments had deployed software around the hospital to ensure that patient information would never have to be entered more than once. The time saved was considerable: on ward rounds his team would have access to each patient’s demographic details, investigation results and previous notes on their handheld computer. But there was improved patient safety because dangerous blood results were clearly highlighted and prescription errors were reduced by warnings from the software.

At one hospital he was even provided with his own smartphone on the first day. The nurses would send text messages or directly phone the devices, the operator explained, because it was much faster than paging and waiting for the doctors to reply. Dr ibn Battuta was glad to see that others were realising the advantages that he treasured in his own device.

Citation: Al-Ubaydli M, Paton C. The Doctor’s PDA and Smartphone Handbook Personal digital assistant. J R Soc Med. 2005 Nov;98(11):494-5.

Citation

Mohammad Al-Ubaydli, “Handheld computers”, BMJ, 2004 vol 328 p1181. [original paper]

Summary points

• Handheld computers are suited to clinical practice because they are small, affordable, and easy to use; can read handwriting; and have a long battery life
• They can run a wide range of medical software
• The devices support clinical teamwork by making it easy to share information with other clinicians’ PCs and handheld computers
• Ensuring security of your patients’ data is vital and requires some effort
• Make sure your budget includes money for software, textbooks, and hardware expansions

Handheld computers

Handheld computers can save you time and increase your accuracy with clinical facts. The computer part means that you can store all sorts of clinically relevant information, and the handheld part means that you can carry the device wherever your clinical travels take you.

Clinical practice entails a lot of information management. Of course, my seniors at medical school tried their hardest to teach me the medical facts that would guide my future practice. But on the wards they also taught me other things: which local protocol to use; the phone number of other specialists for further management; and which parts of the welfare system
would affect clinical outcomes.

And doctors travel a lot. I did not fully understand this until my first few minutes as a doctor: my pager explained to me that I should be heading to another part of the hospital, and it continued to redirect me throughout the day. Such travelling was not just for the inexperienced. My seniors pointed out how much walking they had to do, and their pace put mine to shame. As I began the general practice phase of my rotation, my destinations included not only offices, examination rooms, and committee rooms in the surgery but also patients’ homes throughout the surrounding rural area.

It is difficult to escape the feeling that handheld computers were designed with clinical practice in mind. In fact, handheld computers were originally designed for corporate executives: the devices were a replacement for paper organisers as they included diary, address book, “to do” list, and note functions.

Main uses

Handheld computers have brought important advantages. With a few taps on the screen, for example, you can convert an appointment for Tuesday’s outpatients clinic to an outpatients appointment for every Tuesday of this year (this is much quicker than using a paper diary). Ticking off a task hides it from the handheld computer’s screen, leaving a tidy, shorter list of tasks for completion; a house officer’s paper list of tasks becomes increasingly messy and illegible as tasks are added, amended, and crossed out. I can scribble a note on my handheld almost as fast as scribbling a note on a piece of paper; finding that note on my handheld computer takes a few seconds, but finding that piece of paper after a year is far more difficult. The device also brings up related notes, tasks, addresses, and appointments.

For many doctors the organiser functions alone have been sufficient justification for buying a handheld computer. Others like using custom designed medical software such as PatientKeeper to keep track of patient records. In the United Kingdom, companies such as EMIS and Torex have handheld computer versions of their software to complement the PC versions (fig 1).

Fig 1 Torex produces software for keeping track of patients’ records

Other software, such as ePocrates Rx, can support prescribing decisions. It is a quick reference of all licensed drugs in the United States and can identify drug interactions. Liability insurance companies and governments have understood the potential of the ePocrates Rx. MedAmerica Mutual, for example, provided clinicians with devices running the software because it believed that this would reduce clinical errors. Last year, the US government ran a three month trial with ePocrates DocAlert to provide clinicians with updates on bioterrorism.

In Britain, a handheld computer version of the BNF (the British National Formulary) has been developed by the Swedish company MedHand (fig 2). MedHand’s software also includes reference textbooks such as the “Oxford Handbook of Clinical Medicine”. American publishers such as Franklin, Lippincott Williams & Wilkins, and Skyscape have long provided clinical textbooks for a range of specialties and experience levels, and the BMJ Bookshop sells many of these.

