Published 2008-03-31 in iHealthBeat.
More and more doctors are using smartphones — essentially PDAs that can make phone calls — in their daily lives, yet few of them are integrating the devices into their clinical practice. New clinical software designed specifically for smartphones is helping to overcome some barriers, yet there are other roadblocks preventing smartphones from becoming much more common in medicine than they are now.
As the average cell phone becomes “smarter” and telecommunications companies aggressively expand mobile networks, consumers in both developed and developing countries increasingly have a wireless computer in their pockets, according to Joel Selanikio, a pediatrician in Washington, D.C. Selanikio’s not-for-profit company DataDyne.org makes open-source public health data collection software for PDAs and cell phones. The software is used by the World Health Organization, the World Bank and other organizations around the globe.
Unlike laptops and tablet PCs, smartphones are small enough to carry everywhere, their battery life lasts longer than a clinical shift and they have no standby or hibernation waiting times.
Yet, however convenient, many physicians are reluctant to carry and learn how to use smartphones in their medical practice. Others find it difficult to enter data into the devices using handwriting recognition. A further barrier is that hospital IT departments must provide support for doctors using the devices.
The medical software sector has seen a flurry of activity surrounding the smartphone market in the last few months. Epocrates recently announced the availability of its drug reference software for BlackBerrys, while Skyscape announced the release of all its medical textbooks for the BlackBerry platform. Thomson Healthcare has been providing medical software for BlackBerry devices since 2006.
The publicity surrounding the release of Apple’s iPhone prompted yet another wave of companies pledging support for its platform. eClinicalWorks practice management software is designed for Web browsers, including those operating on iPhone, as is the American Academy of Family Physicians’ CEND Personal Health Record Web site and Life Record’s electronic health records software.
Unbound Medicine, a provider of evidence-based medicine content, announced in July 2007 that its clinical references Web site works on iPhones. Meanwhile, Epocrates announced the availability of iPhone software at an Apple press conference in February.
All of this is in addition to the existing products from medical software vendors for handheld computers and smartphones running the Palm, Pocket PC and Windows Mobile operating systems.
The technology advances come at a time when sales of nonsmartphone handhelds continue to fall. IDC estimates that worldwide sales in the third quarter of 2007 were just under $730,000, a 40% drop from the 1.2 million units sold during the same quarter in 2006.
Rises in smartphone sales are much greater than this drop. In-Stat estimates double-digit growth every year for the next five years by traditionally PDA-centric vendors like Palm, as well as newer smartphone vendors like BlackBerry and the most recent and famous entrant, Apple.
At Virginia Commonwealth University Medical Center, a pilot study with emergency department physicians has been successful enough to justify providing smartphones to each physician in the hospital.
The devices access data from a central EHR system run by Cerner. Physicians also can use their smartphones to search textbooks and the Internet, send and receive e-mails, and make and receive telephone calls with hospital staff. The hospital’s investment largely is covered by the increased charge capture from enabling billing by the bedside with the same PatientKeeper software that provides the Cerner medical records for patient care.
IT teams are still learning how to get the best value from technology like smartphones. At VCU, two earlier pilots uncovered problems with nonsmartphone PDAs, as wireless connectivity was not reliable enough for clinicians, and certain smartphones could not meet clinicians’ need to use several applications simultaneously.
The spread of methicillin-resistant Staphylococcus aureus infections is leading to questions about hospitals’ hygiene policies for clothing and devices, including smartphones. Infections associated with handheld computers are less significant than those spread by not washing hands, explained Anatole Menon-Johansson, a U.K.-trained physician completing a master’s degree in public health at Harvard University.
“Hands are by far the most important, then white coats, shirt cuffs, stethoscopes, ties, rubber hammers, ophthalmoscope, whatever else is in your white coat pocket, and only then cell phones and PDAs,” Menon-Johansson said.
The cost of integration can also be significant for hospitals. However, if hospitals do not make an investment in supporting smartphone technology, physicians using smartphones either have to double-document, entering data into both their own handheld computers and the central medical records system, or they fail to reap the advantages of up-to-date information by patients’ bedsides.
Getting accurate data on how many physicians use smartphones in their practice is difficult because the term “use” can be defined in a broad range from taking practice-related phone calls to data storage, computing and Internet research.
