Mohammad Al-Ubaydli, “Handheld computers”, BMJ, 2004 vol 328 p1181. [original paper]
- 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 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.
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.
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.
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
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).
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.
Figure 1. Google’s Home Page
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 . 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.
Figure 2. Results of the Search Term “Heart Attack”
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.
Figure 3. Results of the Search Term “Myocardial Infarction”
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  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  and the shorter Google Pocket Guide —provide useful additional tips and guidance.
Figure 4. Results of a Google Images Search Using the Search Term “Hip Prosthesis”
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.
Figure 5. Vivisimo Searches the PubMed Database and Clusters the Results by Subject
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.
- National Library of Medicine (2005) PubMed tutorial. Available: http://www.nlm.nih.gov/bsd/pubmed_tutorial/m1001.html. Accessed 21 June 2005.
- National Institute for Clinical Excellence (2002) Myocardial infarction—Thrombolysis. Available: http://www.nice.org.uk/page.aspx?o=38399. Accessed 21 June 2005.
- Calishain T, Dornfest R (2004) Google hacks, 2nd ed. Sebastopol (California): O’Reilly. 480 p.
- Calishain T, Dornfest R, Adams DJ (2003) Google pocket guide. Sebastopol (California): O’Reilly. 144 p.
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
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.