Fig 2 Software for the BNF is available for handheld computers

Furthermore the improving internet connectivity of handheld computers is improving the contribution they can make to evidence based medicine. Last year, for example, the National Library of Medicine customised PubMed (http://certif.nlm.nih.gov:8080/nlm and http://archive.nlm.nih.gov/proj/pmot/pmot.php) for handheld computers. Sites such as the University of Toronto’s Centre for Evidence-Based Medicine provide software for evidence based medicine that is customised for handheld computers. The customisation by Info-POEMs for handheld computers is well thought out. Its creators provide the POEM (“patient oriented evidence that matters”) section in the BMJ, and the software also includes Cochrane Database abstracts and diagnostic test calculators.

But the devices really come into their own when you start storing your own local data using databases. At its most basic, a database form looks like a paper form, and a database table stores data in the way a filing cabinet does. Handheld computers allow you to have the right form wherever you need it. Furthermore, software such as HanDBase can speed up completion of forms, for example, by providing a list of ward names. But it is searches that show the biggest advantage of databases—for example, searching a table to identify patients in a particular age range takes only a few seconds.

Team work

Handheld computers have several features that make them suited for clinical team work.

Each device has a cable that can share information with PCs. This sharing is called synchronisation, and it means that an appointment that a secretary adds on a PC with Microsoft Outlook will appear in the clinician’s handheld computer’s diary. The clinician can also use the device to send and receive emails, dictation notes, and pictures.

Information can also be shared between handheld computers. This sharing is called beaming, and you can do it by lining up your device with a colleague’s and tapping the “beam” command. The day before I started as a house officer, the departing house officer beamed to me the hospital’s phone numbers. The next day I beamed these to another colleague, and so on.

Software such as HanDBase takes advantage of beaming and synchronisation. You can design a simple database, for example, to keep track of patients’ hospital numbers and problems and list the tasks to carry out for each patient. As you begin the day, synchronise your device with those of other members of your team through beaming. As your shift comes to an end, synchronising with the staff of the next shift is fast, accurate, and comprehensive.

Potential problems

Your biggest worry should be security. Like a PC, a handheld computer’s default method for storing data is easily accessible, but unlike a PC, theft or loss of the device is also easy.

The easiest way to ensure that sensitive data do not get into the wrong hands is not to store any sensitive data. Keeping a logbook, for example, of all the operations that you carry out is useful for your audits and college membership, but you should not need to store the patients’ names and dates of births.

If you must store sensitive data, use software that encrypts the data—for example, eWallet allows safer storage of passwords and details of membership and credit cards. HanDBase also has encryption features that you can switch on. And medical record software, such as Pocket Torex, includes encryption. Insist on it when choosing software for dealing with patients’ data.

Encryption does not solve all problems, however. Synchronising with a PC, for example, means that a copy of the data is stored on the PC, so you must
ensure that the PC is secured. And beaming to a handheld means a copy of the data is stored on someone else’s handheld, so that handheld must also be secured, and that person must understand security. Your organisation’s computer experts are usually helpful and always necessary in matters of security.

A more subtle problem comes from the assumption that handheld computers are the same as PCs. Instead, you should think of them as two different surgical instruments. Each is good at handling one part of the operation, but not others. Handheld computers are not good, for example, for writing a lengthy patient history (a PC’s keyboard is faster). Nor should you use the device for looking at x rays films (a PC’s screen gives you the full picture at a high resolution). But a handheld’s portability means that you can read the radiologist’s report or dictate your response while you are with the patient. And its simplicity means that ordering an investigation is faster than finding the paper form or an available PC. Furthermore the battery life and responsiveness of handhelds are better than with laptops and tablet PCs (similar to laptops but the user can “write” on the screen), and suited to the continuous interruptions and lengthy shifts of clinical practice.

Buying a device

In the United States, for $200 (£113; 169 Euros), you can buy a brand new handheld computer that handles all modern clinical software, comes with organiser software, and reads and writes Microsoft Word files. However, you can get by with cheaper or older devices. In Britain, a typical price for a new handheld is £120.

One thing that you cannot compromise on is the operating system of the device. This determines what software you can use, which in turn determines how useful the device can be to you. Only devices with the Palm Powered or Pocket PC logos can run the major clinical software, so you should not consider other devices even if they are cheaper or have more impressive hardware.

