The ability to store patient records on a handheld computer is perhaps the feature that clinicians want the most, yet it also is perhaps the hardest to provide. If you are buying a device for yourself simply so that you can use it for medical records, then you should abandon the purchase and save your money.

Let us explain why we say this. It is relatively easy to store information about your patients in your personal database. Buy HanDBase, create your forms and start entering patient data. The difficulty comes when you have to share information with other clinicians. Beaming may be enough for small teams, but for any more than five clinicians, you will need to synchronize your devices with a central computer… and that requires the help and support of the IT department.

The practice of medicine means that you almost always have to share information with your colleagues. Whether you do it in the paper notes or your institution’s electronic medical records system, you must document what you do to the patients so your team can provide appropriate care.

Thus, if you decide that you do not want to share the patient notes on your device because of the complexity of involving the IT department, you will have to duplicate your writing: once for your device and again for the institution’s notes. You will soon get tired of this; we are all too busy to be duplicating work.

On the other hand, in institutions around the world, and increasingly with the support of national governments, IT departments are switching to electronic medical records. In many cases, handheld computers are part of that switch—or at least they are planned as the next stage. In such institutions, the doctors will be provided with handheld computers as part of good clinical care.

If you are in such an institution—congratulations, make use of your good fortune and enjoy your equipment!

If you are not, then you can change the institution and convince its decision makers of the investment, but this is a long process and requires sustained effort. In the meantime, do not buy a handheld computer for yourself in the hope that you will get the support for medical records software. It will not come soon.

Of course, you should still buy the device for all the other advantages, and we hope that we have convinced you of their value. The rest of this article will discuss the options you have as you move your institution to electronic medical records.

Medical records systems for small individuals and small teams

The easiest way to begin managing your patient’s records at the start is to buy software like Patient Tracker [www.patienttracker.com], which includes a handheld computer version and a PC version. This makes it easy to enter most of a patient’s information at your clinic desk but to add more details with the handheld computer at the patient’s home or to read those details on the device while away from your desk. The data are encrypted.

The software is designed for American clinicians and is ideal for small practices. It is not suitable for general practitioners in the UK, as more than 95% of their practices already have an electronic medical records system—and their complementary handheld computer versions are better. For doctors in hospitals in the UK that do not yet have a such a system, however, Patient Tracker could be a useful purchase for each small team.

If for any reason you do not like Patient Tracker’s interface, however, you cannot modify it. This is why so many clinicians like HanDBase: each team can create the exact forms they need for their workflow. The effort of designing and implementing the forms is not trivial though and will take some time for experimentation.

Whatever you decide, one risk to think about is losing data. You can consider buying a backup SD card for your handheld from companies like MDM [www.gomdm.com]—for around $50 (£29), the card allows a complete backup of your device. Should you lose the data for any reason, you can restore it within a few minutes after inserting the card into the device. More dangerous is losing the device itself through theft or forgetfulness. This is why encryption is so important.

Bespoke medical recrods systems

With the financial and managerial support of your institution, you can consider a medical records system tailored to your team’s needs. Scotland has wonderful examples of this, as the government has standardized data formats (which means that medical software designers can more easily share patient data between their products) and has provided budgets for software investments and target dates for implementation. Unlike the government in England, however, Scotland’s government has not been involved in micromanaging implementation.

This has led to many new companies creating innovative products and tailoring them to clinicians’ needs. For example, Extramed [www.extramed.co.uk] and Kelvin Connect [www.kelvinconnect.com] both created software that allowed hospital clinicians to read information on their patients during the ward round. The information is synchronized automatically between the handheld computer on the ward round, the PCs of the nurses in the medical assessment unit and the workstations of the radiologists in their offices.

What is interesting about these examples is the new working habits that they support and the planning that the team must go through. For example, in Lanarkshire, the software is a small part of the innovation of the night time hospital emergency care teams. A small team of two nurses and five doctors triages and treats the hospital’s inpatients overnight. In the morning, the nurses provide a report on each patient they treated, because it was the nurses that prescribed many of the drugs and the nurses that had the handheld computers.

For these habits, the doctors, nurses, managers and software developers worked together and decided on how to best to proceed for their patients. When you understand the information in this book, you will be one of the best people in your institution to help guide the decision-making for handheld computers. Find out about the committees involved in such planning and contribute to them.

Off-the-shelf systems

Even if you cannot contribute to the design of a custom system for your team, you can still play an important role if your institution chooses an off-the-shelf medical records system. This is happening in England, where the government has designated specific medical records system providers for each region. Furthermore, in many institutions, including the practices of all general practitioners in England, complete medical records systems already exist. You will not be able to switch to a different provider, but you still can buy the handheld computer version of their software. For example Inchware [www.inchware.com] makes impressive PDA versions for the existing products of EMIS, iSoft, Torex and Vision in the UK, while IDX and McKesson in the USA also have had their own mobile software for several years.