According to Thomson Healthcare research, about 31% of physicians in this country use smartphones in their practice. The Diffusion Group, a consulting firm specializing in IT, estimates higher — that nearly half (49%) of U.S. doctors used smartphones in 2006.
Leaders in both the medical and information industries predict smartphone use in physicians’ practices will grow rapidly across the globe. Selanikio of DataDyne predicts African countries will be among the most rapid adopters of wireless smartphone technology because of the relative dearth of land-based computing options.
In the United States, according to research by the Diffusion Group, smartphone use by physicians will increase to 70% over the next three years.
I read in the newspaper today that Internet Explorer has security problems
That’s right, which is why you should always use the latest version of software. Microsoft periodically releases upgrades that fix newly found security problems. On the other hand, you could just get Firefox instead.
Like Internet Explorer, Firefox is web browser software. But it is more secure and has several features that improve your browsing experience. For example, it automatically blocks popup windows.
I hate those—it irritates me when I’m trying to read a page and a window pops up trying to sell me something
Firefox protects you from these. In fact if you like this feature you will love the Adblock extension. Extensions are small programs that add to the features of Firefox, and Adblock is one of the most popular. It allows you to block any picture on a page by clicking on it with the right mouse button, then clicking “Adblock image.” You will find this handy on pages that use colorful flashing adverts that distract you from reading the text.
Brilliant. Any more tips like these?
Firefox has tabs. These allow you to look at several pages within the same window. Each page has its own “tab,” a rectangle at the top. Clicking on a tab shows its page and hides the other pages. Switching between tabs makes it easy to keep track of several webpages without cluttering your computer screen by adding extra browser windows.
I’m not sure I see the attraction. Does it have any features that are useful to doctors?
Certainly. In the top right corner of Firefox is a rectangle. Type some text, press the return key and Firefox uses Google to search the web for pages that contain your text. This is a handy feature because it saves you time.
The clever bit comes because Google is not the only search engine available to you. Click on the arrow on the left hand side of the rectangle, then click on “Add Engines” to get a full list. It includes the National Centre for Biotechnology Information’s (NCBI) PubMed, so you do literature searches, and the NCBI Bookshelf, so you refer to biomedical textbooks.
In fact, tabs and PubMed work well together. When scrolling down the list of results from a PubMed search, click with the right mouse button on the title of any paper that you think would be useful. Then with the left mouse button click on “Open Link in New Tab.” A new tab appears in the background. When you are done looking at the list of results you can look at each of the tabs that you had opened to read the abstracts of each of the papers. In other words, Firefox allows you to keep track of all of these papers without interrupting your train of thought as you read the list of results.
I see how that could be useful. But it sounds rather complicated
If you managed to use Internet Explorer you will find Firefox familiar and easy to use. Just like in Internet Explorer you type the website address in the rectangle at the top of the window and press return to visit the website. And to follow a link to another webpage, click on the blue underlined words. The extra features like extensions, tabs, and search engines are useful but not intrusive. You can easily ignore them. However, try them out once—you will always want to use them.
Sounds great. But how much will all of this cost me?
Nothing. It is available free of charge and you are free to install it on as many computers as you want.
See? There must be a catch—spyware, viruses, advertising?
Nothing of the sort. Firefox is free from spyware, protects you from many viruses, and its popup-blocking and Adblock extension prevent annoying adverts from interrupting your reading. But it is available to you because it was collaboratively built by programmers around the world working under the Free Software GPL license. That also explains its quality—the programming code is available for anyone to look at and critique, which raises standards in the same way that peer review does for clinical research.
So how do I get it?
You can download a copy from www.mozilla.org. Alternatively, many computer magazines include the software
on their bundled CDs. This can save you time and money if you only have dialup internet access. Finally, the website www.8daysaweek.co.uk sells the OpenOffice CD for £10.99. This includes Firefox but also OpenOffice, an alternative to Microsoft Office, and a whole bunch of other GPL Free Software tools.
My daughter is going to university. Do you know where I can get her a cheap copy of Microsoft Word?
You should give her OpenOffice. It’s available free of charge and works like Microsoft’s Word, Excel, Power-Point, and Access. It even includes a drawing program, something you don’t get from Microsoft Office (MS Office).