One notable exception is Research In Motion’s BlackBerry range of handheld computers. Clinicians like the devices because they provide instant notification of and access to new email messages. IT administrators like the devices because they are easier to administer and secure. However, only a few clinical software applications are available for them (although these do include the excellent Johns Hopkins Antibiotic Guide, and clinical software providers are standardising on the Palm Powered and Pocket PC devices.

Some software only runs on one type of device—for example, users of EMIS software need a Palm Powered device, while Torex customers need a Pocket PC. But most of the important software products, such as HanDBase, run equally well on both devices. The BNF currently runs on Palm Powered devices made by PalmOne (but not those made by Sony), although a Pocket PC version is planned for release by 2005.

There are several features to look out for in the hardware. In the United States, the $200 devices all have bright colour screens for clarity. The screen’s pixels affect how much text you can read at one time. Pocket PCs have 240×320 pixels, while a top of the range Palm Powered device has 480×320 pixels. The RAM represents the amount of information that the device can store at any one time, and Pocket PCs tend to have more RAM than other devices. Finally, some models have a built-in camera or phone, or both. In one ongoing clinical trial, paramedics are using these features to provide advance notification to hospital staff from accident scenes.

You must budget for other spending too for your handheld computer. Textbooks and software can cost a lot of money—most textbooks in the United States cost at least $60. Textbooks often require an expansion card for storage. Finally, you may find an expandable keyboard useful—this folds to the same pocket size as the handheld but unfolds to match a full size keyboard.

Websites for further information

• www.doctorsgadgets.com — Complete reviews on the latest handheld computers and medical software
• www.pdaconsult.co.uk/bbs/index.php — UK forum for handheld computing in medicine
• www.handango.com — Guide and shop for new software. Browse and try before you buy from their secure shop
• http://pbrain.hypermart.net —The latest news and views on using your Palm Powered device
• www.medicalpocketpc.com —The latest news and views on using your Pocket PC. A small team of US junior doctors keeps the site fresh and entertaining
• http://denison.uchsc.edu/evidence_based.html —     Includes a good a list of evidence based medicine resources for handheld computers
• www.handheldsfordoctors.com/book/text/chapter11.htm — Guide to handheld computer software that is suitable for patients

Author information

Contributors and sources: The information collected in this article is based on over five years’ experience I have had with handheld computers, setting up projects, and working with fellow experts in use of handheld computers. The projects include Medical Approaches, a free medical textbook for handheld computers, Project Palm at Cambridge University, and working at the Queen Elizabeth Hospital, in King’s Lynn. I subsequently wrote the book Handheld Computers for Doctors and continue to develop handheld computer solutions (www.handheldsfordoctors.com).

Funding: None.

Competing interests: I own the website handheldsfordoctors.com. It sells my book and handheld computers. I receive a commission from sales through my site, and from sales of my book. I work at the National Library of Medicine, which created the handheld computer versions of PubMed mentioned in this article.

Brewster Kahle, creator of the Internet Archive (www.archive.org)—a digital library of Internet sites and other cultural artifacts in digital form—has been inspirational in discussing the Internet’s potential to become a modern Library of Alexandria. He campaigns for a resource that makes all of humanity’s knowledge available to all of humanity.

The Internet certainly provides a number of resources for finding medical evidence. The Cochrane Collaboration (www.cochrane.org), for example, posts freely available abstracts of systematic reviews of health interventions (access to the full text of the reviews requires a fee). PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi), the United States National Library of Medicine’s search service, provides access to abstracts of articles in MEDLINE, PreMEDLINE, and other related databases. PubMed’s MyNCBI feature provides useful filters such as “free full-text,” which shows papers for which the full text is available through the Internet, free of charge. The “HINARI” filter (www.nlm.nih.gov/pubs/techbull/jf05/jf05_myncbi.html#filters) shows papers for which the text is freely available to residents of a small number of developing world countries—those with a Gross National Product per capita below $1,000—who are part of the HINARI agreement (www.healthinternetwork.org). PubMed Central (www.pubmedcentral.nih.gov) is the US National Institutes of Health’s free digital archive of the full text of biomedical and life sciences journal articles.

