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Published on 1 January 2003

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Handheld computers: will they change your practice?

Scott Pegler
BPharm(Hons) MRPharmS
Medicines Information Pharmacist Pharmacy Department Morriston Hospital Swansea
UK
E:scott.pegler@swansea-tr.wales.nhs.uk
Competing interests:
the author is the distributor of electronic products produced by King Guide to Parenteral Admixtures and Lexi-Comp, Inc. in the UK and Ireland

A visit to a state-funded hospital pharmacy department in San Diego in May 2000 was an eye-opener. Not the use of a robot programmed in pharmacy to deliver drugs to wards (it even ordered the lift itself!) or the use of a mobile laptop by pharmacists on consultant ward rounds. It was, however, the routine use of Palm OS PDAs (personal digital assistants) by pharmacists as a clinical resource at the point-of-care that intrigued me – this at a time when such devices were not even readily available for purchase in the UK.

Two-and-a-half years later, and despite PDAs now being available for sale in any high street, they still remain a mystery to the majority of hospital pharmacists. This review will hopefully encourage pharmacists to investigate the potential for PDAs in their own clinical practice.

What is a PDA?
In its simplest form, the PDA is a handheld electronic organiser offering diary, address book, to-do lists and memo pad functions. Information is exchanged with a PC or laptop using a HotSync cradle that also recharges the PDA when not in use. The PDA has an infrared port allowing information and applications to beam from one device to another.

PDAs are robust, are not prone to crashes, turn on quickly, fit neatly into a pocket and are cheap. However, it is the ability to download customised packages of information to the PDA that makes it an invaluable tool in clinical practice.

Palm OS or Pocket PC?
The operating system chosen will ultimately depend on the proposed use of the device, with Pocket PC appealing to the pharmacist with more administrative than clinical duties. Devices running Palm OS are generally cheaper and easier to use than Pocket PC. About 75% of the medical and pharmacy applications for PDAs are written for Palm OS, hence Palm OS is currently the system of choice for the clinical pharmacist.

This review will therefore focus on devices running Palm OS and their applications. Readers are referred to an excellent review for a more comprehensive comparison of the two operating systems.(1)

Which device and at what cost?
Any Palm OS PDA with a minimum memory of 8MB (ideally expandable) is recommended, such as Palm M500/515 or Handspring Visor Edge. Prices start at less than £200.

Clinical applications and software for Palm OS
Applications of particular interest to the clinical pharmacist include detailed databases of drug information and interactions,(2,3) evidence-based medicine,(4) herbal medicines(3) and intravenous drug compatibility.(5) Others applications include medical calculators,(6,7) medical abbreviations(8) and medical reference material.(9,10) A PDA version of the BNF is scheduled for spring 2003.(11) In general, commercial products tend to provide more detailed and practical information.

Clinical information for PDAs is specifically designed for use at the point of care, and therefore tends to complement rather than compete with traditional resources used. Many drug databases for PDAs are updated on a daily basis, ensuring currency of the information. Drug databases provide digested layers of information, which are accessed by tapping the appropriate field of the drop-down menu, taking the user immediately to the relevant section of the drug monograph.

Fields of information are specifically chosen to reflect the information needs of the busy pharmacist, such as drug monitoring recommendations, pharmacokinetic data, and nursing implications of drug therapy. Information is presented in a concise, easy-to-read format, allowing the pharmacist to make an informed clinical decision at the bedside, in the clinic, on the ward round or while on-call.

A recent review assessed the breadth, clinical dependability and ease of use of nine drug information software programs for PDAs running Palm OS.(12) Assessment was based on responses to 56 questions designed to be applicable to daily practice in both inpatient and outpatient settings. The drug database Lexi-Drugs Platinum was considered to offer the greatest breadth of information and the most clinically dependable content.(3)

To mark the availability of the BMJ in PDA format, the eBMJ is currently compiling a list of useful medical resources for PDAs,(13) while websites such as HealthyPalmPilot(14) and HandHeldMed(15) are good starting points when browsing for clinical applications.

PDAs may be used for clinical intervention monitoring(16) and to assist with data collection in clinical audit, while the infrared port can scan barcodes. At the Morriston Hospital, the administration of blood was considered an area of high clinical risk. The use of a PDA to scan barcodes on blood, the patient and the administering nurse has been successfully developed in ITU to address this risk and record the audit trail.(17) A pilot project is now being considered to apply this technology to drug ordering, distribution and possibly drug administration.