All that free of charge? There must be a catch—bugs, spyware, or adverts to get me to buy something?
It has none of these problems. It matches Microsoft’s software for every feature that you use, and has a few extras to boot. Because it runs efficiently it works well even on older machines that could not cope with new versions of MS Office. It has no spyware, and we know this because its entire code is available for anyone to look at—software with this freedom is known as Free Software. It has the same transparency and quality that peer review has in medical research.
And it really is free, although you can buy a version with technical support (www.staroffice.com).
Aha, it must be really difficult to use so you end up having to buy the technical support.
If you have managed to use MS Office, you will find OpenOffice easy to use.
Well maybe my daughter could try it.
And you should too. A lot of UK doctors use it, including locums and overseas doctors who do not get MS Office from the NHS. Others use it just because it doesn’t crash as often and is less susceptible to viruses.
Oh no, I can’t use it—other doctors keep on sending me Word documents that I need to read and edit.
OpenOffice can open and save all MS Office formats. For example, this article was written with OpenOffice but saved in Microsoft Word format because the editor does not (yet) have OpenOffice. Your colleagues would not notice that you have switched.
However, sending Word documents can be a bad idea. For example, if you are sharing a protocol the last thing you want is for the person reading the document to accidentally change a drug dosage and then share that incorrect document with others. And if you are sending a CV, Word lets your potential employer see all the changes and comments that the CV has gone through, which can be embarrassing.
That is why OpenOffice lets you save your document in PDF format—this can be opened by anyone else using
the free Adobe Acrobat Reader (www.acrobat.com) but they would not be able to edit it, nor see all your changes. It also gives a professional air to your CV.
Are there other features that OpenOffice has that MS Office doesn’t?
OpenOffice Draw is particularly useful. It helps you create posters for your teaching sessions and complex layouts for your team newsletter.
OpenOffice also supports other formats that Word does not, including AportisDoc for Palm Powered and Pocket Word for Pocket PC handheld computers. And it converts presentations into PDF or Flash files for easy placement on websites. Both options mean your presentation is safe from changes by the reader.
All right, how do I get a copy then?
To get the latest version of the software, visit www.openoffice.org and click on “Download”. On the right hand side are instructions guiding you through download and installation of the software.
The file you download will be about 70 MB in size so if your internet connection at home is dialup you might find it easier to download the software at work, transfer it on to a CD, and then use the CD at home. Alternatively, some computer magazines include the software on their free CD. Look out for “OpenOffice” on the CD cover.
Finally, for £10.99 you can buy a CD from www.8daysaweek.co.uk, which includes OpenOffice and several other useful Free Software tools.
However you get the software you have the right to install it on as many computers for as many colleagues
as you want.
Anything else I should know?
Computer skills are useful to your career and daily practice. You might want to speed up your switch from Microsoft Office by getting a copy of the book OooSwitch. If you want to improve your typing skills, Tux Typing is another example of Free Software and you can get it from http://tuxtype.sourceforge.net/. Finally, my own book Free Software for Busy People is freely available online at www.freedomsoftware.info.
Mohammad Al-Ubaydli is author of “Free Software for Busy People” and “Handheld Computers for Doctors”.
1 Granor TE. “OOoSwitch: 501 things you wanted to know about switching to OpenOffice.org from Microsoft Office“. Hentzenwerke Publishing, 2003 (ISBN 1 930919 36 0).
Published in BMJ Career Focus 2005;331:101.
World wide web domaination
An internet address is called a domain; an example is “doctors.net.uk” or “bmj.com”. Different prefixes give different functions. An example of a web address is “www.bmj.com“, and an email address is “
var prefix = ‘ma’ + ‘il’ + ‘to’;
var path = ‘hr’ + ‘ef’ + ‘=’;
var addy5978 = ‘mohammad’ + ‘@’ + ‘doctors’ + ‘.’ + ‘net’;
document.write( ‘<a ‘ + path + ‘\” + prefix + ‘:’ + addy5978 + ‘\’>’ + addy5978 + ‘</a>’ );
What’s in a name?
Choose a simple name that others can remember, or even guess. The name should be associated with, or describe, your organisation. Avoid abbreviations if you can.