Yet, as many a doctor will point out, the bigger problem with medical knowledge today is not its paucity, but the difficulty of navigating what there is. Finding the right answer quickly for a patient is difficult, and perhaps nothing will replace a good medical librarian in finding that information.

The rise of the search engine Google (www.google.com), along with other freely available search engines, has made it easier to find information, although the clinical uses of Google have not been as well documented as those of PubMed [1]. Google will not point to the answer to every question, and often the articles it finds in response to your question are not freely available. But for many clinical scenarios, Google and other search engines can provide, quickly enough, an answer that is good enough. This article aims to provide tips that will help with these clinical scenarios, saving time that can be used with a medical librarian to answer more difficult problems.

Search Engine Basics

Google provides a Web search engine—a tool that constantly indexes the expanding World Wide Web and allows you to search the index. Google’s Web site is deceptively simple, designed to give you results quickly (Figure 1). Start by typing something into the text field and pressing the “Google Search” button. What you type in is the query, and what Google responds with is the results page.

For example to learn about heart attacks, type “heart attack” as a query. Google’s first page of results includes ten Web pages that cover heart attacks. The top right corner of Figure 2 shows that at the time of writing Google had found a total of about 20 million Web pages relevant to this query. Google ranks each of these Web pages by how many other Web pages provide links to them. This is the equivalent of the number of times a paper is cited; the more links a Web page gets, the greater the importance Google assigns to it, in the same way that the more citations authors receive, the greater the importance that academic institutions assign to their work.

Simply typing in the name of the medical condition is a good starting point, but it is a crude approach. For example, if your aim is to find information about thrombolysis for patients who have had a heart attack, then at least one of the 14.5 million pages that Google indexes in response to the query “heart attack” will be relevant. However, the first 20 pages Google produces say nothing about thrombolysis, and most of them are devoted to providing information for patients rather than clinicians. Rather than going through each of the millions of pages on heart attacks, it is faster to enter a slightly different query.

To find Web pages that are appropriate for clinicians, the query should include words that clinicians use. “Myocardial infarction” provides around 2.1 million results from Google, and some of the sites listed on the first page are likely to be relevant to clinicians (Figure 3). Being more specific with your search gives more specific results; the query “myocardial infarction thrombolysis” provides just 108,000 results, the first of which shows the guidelines on this topic [2] from the influential and well-respected National Institute for Clinical Excellence.

Restricting the Web Sites Included in Your Search

Google has hidden depths. For example, adding “site:” to the end of a query restricts the search to certain Web sites. To focus on guidelines from Web sites maintained by the US federal government, type “myocardial infarction site:gov.” Using “site:nih.gov” focuses on the National Institutes of Health; “site:edu” restricts the search to American universities; “site:harvard.edu” to Harvard University; and “site:org” to nonprofit organizations.

Using “site:fr” as a search term will restrict your search to French Web sites, although not all French Web site URLs end with “fr” (for example the French Web site of Médecins Sans Frontières is www.paris.msf.org). There are similar search terms that you can use to restrict your search to particular countries, national health systems, or government agencies. For example, “site:nhs.uk” restricts the search to the British National Health Service, while “site:gv.kr” focuses on South Korean government Web sites.

Google also provides country-specific versions of its Web site. For example Google India (www.google.co.in) gives preferential ranking to Indian Web sites in its results and Google Kenya (www.google.co.ke) provides a Kiswahili interface. The full list of country-specific Google sites is available at www.google.com/language_tools.

Other Google Features

At the top of the page (see Figure 1) are some of Google’s other tools. For example, to find images of hip prostheses, type “hip prosthesis” as your search term and click the “Google Search” button. Clicking on the “Images” link will show a series of relevant photographs and diagrams that have been reduced in size (Figure 4). Clicking on any of these will display the image at full size. If the copyright owner of the image grants you permission, you can click on the image with the right-hand mouse button and choose to save it to your computer, then insert the image into your presentation or article.

The “News” link at the top of the page finds the latest news stories on a particular topic, and can be helpful for finding out what your patients have read in the lay press about a recent piece of medical research. The translation feature is useful for understanding content in languages that are not your own. On Google’s English-language sites, the “Translate this page” link appears next to pages that are in languages other than English. Two books published by O’Reilly—Google Hacks [3] and the shorter Google Pocket Guide [4]—provide useful additional tips and guidance.