Even after the purchasing decision has been made, and even if the product is fixed and not customized, you still will play a crucial role. For example, you can take part in the early testing. This will mean that you can advise on the rate of deployment—which wards should come first—and will be ideally placed to provide training for your colleagues.

Such work is good for your career. For many clinicians, such satisfying work has prompted a switch to medical informatics as a specialty. In the end, of course, it will be the patients that benefit. Medical errors are many, expensive and dangerous. To reduce these and improve care governments around the world are investing billions of dollars in solutions. Electronic medical records are a vital part of these, and handheld computers are already making their mark. We hope that these articles help you bring the benefits to your patients.

Clinical vignette of medical records

Impressed by the work of Dr Cochrane in her general practice surgery, Dr Snow bought a handheld computer. It greatly improved his organization, and they designed a database to store audit information about their patients with diabetes for audits.

Soon, their seven colleagues wanted to make the same investment. In a practice meeting, they decided that each doctor should buy their own device to suit their tastes. Because the practice had an EMIS medical records system, the clinicians with Palm Powered devices could use the EMIS PDA software, while those with Pocket PCs could get EMIScompatible PDA software from Inchware.

This allowed Dr Snow to take the records of the patients he would see on a home visit, refer to the prescriptions and past medical history while with the patient and make notes on the visit on the handheld computer. Once back in the practice, the new notes would synchronize back to the central computer and become available to the PCs and PDAs of the other doctors and nurses.

The software did not do everything the team required, however, so Dr Snow wrote a business case for the purchase of custom software to monitor the progress of patients with cardiological conditions and diabetes. He received funding from his primary care trust and found a small company in the area. They collaborated on the design of the software and made sure that it integrated into the existing EMIS system.

The product was so well suited to the management of the patients’ conditions that he was able to coauthor several papers that documented the improved control of hypertension, and several practices in the surrounding area also invested in the software.

By this time, Dr Snow was hooked on the benefits of handheld computer for good clinical practice. He started a long-distance course in medical informatics, supported by a scholarship from his primary care trust, and searched for other areas in which he could improve patient care.

Footnotes

This is the fifth in a series of extracts from a forthcoming book by M Al-Ubaydli and C Paton. The website [www.rsmpress.co.uk/bkpda.htm] includes video tutorials to accompany this text.

Citation: Paton C, Al-Ubaydli M. The Doctor’s PDA and Smartphone Handbook Medical records. J R Soc Med. 2006 Apr;99(4):183-4.

A handheld computer smaller than a paperback can carry the equivalent of several bookshelves of text, and you have whole libraries from which to choose. For many doctors, the ability to carry and refer to their own favourite books on a handheld computer is the best reason for investing in a device.

The investment can be expensive, however, so you should consider your options before buying. The first consideration is storage. Although some devices today can carry a lot of data—measured by the amount of random access memory (RAM)—they still store less than 10% of the storage capacity of the biggest secure digital card. Furthermore, the cost of storage on a secure digital card is less than 10% of the cost of a handheld computer’s built-in RAM. In other words, it is far better to buy a $200 (c.£114) handheld computer with modest RAM and a $100 (c.£57) high-capacity secure digital card than to buy a $300 (c.£171) handheld computer with more RAM. Even if you buy a $600 (c.£340) device, you will still not come close to the capacity of the $100 (c.£57) card. This capacity is impressive. A 1 gigabyte card can store around 600 000 pages of text. Pictures take up far more space than text, but you will still be able to carry several anatomy textbooks on a 1GB card, along with hours of music and scores of photographs.

The second consideration is that a lot of reference texts are available free of charge, and many are perfectly good for your needs—even if the lack of advertising budget means that they are not as easy to find. Furthermore, for most doctors, the most valuable and important reference texts are generated locally—your own Word documents, your clinic’s guidelines, your hospital’s protocols or the local government’s social services documentation. For around $30 (c.£17), you can create handheld computer versions of all of these and share them with your team.

Finally, if you do decide to buy commercial textbooks for your device, consider that each costs at least $60 (c.£34)—and many cost much more. Choose carefully and take your time in doing so, because so many excellent offerings are available. It is easy to be tempted by all of these.

Free references

The National Library of Medicine (NLM) in the US makes several resources available free of charge at [www.nlm.nih.gov/mobile]. These include two versions of the Medline database which allows you to search the medical literature and read abstracts of most modern biomedical papers on your device. The Wireless System for Emergency Responders (WISER) software provides differential diagnoses and treatment guidelines for clinicians who suspect their patients have encountered hazardous materials.

Finally, the National Center for Biotechnology Information Bookshelf has handheld computer versions of several textbooks (Figure 1). These include Clinical Methods (a comprehensive guide to clinical examination), Genes and Disease (a primer on many common hereditary diseases) and Medical Microbiology (with encyclopaedic discussions of common microbes). The NLM’s own AHRQ Evidence report summaries is well worth downloading, because it lists protocols for the management of many conditions and even clinicians outside of the USA will appreciate the depth of the content.