A happy ending
You have several choices for the end of your web address. A “.com” implies a company that operates internationally, and “.org.uk” suggests a non-profit organisation that operates in the UK.
Get on the register
To get these addresses you need a domain name seller, who will sell you a name at a yearly rate of less than £30 ($54; Euro 45). Two excellent places to do this are the UK’s Nominet (www.nic.uk), and the American Register (www.register.com); an awful place to do this is the company that provides you with internet access because they usually overcomplicate transferring your address as you switch to another company.
A basic web address forwards all email to your existing email box (which can be free, for example, from hotmail.com) and all web traffic to your existing web space (which can also be free, for example, from Freeserve). The registration process guides you through this.
Companies like bizland.com offer you extras. These include separate email boxes (for example,
var prefix = ‘ma’ + ‘il’ + ‘to’;
var path = ‘hr’ + ‘ef’ + ‘=’;
var addy79031 = ‘patients’ + ‘@’ + ‘yoursurgery’ + ‘.’ + ‘com’;
document.write( ‘<a ‘ + path + ‘\” + prefix + ‘:’ + addy79031 + ‘\’>’ + addy79031 + ‘</a>’ );
var prefix = ‘ma’ + ‘il’ + ‘to’;
var path = ‘hr’ + ‘ef’ + ‘=’;
var addy6830 = ‘partners’ + ‘@’ + ‘yoursurgery’ + ‘.’ + ‘com’;
document.write( ‘<a ‘ + path + ‘\” + prefix + ‘:’ + addy6830 + ‘\’>’ + addy6830 + ‘</a>’ );
Prices are low and stratified, and you can easily upgrade to the higher cost whenever you need the extra service.
published in the March 26th 2005 issue of the British Medical Journal’s Career Focus
In a busy hospital environment, getting access to the notes for your audit data can be a haphazard and temporary affair. Always carry a handheld computer. Most Palm compatible machines come with ExcelToGo while Pocket PCs come with Pocket Excel. Data you enter there will easily transfer to your desktop computer’s Microsoft Excel.
To add up all the cells in a column, click inside the cell that you want the sum to appear in. Type in =SUM(. Keep the shift key pressed and click inside the first cell in the column. Then type a colon. With the shift key still pressed, click at the bottom of the column. Finally type in a closed parenthesis and press the return key.
When you scroll down the page, you still want to see the row of your column headings. Click on the number of the row underneath the row of your column headings. Then, from the Windows menu, click on freeze panes.
To create a graph, click in the top left corner of your table. With the shift key pressed, click in the bottom right corner. Press the F11 key, and Excel creates a chart for you. To over-ride its choices, click twice. For example to change the font of the x axis: click twice on the axis, click “Font” and choose your font.
Excel is great for analysing and charting data – but for serious data collection and storage, Microsoft Access is king. If you have two or more tables, or your table is rather long, consider Access. The program can import your Excel data. Create a new database in Access. From the “File” menu, click “Get External Data”, then “Import”. At the bottom of the dialogue that appears, you will see the label “Files of type”: click to its right, and scroll down to Microsoft Excel (*.xls) .Click there, and find your files. Access will guide you through the rest of the process.
published in the January 1st 2005 issue of the British Medical Journal’s Career Focus
Content is king. MS PowerPoint has lots of power, but the points only come from you. Before you add exciting animations, colourful logos, and smooth transitions, think about what you are trying to tell your audience, and how best to tell them.
The main thing is to keep the main thing the main thing. Include a summary of your talk on one of your first slides, and one of your last slides. On each slide, make sure the important points are in the largest font, and your less important points are in smaller font. Better still, only include important points.
- Less is more—Mention two to four main points per slide. Never more. And never paragraphs. Your slides guide your audience to the main points, while your speech and handout fill them in on the details. Finally, keep the length of your talk short. No one in your audience will listen to you after 50 minutes, and many will switch off after 30 minutes.
- Lay out your argument—Each slide can have different layouts. For example, some slides are all text, whereas others have a diagram on the left or right. From the Format menu, click Slide Layout, and choose the layout that best illustrates your argument.
- Mastery—Even if all your slides have different layouts, they still have a similar look and feel. To change it, click on the View menu, then Master, and choose Slide Master. Every change you now make will apply to all your slides. When finished, click on Normal from the View menu.