Google Scholar

Perhaps the most clinically significant tool is Google Scholar (scholar.google.com), which is similar to PubMed in that it is a search engine that focuses on academic papers. In fact, many of the search results it returns are pages from the PubMed site. Google Scholar has a number of useful features that are not shared by PubMed. First, it is more comprehensive, indexing all academic fields, including non-biomedical ones. Second, and more importantly, the ranking mechanism is valuable. As with the rest of Google’s technology, the pages are ranked based on the number of links that they receive. In the case of Google Scholar, “links” are citations from different papers. This means that review papers and seminal papers are most likely to top any list of results from a Google Scholar search.

Google Scholar is not a replacement for PubMed, since it lacks PubMed’s precision searching. Furthermore, finding newer papers with Google Scholar is difficult; newer papers will not have been cited as much and so will be at the bottom of the results, and sorting by publication date is not possible.

Other Search Engines

Google is the most popular search engine, but it is by no means the only one. Other search engines have different approaches with their own advantages. For example, Microsoft Network’s query builder (search.msn.com) makes building complex queries easier. Yahoo’s Creative Commons search feature (search.yahoo.com/cc) restricts searches to content (such as all of the content of the PLoS journals) that has been published under a Creative Commons license (www.creativecommons.org). These licenses are much less restrictive than the traditional “all rights reserved” copyright license. For example, if the content you have found (articles, photos, or images) is licensed under the Creative Commons Attribution License, you are legally entitled to reproduce it, distribute it, and make translations and derivative works, provided you cite the work properly.

The search engine Teoma (www.teoma.com) clusters search results according to different meanings of the words in the query. This clustering is useful because the medical meaning of some words, such as “hip,” is less commonly used than the non-medical meaning. Google lacks this clustering function. Finally, Vivisimo (www.vivisimo.com) can cluster results by subject (Figure 5). Its ClusterMed (www.clustermed.info) tool searches PubMed, while www.biometacluster.com simultaneously searches several relevant sources such as ChemBank and ClinicalTrials.gov. These are useful if you are searching for papers in a narrow specialty.

Conclusion

All of these freely available search engines have their limitations, and they rarely give you the perfect answer to your clinical query. But they do at least help to reduce the obstacles to finding medical information online. Kahle would certainly approve.

References

1. National Library of Medicine (2005) PubMed tutorial. Available: http://www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.html. Accessed 21 June 2005.
2. National Institute for Clinical Excellence (2002) Myocardial infarction—Thrombolysis. Available: http://www.nice.org.uk/page.aspx?o=38399. Accessed 21 June 2005.
3. Calishain T, Dornfest R (2004) Google hacks, 2nd ed. Sebastopol (California): O’Reilly. 480 p.
4. Calishain T, Dornfest R, Adams DJ (2003) Google pocket guide. Sebastopol (California): O’Reilly. 144 p.

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Mohammad Al-Ubaydli is a physician and programmer. He is the author of the books Free Software for Busy People and Handheld Computers for Doctors (www.handheldsfordoctors.com), and is based in Bethesda, Maryland, United States of America. E-mail:
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Competing Interests: Mohammad Al-Ubaydli wrote this article in his own time and without the support of federal funds. The views in the article are his alone and do not represent those of his employer, the National Institutes of Health.

Published: August 2, 2005

DOI: 10.1371/journal.pmed.0020228

Copyright: © 2005 Mohammad Al-Ubaydli. This is an open-access article distributed under the terms of the Creative Commons Public Domain declaration which stipulates that, once placed in the public domain, this work may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose.

Citation: Al-Ubaydli M (2005) Using Search Engines to Find Online Medical Information. PLoS Med 2(9): e228

Citation

Mohammad Al-Ubaydli, “Handheld computers for surgical logbooks”, International Journal of Surgery, 2004 vol 2 issue 1. [Original paper]

One of my favourite books is Michael Bliss’ biography of the great Sir William Osler[1]. Osler is often described as the greatest of all modern physicians, and it is a joy to read about his achievements. One habit that he cultivated and encouraged his trainees to adopt was taking their work with them wherever they went. He hated wasting time, especially waiting in between his formal clinical duties. For example on carriage rides in between appointments, he would read scientific papers.