Textbooks are not the only valuable references—laboratory result normal ranges, Spanish medical dictionaries and lists of medical abbreviation also can be useful. Such information is stored in databases, which was covered in more detail in the January issue. The advantage of using a database rather than an electronic book for storing this information is the ability to categorize data and run sophisticated searches. You can find all these data files on portals such as [www.handango.com], but if you follow our recommendation to buy the HanDBase database software, you should look through the HanDBase website [www.ddhsoftware.com] in the `Free Downloads’ section.

Finally, ePocrates [www.epocrates.com] makes a USA formulary, Epocrates Rx, available free of charge (Figure 2). British, German and Spanish versions exist for clinicians outside the USA. The software’s ability to identify drug interactions already has prompted one medical indemnity company to subsidize the purchase price of handheld computers for its residents because it could reduce prescription errors. In many cases, however, the most important references are local ones.

Making your local references available

Your local references are available in several formats, and it is unusual for these to be suitable for the small screen of your handheld computer. Paper is the worst format, of course, because you have to retype the information into your computer before you can use it. Someone somewhere in your institution, however, has the original file from which the paper version was printed. Find that person and ask for that file.

The three most common formats are Microsoft Word documents, Adobe Reader documents and web pages. Each of these has its problems.

Although most devices include software that is compatible with Microsoft Word, the compatibility is not perfect. Ironically, Microsoft’s own Pocket Word is rather poor, losing a lot of the formatting that you may depend on to read the text correctly and coping poorly with tables.

Far more significantly, all of these software tools allow the user to edit the Microsoft Word document. This means it is possible to for you to write a protocol that includes drug dosages, but for a colleague then to accidentally delete a decimal point in one dosage—worse still, they can beam that incorrect document to other colleagues.

Reference information on handheld computers should not be editable

A great alternative is to use RepliGo’s software [www.repligo.com]. This comes in two versions: the desktop version costs $30 (c.£17) and can convert your Word documents into uneditable RepliGo documents. Buy one copy for your team. The second version works on handheld computers and can read RepliGo documents. Install it on all of your colleagues’ devices, because it is available free of charge.

RepliGo is also good for Adobe Reader documents. These documents cannot be edited, and Adobe makes Adobe Reader software for Palm Powered and Pocket PC devices. The software adjusts poorly to the small screen size, however, which makes for a frustrating experience for the user.

RepliGo’s desktop software converts Adobe Reader documents into RepliGo documents. On your handheld computer, you have two options for reading the document. The first is to look at the document as it was originally designed for Adobe Reader, which preserves the layout, columns of text, pictures and tables. This is good for getting an overview of the pages originally designed for printing (Figure 3). The second option, which you will find most useful most often, is the text reflow view. By clicking the `REFLOW icon’ button, RepliGo will reflow the text of the page so that it is in just one column the same width as your device. This means you can comfortably read the document from start to finish by pressing the up and down buttons on your device. Adobe Reader, by contrast, can force you to scroll right every few words to read more of the line, as it tries to preserve the original formatting of the page.

To see an example of this, visit [www.handheldsfordoctors.com/plos] where a RepliGo version of PLoS medicine is stored. This is the leading open access clinical journal, and its funding means that all its issues are available free of charge. The RepliGo handheld computer version of the issues combines the great illustrations of PLoS with the illuminating text of its authors.

RepliGo is not useful for webpages, however, because useful websites usually are composed of many webpages, with rich links between those pages. A single RepliGo document, by contrast, cannot contain more than one webpage and certainly does not allow linking between webpages. Instead, you should use Plucker [www.plkr.org]. As with RepliGo, a desktop version of Plucker creates Plucker documents and a handheld computer version reads them. Unlike RepliGo, both versions are available free of charge, as they are examples of high-quality, open-source software. Plucker is capable of downloading entire websites, including your hospital’s internal webpages, and compressing the pages for efficient storage on your device but optimizing the presentation for the small screen.

Finally, HanDBase is good for storing local data, such as the appropriate blood tube for each blood test.

Converting a document to RepliGo format

After you have installed RepliGo onto your PC and handheld computer, the software can convert any document that can be printed. For example, to convert a Microsoft Word document that details your hospital’s protocol for patients with febrile leukaemia:

1. Open the document in Microsoft Word
2. From the `File’ menu, select `Print…’
3. To the right of the printer’s `Name:’, select `RepliGo’ from the drop-down menu (Figure 4)
4. Click the `OK’ button
5. Enter the name you want for the document on your handheld computer
6. Select from the drop-down list to the right of `Location:’. `Handheld’ means the file will be stored on your device, which means it is fast but will occupy precious space. `SecureDigital (SD) Card’ is a little slower, but it is preferable as you have a far bigger storage area
7. Click the `OK’ button
8. Synchronize your handheld computer
9. Open RepliGo on the device to read the document.