- PowerPoint makes practice makes perfect. To practise your presentation, choose Rehearse Timings from the Slide Show menu. Make sure you are able to comfortably get through your talk using only the allotted time. On the big day, overrunning is unfair on others, and cutting your talk is unfair on you.
- Paper is your saviour. Computers are complicated, which means they crash. Always bring a paper version of your talk.
Microsoft PowerPoint lets you draw diagrams for your essays, flowcharts for your organisation, or designs for your website. Here are some tips on how to get the most out of it.
- Create your canvas—From the Insert menu, click New Slide. From the Format menu, click Slide Layout and choose the blank layout. You should now have a new and empty slide.
- Tools to use—From the View menu, click on Toolbars, and make sure that there is a tick mark next to Drawing. If not, click on Drawing. The bottom of your window now has tools for your drawing. Clicking AutoShapes reveals a whole range of shapes.
Choose the shape you want, and press the mouse down on your empty slide. This will be the top left corner of your shape. While the mouse is still pressed, drag it down and right. Where you let go will become the bottom right hand corner of your shape.
- Add some colour—At the bottom of your window is a bucket of paint – that controls a shape’s main colour. To its right is the paintbrush – that controls the border colour.
- ALTernative movement—You can move your shapes around your slide. Press the mouse down, move it, and let go. The shape moves, but not freely, because PowerPoint uses a grid.
To escape this grid, and place shapes exactly where you want to put them, press the ALT key (or Apple key on a Macintosh) while moving your mouse.
- Connect your thoughts—The AutoShapes menu includes a range of connectors. If you pick one and start drawing from one shape to another, PowerPoint will draw a connecting line. Even if you move the shapes around later on, PowerPoint redraws the connections correctly. This is perfect for organisational flow charts.
- Copy right—When your diagram is finished, you can print it, or use it in any other program. From the Edit menu, click Select All. Then choose Copy, also from the Edit menu. Finally, in the other program choose Paste from the Edit menu.
Around 1250 AD, Matthew Paris drew the map of Britain show in Figure 1. As you might notice, Scotland is a little underrepresented. In fact a note on the map, I am reliably told, says that “the whole island should have been longer if only the page had permitted”. This is what happens when you do not think about the size of your display area.
A handheld computer is good for storing and displaying information that is the size of your hand – a blood form, for example. A handheld computer is not so good for storing and displaying information that is the size of your arm – a radiogram, for example. With a little planning, information the size of your arm can be redesigned to for display on devices the size of your hand – for example an A4 paper textbook. A small disk can hold several textbooks, and a small computer can display and search through all of them quickly and efficiently.
The fact that a small display is not good for a large radiogram does not mean that only large devices are useful. A surgeon in an operation uses large retractors for parts of the operation, and small retractors for other parts of the operation. The surgeon’s skills include choosing and using the right retractor at the right time in the right way.
And this was the theme of the advanced track of the Royal Society of Medicine’s workshop on handheld computers. When are handheld computers useful? And when are they not useful? When they can be useful, how are they best used? Through the sessions I hoped that we would arrive at answers to these questions.
The five sessions began with case studies from Dr Andrew Choong and Dr Adam Towler, and a paper by Rotich et al. I then led discussions on designing databases, security, training other users, sharing clinical data, and contracts. The attendees were a mixture of clinicians, IT staff, and managers, and their discussions were informed and informative.
In parallel, Dr Chris Paton was chairing the sessions for the beginners. There, the focus was on introducing the audience to using handheld computer tools for managing patients (Dr Nic Price), reference texts (James Stanley), team work, and wireless networks (Kevin Beatson). Claire Honeybourne, librarian from Leicester, discussed her team’s work with clinicians and library users.
Attendees earned five Continuing Professional Development points as formal recognition of the knowledge that they gained from the day. But the commonest comment was how delighted they were to have met so many others working on these issues. And some of them even came from that small part of the map known as Scotland.
 Installing and Implementing a Computer-based Patient Record System in Sub-Saharan Africa: The Mosoriot Medical Record System. Joseph K. Rotich et al, Journal of the American Medical Informatics Association 10:295-303 (2003).
review published in British Medical Informatics Today Spring 2004 issue