Had Osler been practicing today, my guess is that he would have bought a handheld computer. On it he would store all the papers that he wanted to study, all the textbooks that he needed to consult, all the articles that he was writing, and a record of all the patients that he had ever treated. For surgeons, that last application is particularly important. Whether you are a trainee who wants to document your experience or a consultant who wants to audit your surgical outcomes, a surgical logbook is an important part of your practice. Handheld computers simplify and advance the task of keeping a logbook, and this article explains how you can go about doing this yourself.

Background

A handheld computer is one that is small enough to hold in your hand, or keep in your pocket. It helps you organise all the information you need to keep track of as a doctor. Handhelds are affordable, with prices starting at £100 for a good machine [2]. If you want extras such as a colour screen, a camera, or even a car-navigation system, you can pay more. Nevertheless, even the cheapest model is powerful enough to handle most medical software. They are also simple to use. Whereas your first brush with a desktop computer was probably a painful learning experience, you will find that a handheld is easy to pick up. You can write on one using a pen (or even your finger) and the programs are clear and functional. Nor do handheld computers crash frequently. Instead, their reliability makes them attractive for the medical setting.

There are currently two types of handheld that you should choose from: one has the “Palm Powered” logo, and the other the Microsoft “Pocket PC” or “Windows Powered” logo. Palm Powered machines are the cheapest and simplest to use, whereas Pocket PCs are preferred by IT departments. Two things to be aware of though are that most of your colleagues will have Palm Powered machines, and sharing data is easier if you have the same type of machine as your colleagues. All machines work with Microsoft Office programs such as Word and Excel, and ironically the Palm Powered machines do this job a little better than the Microsoft Pocket PC machines [3].

HanDBase database software

The reason that you must stick to Palm Powered or Pocket PC machines is the software that the machines run. No matter how advanced your phone is, there is little medical software available. Palm Powered and Pocket PC machines, on the other hand, have an impressive range.

One of the most important software packages that you should invest in is called HanDBase [4,5]. This is database creation software. In other words, it allows you to create electronic versions of any of the paper forms that you fill out every day in the NHS. Because the data is electronic you get the extra advantages such as fast entry, efficient backups, and powerful searches.

For logbooks, these searches are important. If you have entered the data correctly, you can search for all the patients that have had DVTs as a post-operative complication; you can count all the operations that you did without your consultant present; you can tally how many operations you did in March; or you can print a detailed report of every single operation that you took part in.

I have used HanDBase to create such a logbook. This is analogous to using Microsoft Word to create a letter. When you buy the software, you too can create your own logbook. By using my logbook rather than designing your own version you will save time and effort, and you can exchange data more easily with other colleagues who are using the same logbook. I have based the forms of my HanDBase logbook on the forms that you have to complete for the Royal College of Surgeons paper logbook. I have ensured that the translation into HanDBase format is faithful to the spirit of the paper logbook, but takes advantage of the features of handheld computers. For this I relied on my past experience in converting the NHS Personal Development Plan paper forms into HanDBase forms for GPs [6]. This logbook is freely available for your use and distribution.

Because HanDBase runs on a handheld computer, it is easy for you to enter the data correctly. First, handheld computers are easy to take with you to theatre, so you can document every operation straight after you do it. Second, I have designed the forms so that they automatically fill out certain data, such as the date of the operation. Third, the more you use the forms, the better HanDBase gets at automatically filling in other data, such as the type of the operation.

Surgical logbook HanDBase database

There are three steps to getting the surgical logbook onto your handheld computer. The first is for you to buy HanDBase through the web site [7]. The HanDBase Plus version costs $29.99 (about £17) and will do the job perfectly well, but HanDBase Pro is worth the $39.99 (about £22) price because of its advanced form features. After buying the software, you need to download and install it. www.PDAMD.com has an excellent guide that takes you through downloading and installing software [8].

The final step is to get the surgical logbook forms that I have designed to work with HanDBase. You can get a free copy from the The Journal of Surgery online (www.journal-surgery.com) or from my own site [9]. The license for the logbook allows you to make as many copies as you would like, and to share these with your colleagues. Your colleagues will of course need to buy their own copy of HanDBase to use the logbook. However if you make improvements to the logbook, I would like you tell me about these so that I can share them with other surgeons.