Converting a document to Plucker format

After you have installed Plucker onto your PC and handheld computer, the software can convert any webpage or website into a single file. Your connection to the Internet must be working at the time of conversion, but after that you can read all the webpages on your device without the connection. For example, to convert the website of the government’s driving regulations for medical conditions:

1. Use your web browser to go to the main webpage for that website. This will be the starting point for Plucker on your device
2. Copy the address of that webpage from you web browser
3. Open Plucker
4. From the `File’ menu select `Add new channel using wizard…’
5. Enter a name for the channel and click the `Next’ button
6. Paste the address you had copied and click the `Next’ button
7. Type a number to the right of `Retrieve linked pages to a depth of’. A good number is `2′. The higher this is, the less likely that you will miss out a copy of a page from the site, but the much greater the storage space on your handheld computer. Click the `Next’ button
8. Confirm that the channel’s content will be sent to your handheld computer and click the `Next’ button then the `Finish’ button
9. From the `Update’ menu, select `Update all channels’ to get the latest copy of the websites
10. Synchronize your handheld computer
11. Open Plucker on the device to read the website.

Commercial references

Few commercial textbooks are available for less than $60. High-quality publishers include Skyscape [www.skyscape.com], Franklin [www.franklin.com] and Lippincott Williams & Wilkins [www.lww.com]. They make available such famous general textbooks as the Oxford Handbook Of Clinical Medicine,² Griffith’s 5 Minute Clinical Consult³ and Harrison’s Principles Of Internal Medicine,⁴ as well as excellent texts for each specialty.

InfoRetriever takes a different approach, providing the text of InfoPOEMs [www.infopoems.com]. This consists of Patient-Oriented Evidence that Matters (POEM), which means that the authors have scanned the literature for evidence that affects your clinical management. Furthermore, they have condensed it significantly so that accessing the information while the patient is surprisingly quick.

You should, however, choose carefully before paying the prices that publishers charge. In particular, try to install a trial version of any book you are interested in, because this will give you an idea of the complication of the publisher’s digital rights management software. This is the software that the publisher uses to stop you making copies of its textbook. While it is important to make sure that the publisher does not lose money from piracy, it can punish honest customers. The more complicated the software, the more likely that a problem will arise in the future that stops you from reading a book for which you have paid good money.

Stay away from publishers with complex installation software. One notable exception is MedHand [www.medhand.com]. The company sells subscriptions to its textbooks of 1 year’s duration. In return you get four secure digital cards per year. Each contains the latest version of the British National Formulary, as well as more than 20 textbooks, including the Oxford Handbook Of Clinical Medicine and an astonishing anatomical atlas. No installation is necessary—you simply insert a card into your device and it is ready to use. The downside to this is the cost. At the time of writing, one year’s subscription cost more than £300. Institutional discounts are available, which is why some hospitals are buying the cards for their clinicians. One irritating aspect is that each card stops working after a certain date. The company explains this by saying that out-of-date prescription information must not be made available, but old paper copies of the British National Formulary and other formularies still are available in most wards and clinic and are perfectly useful.

That computer technology is used to produce greater restrictions at a greater price than with paper texts is unfortunate. The reverse should be true, and you should direct your money to publishers that understand this best.

Reading for fun

The fondness we had for our first PDAs was because the device allowed us to reclaim reading time. Clinical school meant spending a lot of time in the hospital. We had plenty of spare moments, but few paper books that we could carry. The PDA, however, could store novels and biographies as electronic books, and eventually Mohammad would also buy audio books to listen to while walking.

Project Gutenberg [www.gutenberg.org] provides free digital versions of books that are in the public domain. For the most part, this means old texts that are out of copyright, but we all could benefit from a classical education. Each book is available in any of several formats—usually simple text or a single webpage. Use RepliGo or Plucker to convert it into something suitable for your device.

For the latest books, you will have to pay money, and one of the best sites is eReader [www.ereader.com]. Each electronic book costs about the same price as the hardback edition on amazon.com. That means a 10-30% discount, but it is still more expensive than the paperback version. The freely available software for reading these books, however, is wonderfully unobtrusive. A lot of thought went into providing a good interface that helps reading.

Most importantly, of all the companies that produce electronic books, this one treats its customers with the greatest respect. To unlock a book, you simply need the name and credit card number of the person who bought the copy in the first place. This simplicity is why Mohammad still has the library of 30 books he bought from them and why we recommend the company to colleagues and friends.

Audible [www.audible.com] is the other company that we recommend - this time for audio books. If you sign up for the $15 (c.£9) a month deal, you can get one book and one radio programme per month for your handheld computer, while their $20 (c.£11) deal gets you two books. You can interrupt and restart your subscription whenever you want. Once you get a book, though, it is yours forever—regardless of subscription status—and the company allows you to download it as many times as you want in the future. Mohammad has been subscribing on and off since medical school and has gone through several PCs, handheld computers and countries in the process.

He still has access to more than 50 audio books that he bought and can make CD versions to lend to friends and family. It is not quite as simple as beaming but is still a wonderful way of sharing.