A document in Word format can be copied and pasted into the Palm desktop memo pad and then HotSynced to the PDA. Documents-to-Go,(18) a document manager, now comes preloaded on newer Palm OS PDAs. It includes a document, spreadsheet reader and editor that retain original formatting. Suitable documents for inclusion on the PDA may include local policies, prescribing guidelines and shared-care protocols. Documents can be easily located using the free text search facility “find” available on the PDA, allowing them to be accessed immediately at anytime and from anywhere.

Possible problems with PDA use by pharmacists
A criticism made of PDAs is that much of the clinical information available for download (free and commercial) originates in the USA and may not therefore accurately reflect data contained in EU product licences. Although US databases are not ideal for use in the EU, a high-quality US drug database still provides an excellent resource to complement and augment the clinical judgment of the experienced pharmacist. Moreover, an insightful and experienced pharmacist would presumably be able to identify those times when information retrieved was inappropriate and would reject it.

However, not all pharmacists are so intuitive. Indeed, many exploring this technology will be young, professionally inexperienced and less able to identify potential weaknesses or omissions in software. Thus training in the appropriate use of PDAs, particularly for less experienced pharmacists, is essential.

The future – now!
The uses of PDAs as described above represents the tip of the iceberg.

Electronic handovers are already a reality at some hospitals in the USA – clinicians beaming patient information from one PDA to another.(19) Wireless handheld technology now allows the PDA to act as the interface between the clinician and the hospital intranet/internet. With a couple of taps on the PDA, encrypted patient data such as lab results, reports and past medication records can be viewed instantly from anywhere.(20)

Although issues relating to the security of patient information need to be fully resolved before being adopted in Europe, these problems are not insurmountable. Bluetooth wireless technology provides high-speed short-range radio links between PDAs, PCs and other devices, and has built-in security encryption, possibly making it suitable as a data exchange system for confidential patient information.(21)

Indeed, the white paper Information for Health(22) and its update,(23) outline the commitment of the UK National Health Service to electronic health records, meaning this technology will be in use sooner than we think.

PDAs have the potential to improve patient care,(19) as well as saving both time(24) and money,(25) and I predict PDAs will revolutionise the way pharmacists and doctors work in the future.

References

  1. Felkey BG, Fox BI. Hospital Pharmacy 2002;37:545-50.
  2. ePocrates. www.epocrates.com
  3. Lexi-Comp, Inc. http://store.lexi.com/lexistore/servlet/Controller?a=sca&t=HH
  4. Clinical evidence. www.unboundmedicine.com/cgi-bin/survey/survey.pl?f=on
  5. King guide to parenteral admixtures. www.kingguide.com/palmos_edition.htm
  6. MedCalc. www.palmblvd.com/software/pc/MedCalc-2000-09-27-palm-pc.html
  7. MedMath. http://smi-web.stanford.edu/people/pcheng/medmath/index.html
  8. Pharma-lexicon. www.pharma-lexicon.com/index.php?language=&page=palmpilot>
  9. The Merck Manual. Centennial (17th) Edition . www.pdamd.com/vertical/reviews/Merck17.xml
  10. Harrison’s On Hand. www.harrisonsonline.com/harrisons/public/hoh/about_hoh.html
  11. Macfarlane C, Connor E. BMJ 2002;325:777.
  12. Enders SJ, et al. Pharmacotherapy 2002;22(8):1036-40.
  13. Resources for handhelds. http://bmj.com/cgi/content/full/324/7334/DC2
  14. HealthPalmPilot. www.healthypalmpilot.com
  15. Handheldmed. www.handheldmed.com
  16. HealthProLink. www.healthprolink.com
  17. Tomorrow’s World. BBC1, 17 July 2002.
  18. DataViz. www.dataviz.com
  19. Larkin M. Lancet 2001;358:1438.
  20. Duncan R, Shabot M. Proc AMIA Symp, Los Angeles, CA, USA; 4-6 November 2000.
  21. The Official Bluetooth Wireless Info Site. www.bluetooth.com
  22. Department of Health. Information for health. London: Stationary Office; 1998.
  23. Department of Health. Building the information core: implementing the NHS plan. London: Stationary Office; 2001.
  24. Rothschild JM, et al. Proc AMIA Symp; 4-6 November 2000, Los Angeles, CA, USA.
  25. Gardiner MD, et al. www.studentbmj.com/back_issues/0801/editorials/266.html


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