Filling out the forms

After you install HanDBase software and the surgical logbook, tap the “HanDBase” icon on your handheld computer. Then tap the “Surgical logbook” line, shown in figure 1. The software asks you for the password (figure 2). Tap “OK” as the default is for no password, but the next section will show you how to change the password. The software then shows you a list of all the operations (figure 3). Of course the list begins empty, and to document your first operation, tap the “New” button. As figure 4 shows, the “Date” line has already been completed for you, defaulting to the date on which you began completing the form. You can change the date by tapping on it. The “Patient ID” line is empty, waiting for you to add the identification number of your patient. Tap on the dotted line and start writing.

figure 1

figure 2

figure 3

The rest of the form is self-explanatory, and similar to the paper forms from the surgical Royal Colleges (figures 5-6). However the more effort you put into the logbook, the more effort it can save you. For example, you can enter the operation name by writing on the dotted line to the right of “Operation” (figure 4).

figure 4

figure 5

figure 6

However if you tap on the triangle to the left of “Operation”, a list pops up with “Edit Popup List” at the bottom. If you tap on “Edit Popup List”, you have the opportunity to edit that list (figure 7). Add the names of the operations that you do most commonly. For example, if you are an ophthalmic surgeon, you could tap “New”, write “Drainage of orbit” (figure 8), tap “OK” and then “OK” again. From then on, if you tap on the triangle to the left of “Operation” you will find “Drainage of orbit” is included in the list (figure 9). If you tap on that, “Drainage of orbit” is automatically filled in on the dotted line (figure 10). It is worth spending a little time tailoring all the lists (including “Operation” and “Complication”) to your speciality.

figure 7

figure 8

figure 9

figure 10

Security

The logbook does not allow you to enter a patient’s name. I did this for security. First, cataloging identifiable data about your patients makes you subject to the Data Protection Act. Although it is reasonably straight-forward to comply [10], in the case of a logbook there is not much to gain. Furthermore the risks of data falling into the wrong hands (if, for example, you lost your machine) are too great.

As an additional security measure the logbook is encrypted and password-protected. The encryption means that every time you stop using the logbook HanDBase converts the data into a format that can only be decoded if the right password is entered. It is important that you choose a good password. At the beginning there is no password so you must change this. Tap “DB Properties” in the “Options” menu (figure 11) then tap “Security” and “Set Access Password”. The software asks you to choose any password, which can be as long as you want and contain any combination of letters and numbers. For speed on the wards, you should stick to numbers because HanDBase provides you with a number pad. For security, you should choose a number at least six digits in length, and avoid predictable sequences (like ’111111′ or your date of birth).

figure 11

Advanced features

The full advantages of using electronic logbooks become apparent when you have to audit your surgical outcomes or summarise your surgical experiences. HanDBase allows you to create reports, search the data or highlight particular operations. The user manual contains full documentation of these features and you should read the sections about “Search Database”, “Filters” and “Reports”. This software gives you more tools than Osler ever had access to.

Conflicting Interests

I am the author of the book “Handheld Computers for Doctors” and the accompanying website www.handheldsfordoctors.com which sells handheld computers.

References
1 – Bliss M. William Osler: A Life in Medicine. Oxford: Oxford University Press 1999. [Amazon.com] [Amazon.co.uk]
2 – Al-Ubaydli M. Shop for Handhelds [online] [accessed 1.1.2004]
3 – Bush SG. Better than Pocket Office [online] [accessed 1.1.2004]
4 – Hildebrandt SS. HanDBase from DDH Software [online] [accessed 1.1.2004]
5 – Al-Ubaydli M. HanDBase 3.0 Review [online] [accessed 1.1.2004]
6 – Al-Ubaydli M. Handheld Computers for Doctors. London: John Wiley and Sons 2003. Chapter 13. Pages 75-84.
7 – DDH Software Inc. HanDBase [online] [accessed 1.1.2004]
8 – pdaMD.com. Installing Sofware [online] [accessed 1.1.2004]
9 – Al-Ubaydli M. Surgical logbook [online] [accessed 1.1.2004]
10 – Information Commissioner. Welcome to the Information Commissioner’s Office [online] [accessed 1.1.2004]