Clinical vignette of a junior doctor’s shift

In his prime, Dr Avicenna was a skilled surgeon and an expert in his specialty. He liked to carry around general medical textbooks that he could refer to for knowledge outside his specialty. For £30, he bought Saunders Pocket Essentials Of Clinical Medicine [www.fleshandbones.com/medicine/ballinger], which included the paperback version and a handheld computer version. He knew that the medical team in the hospital was provided with subscriptions to MedHand, but for his team he just used ePocrates Rx to spot any drug interactions.

Dr Avicenna stored all these books on a $200 4GB secure digital card that he bought for his smartphone. This card also allowed him to store his entire classical music collection. By connecting a speaker to his device, he could play his favourite symphonies in theatre while operating. For his car, he had a $20 connector from his cassette player to his smartphone. He could play the same music through his car’s speaker, but he preferred to listen to audio books from Audible for his morning commute.

Finally, on nights that he had to stay in the hospital, Dr Avicenna appreciated having the books he had bought from eReader. He could switch off the light in his room and yet read comfortably through the brightness of his smartphone’s screen. Two minutes after he fell asleep, the screen would switch off, saving the page he had been reading till the next time he wanted to resume the novel.

Footnotes

This is the fourth in a series of extracts from a forthcoming book by M Al-Ubaydli and C Paton. The website [www.rsmpress.co.uk/bkpda.htm] includes video tutorials to accompany this text.

References

1. Al-Ubaydli M, Paton C. The Doctor’s PDA and Smartphone Handbook: Databases. J R Soc Med2006; 99:20 -23
2. Longmore M, Wilkinson I, Rajagopalan S. Oxford Handbook Of Clinical Medicine. Oxford: Oxford University Press,2004
3. Dambro MR. Griffith’s 5-minute Clinical Consult. Philadelphia: Lippincott Williams & Wilkins,2005
4. Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, eds. Harrison’s Principles Of Internal Medicine. New York: McGraw-Hill Professional, 2004

Citation: Paton C, Al-Ubaydli M. The Doctor’s PDA and Smartphone Handbook Medical references. J R Soc Med. 2006 Mar;99(3):120-4.

A good house officer is an organized house officer; and keeping track of the jobs to be done for each patient is arguably the most important skill for doctors beginning their career. Your handheld computer’s task list will not make you organized, but it will provide you with the tools you need to be organized.

Like the diary and address book, the task list’s importance means that most handheld computers include a button that takes you straight to the program. This is usually in the bottom right-hand corner, second from the right. Alternatively, on Palm Powered machines, tap on the HOME icon and then the icon labeled To Do List. On Pocket PCs, tap on the START icon and then Tasks.

The tasks are given in a list, with a tick box next to each task (Figures 1 and 2). Tap on a tick box if you have completed its task, and tap again to remove the tick from the box. Tapping on a task allows you to look at the task’s related text, priority and due date. The priority and due date are what you really need to manage your tasks for the day.

Creating a task

To add a task about setting up a chest computed tomography scan for a patient with hospital ID ABC123456:

1. Tap on the New button on a Palm Powered device or the New menu item on a Pocket PC
2. Write ‘CT scan ABC123456′
3. 3. On a Pocket PC, tap the OK button.

It is important to make the text for each task short yet explanatory. As you look at the list of tasks during the day, you will mostly rely on this writing to give you the information you need at a glance.

Using the patient’s hospital ID rather than their full name is doubly important. First, tasks are not encrypted, so they are not secure enough to include identifying information about your patients. Second, as you fill out the computerized tomography request form later on, the ID is the most important detail you will need.

This works fine if you are already in the habit of attaching a sticky label from your patient’s notes onto your white coat. Combine this with the hospital number on your task list and you have a convenient system that still maintains confidentiality and complies with data protection rules.

Adding notes to a task

For some tasks, it is necessary to include extra information about the task. In the chest computerized tomography example, you might want to include a clinical summary of the patient and the question you want the radiologist to answer. Use the task’s notes to do this. On a Pocket PC:

1. Tap on the task you want to edit
2. Tap the Edit menu item
3. Tap on the Notes tab
4. Write the note
5. Tap the OK button

On a Palm Powered device:

1. Tap on the task you want to edit
2. Tap on the Details… button
3. Tap on the Note button
4. Write your notes
5. Tap the Done button.

Again, remember that the notes part of the tasks list is not encrypted, so you should not include any information that could identify your patients.

Figure 1 Pocket PC’s Tasks	Figure 2 Palm Powered device’s To Do list

Priority and due dates

The key to being organized is to make sure that every task has a priority and a due date. Then you can begin your day’s efforts with the tasks that are most important or urgent. Once these are complete, you can focus your attention on the other tasks.

To change the priority and due date on a Pocket PC:

1. Tap on the task to edit it
2. Tap to the right of Priority:
3. Select from Low, Normal and High. Normal is the default, while High priority tasks appear with a red exclamation mark in the tasks list
4. Tap to the right of Due:
5. Select the date by which the task needs to be completed.

On a Palm Powered device:

1. Tap on the task to edit it
2. Tap on the Details… button
3. Select from 1 to 5 to the right of Priority: 1 is the default and is also the highest priority
4. Tap to the right of Due:
5. Select the date by which the task needs to be completed. You can quickly choose from Today, Tomorrow, One Week Later and No Date or you can tap on Choose Date… to get a calendar from which to choose another date.

Sorting and the satisfaction of purging

1. Tap on Sort By in the top right corner
2. Select Due Date instead.

By default, Palm Powered devices sort first by due date and second by priority. To change this:

1. Tap on the Show… button
2. Tap to the right of Sort by:
3. Select Priority, Due Date to sort first by priority and second by due date
4. It is worth also unticking the box to the left of Show Completed Items
5. Tap the OK button.

To untick the Show Completed Items box is optional but very useful. The result is that whenever you tick a task to signal it has been completed, it will disappear from the list. To do the equivalent on a Pocket PC:

1. Tap on the Show menu in the top left corner
2. Tap on Active Tasks….

It is satisfying to see your list of tasks gradually getting shorter during the day as you go about your work.

Categories

As with the address book, categories are useful. Good categories to create include the names of the wards of your patients and the names of the consultants for whom you work. On a Pocket PC:

1. Tap on the task to edit
2. Tap the Edit menu item
3. Tap to the right of Categories:
4. Tick the box next to each category you want
5. If you do not find the category you need, tap on the Add/Delete tab and add the name of your new category
6. Tap the OK button.

On a Palm Powered device:

1. Tap on the task to edit
2. Tap on the Details… button
3. Tap to the right of Category:
4. Select the category you want
5. If you do not find the category you need, tap on Edit Categories… and add the name of your new category
6. Tap the OK button.

Categories are particularly helpful for beaming.

Beaming

To beam a task on a Pocket PC:

1. Tap and hold on the task
2. Select Beam Task… from the menu that appears.

On a Palm Powered device:

1. Tap on the task
2. Tap on the MENU icon
3. Tap on Beam Item from the Record menu.

To beam all the tasks within a category on a Pocket PC:

1. Select the category from the list of categories in the top left-hand corner
2. Tap and hold on the first task in the category
3. Drag down to the last task in the category. You can tell when all of the tasks in the category are selected because they will switch to white writing over a blue background
4. Select Beam Task… from the Tools menu.

On a Palm Powered device:

1. Select the category from the list of categories in the top right corner
2. Tap on the MENU icon
3. Tap on Beam Category from the Record menu.

Advanced uses

Two types of additional software are available. The first type is useful because it allows you to link a task to a person. For example, you can link each of your referral tasks to the consultant the patient needs to see. When you meet the consultant, their name in the address book will list all the referral tasks for that consultant. You can discuss all the relevant patients with that consultant. Examples of software in this group include Agendus [www.iambic.com] for Palm Powered machines and Agenda Fusion [www.developerone.com] for Pocket PCs.

The second type of software allows hierarchical tasks. For example, the main task for a patient might be setting up a referral to a neurologist, but this would depend on the completion of two other tasks: scheduling a computerized tomography scan of the patient’s head and putting the radiology report in the notes for the neurologist to use. It is best to set up one task with the title `refer to neurologist’ and give it three subsidiary tasks: `CT head’, `add CT head report to notes’ and `write referral letter’. Hierarchical software, such as ThoughtManager [www.handshigh.com] for Palm Powered devices and TreNotes for Pocket PCs [www.fannsoftware.com], allows correct sequencing for the subsidiary tasks and tracks the progress of each of these.

Sadly, no software allows linking to both addresses and hierarchical tasks, so you will have to choose which feature matters to you most. If you are already using Agendus or Agenda Fusion, it is best to stick to it for your tasks. If you end up using ThoughtManager for its note-taking skills, you should use it for your tasks as well. Otherwise, you should try both types of software, as they include free trial versions that will allow you to decide which best suits your habits.

Footnotes

This is the third in a series of extracts from a forthcoming book by A Al-Ubaydli and C Paton. The website [www.rsmpress.co.uk/bkpda.htm] includes video tutorials to accompany this text.

Clinical vignette of a junior doctor’s shift

Tuesday mornings were Dr Charcot’s busiest, as they began with her consultant’s ward round. During the round, she would keep track of every job for the patients on her handheld computer’s task list. From each patient’s notes, she attached a sticker to her coat pocket. For each task, she included the patient’s hospital number. For the more complex tasks, she added a note with extra information.

Dr Charcot categorized the tasks by the ward on which the patient was present. She also included the priority and due date for each task.

After the round, Dr Charcot carried out the most urgent and highest priority tasks before going for lunch. After lunch, she could go through the other tasks at her leisure. It was satisfying to see her list get shorter as she ticked off each task as completed.

The stickers on Dr Charcot’s coat provided her with each patient’s identifying information. Combined with the patient number on each task, she could keep track of who needed what without compromising patient confidentiality on her handheld computer.

At the end of Dr Charcot’s shift, she would beam the categories with tasks that she had not yet completed to the night shift’s junior doctor. The next morning, she would confirm that the junior doctor had completed all the tasks overnight. As Dr Charcot left the hospital, she made use of the `shopping’ task list category. She ticked off every item as she went down the supermarket’s aisles. Soon it would be time to relax over dinner.

Citation: Paton C, Al-Ubaydli M. The Doctor’s PDA and Smartphone Handbook Databases. J R Soc Med. 2006 Feb;99(1):73-6.

A database is the computer equivalent of a filing cabinet full of forms. Like a filing cabinet, a database can store a lot of information, and by using forms, the information is structured, which paves the way for statistical analysis and audits.

A database on a handheld computer has many advantages over a filing cabinet. First, you can carry all the forms you need. This is great for audits, because you can enter data about patients at any time, including while you are with the patient during the ward round or when you can get hold of the patient’s notes from the consultant’s secretary.

Second, you can carry all the information you have filled out in the past. Not only is the handheld device orders of magnitude smaller than a filing cabinet, the sorting and searching tools are very fast. For example, if you have a list of patients, it only takes a few seconds to sort it by each patient’s name and then to sort it again by consultant’s name. You can quickly search for a patient whose date of birth is before a certain year and whose blood results are within a certain range.

Finally, you can share the information with colleagues. Beaming makes this quick and easy to do as you meet with colleagues during the day. It takes more effort and expertise to do this with synchronization, but it means you can get the information without needing a face-to-face meeting.

Choice of database

Many database programs are available to choose from. For the palm powered devices, you can use Pilot-DB [http://pilot-db.sourceforge.net/], which is free of charge but lacks encryption and is not very user friendly. JFile is well worth the US$25 [www.land-j.com], as is Sprint DB Pro for pocket personal computers [www.kaione.com].

For most users, however, HanDBase is the most appropriate database software. First, it is available for both palm powered and pocket PC devices, which makes sharing data with your colleagues easier. Second, it has the most example databases available, both free of charge and for sale, which means that you can use someone else’s work
rather than design your own database forms.

Using someone else’s database

Freshly installed database software has no forms for you to enter data, so you must either spend the time creating your own forms or use someone else’s. Many doctors prefer creating a form that is perfectly suited to their habits and work, and this has its advantages. For the novice user, however, creating a form can be daunting. Furthermore, it is more efficient to use someone else’s work and customize it than to create a brand new form. Finally, standardization can be a good thing, especially if you would like to share data with colleagues. In other words, if you use a different form to your colleagues, you cannot share the data in each other’s forms.

This is why so many medical institutions make database forms available to their members. For example, the Association of Surgeons of Great Britain and Ireland [www.asgbi.org.uk] has created a surgical logbook built on HanDBase, which you can download free of charge from [www.surgeonslog.com]. What is particularly impressive is the ability to transfer the data from your handheld computer to the association’s website so you can back up and view it over the web.

The Royal College of Anaesthetists’ logbook is available at [www.logbook.org.uk] and is also built on HanDBase. The author’s own website [www.handheldsfordoctors.com/databases] makes other databases that you can customize and share with colleagues available free of charge. The next few examples will use the surgical logbook HanDBase database from this site.

Entering data

To open HanDBase on pocket PCs, tap on the ‘Start’ icon, then ‘Program Files’ and then the icon labelled ‘HanDBase’. On palm powered machines, tap on the ‘Home’ icon and then the icon labelled ‘HanDBase’. You will see a list of the databases you have installed. Tap on ‘Surgical logbook’ for this example (Figure 1).

Figure 1 HanDBase lists the databases you have installed	Figure 2 Tap the ‘New’ button to enter a record in your database. This example is from the surgical logbook database.

For security, this database is encrypted. The default password is blank, so just tap the ‘OK’ button, but you will have to change this when you finish entering data.

You will see a list of column headings across the top, including ID, Date, Patient ID, DOB, Sex and Age. As you add data about your operations, a row will appear for each operation (Figure 2).

To enter data:

1. Tap the ‘New’ button
2. By default, the date of the operation is today’s date.
3. Tap to the right of ‘Date’ to select a different one
4. Write the patient’s hospital identification number to the right of ‘Patient ID’
5. Tap to the right of ‘DOB’ to select the patient’s date of birth
6. Select the patient’s sex by tapping to the right of ‘Sex’
7. Write the patient’s age to the right of ‘Age’
8. By default, the current time is used for the operation’s starting and ending times. Tap to the right of ‘Start’ and ‘End’ to select different times
9. Tap on ‘Operation’ to select the operation from the list of operations. If the operation you want is not in the
   list, tap ‘Edit Popup List’ to add its name
10. By default, the priority is ‘Routine’. Tap on ‘Priority’ to select an alternative, such as ‘Day case’, ‘Emergency’ or ‘Urgent’
11. By default, your role is ‘1st assistant’. Tap on ‘Role’ to select a different one, such as ‘Performed alone’
12. This should be enough information to enter about the patient at the start. It is useful for your own records and for submission to your surgical college, however, to enter more information. For example, further down the form, you can document the patient’s past medical history (tap to the right of ‘PMH’) and complications at 24 hours, 1 month and in the long term
13. Tap on the ‘Down’ icon button to go down and the ‘UP’ icon button to go up
14. When you are finished, tap the ‘OK’ button.

Sorting

In each database, the records usually are listed in the order you entered them. To choose a different method, tap on a column name. For example, to sort by date, with the latest operations appearing at the top:

1. Tap on the column titled ‘Date’
2. Tap ‘Sort Reverse’

You can sort using multiple criteria. For example, to sort your operations first by your role and then by the date of the operation:

1. Tap on the ‘Tools’ button
2. Tap on the ‘Sort’ button
3. Tap to the right of ‘Primary Sort’ and select ‘Role’
4. Tap to the right of ‘Secondary Sort’ and select ‘Date’
5. Underneath ‘Secondary Sort’, tap on ‘Reverse’
6. Tap the ‘OK’ button.

Filtering

Filtering allows you to find a particular group of patients. For example, to find all the patients between the age of 30 and 40 years who had diabetes in their past medical history:

1. Tap on the ‘Tools’ button
2. Tap on the ‘Filter’ button
3. Tick the box labelled ‘Filter 1 Enabled’
4. Tap to the right of ‘Select Field’ and select ‘Age’
5. Write ‘30’ to right of ‘Lower Limit’ and ‘40’ to the right of ‘Upper Limit’
6. Tick the box labelled ‘Filter 2 Enabled’
7. Tap to the right of ‘Select Field’ and select ‘PMH’
8. Write ‘diabetes’ to the right of ‘Must Contain’
9. Tap on the ‘Down 2’ icon button to go down and the ‘Up 2’ icon button to go up and add any other filters
10. When you are finished, tap the ‘OK’ button.

The list of operations now will include only those that meet the criteria of these filters.

To remove the filter:

1. Tap on the ‘Tools’ button
2. Tap on the ‘Filter’ button
3. Untick the boxes labelled ‘Filter 1 Enabled’ and ‘Filter 2 Enabled’
4. Tap the ‘OK’ button

The list will return to showing all of the operations.

Running a report

You can do simple statistical analyses of your data. To find the average age of your patients on a palm powered device, tap on the ‘Menu’ icon. Then, on this device or a pocket PC:

1. Tap on the ‘Actions’ menu and select ‘Run Report’
2. Tap on ‘Select Field’
3. Tap on ‘Age’
4. Tap the ‘Go’ button.

You will see the average age to the right of ‘Average’, as well as the minimum (‘Min value’) and maximum (‘Max value’) ages. The ‘Sum’ is not useful in this case, but it would be important for adding up the cost column in a database that tracked the purchases made by your department.

Designing a database

It is technically fairly easy to design your own database, but coming up with a good design can be hard. It certainly takes experience and a little thinking in advance. It is worth trying the example databases with your patients for a few days to note which parts of the design you would like to change.

To change the design of an existing database on your pocket PCs, tap on the ‘Start’ icon, then on ‘Program Files’ and then on the icon labelled ‘HanDBase’. On a palm powered device, tap on the ‘Home’ icon and then the icon labelled ‘HanDBase’. Then:

1. Tap on the name of the database you want to edit
2. Tap on the ‘Details’ button
3. If the database is encrypted or password protected, enter the password and tap the ‘OK’ button
4. Tap on the ‘Fields’ button.

You will see a list of fields. Each field is the equivalent of a column heading that you see when listing the records in your database. Tap on the field that you want to edit. For example, if you tap on ‘DOB’ from the surgical logbook database, you can see that its ‘Field Type’ is ‘Date’ (Figure 3). This means that changing the value of this date in a record will bring up a calendar.

Figure 3 The date of birth field in HanDBase

If you had selected ‘Text’ instead, you would have to write ‘01/26/1976’ for a patient’s whose date of birth is 26 January 1976. This might seem faster, but it means that running the filters feature is practically useless for ‘DOB’.

You will not be able to filter patients born before 1975, for example, as the database does not treat ‘DOB’ as a date.
Similarly, the ‘Age’ field is an integer, which means that the database treats it as a whole number. This is useful because the surgical logbook database will prevent you writing ‘67.5’ or ‘67a’ by mistake, which keeps your data clean. It also means you can see the sum of that field’s data when you run a report on the database.

As you can see, designing a database can be complicated at the start. Fortunately, HanDBase’s website has excellent explanations of all of the field types, as well as excellent tutorials that walk you through setting up your own database [www.ddhsoftware.com/support.html]. The RSM course that we run every year [www.handheldsfordoctors.com/rsm] also provides hands-on training.

Citation: Al-Ubaydli M, Paton C. The Doctor’s PDA and Smartphone Handbook Databases. J R Soc Med. 2006 Jan;99(1):20-3.

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]