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Category: Computers & Technology
Introduction
This article is meant to provide an introduction to the use of handheld computers in medicine. Just in the past few years, the popularity of handheld devices such as the Palm Pilot has grown significantly. Once the toys of the "early adopters", Personal Digital Assistants (PDAs) have now fallen into the hands of consumers and professionals alike. It's no surprise that physicians would start looking towards these devices to help organize medical information as well as their calenders.
How these devices perform in that capacity, however, is dependent on many factors which I will try to address in this paper.
Platforms
Newton
Apple Computer, Inc.
http://www.apple.com
The Newton Messagepad is included in this list for historical reasons. The Newton Messagepad was the first commercially released "keyboardless" handheld computer. It was released in 1993 by Apple Computer complete with handwriting recognition and many expectations. Even with early models, the application of such a device was recognized in the medical community. Many of the early Medical applications were originally developed on the Newton. The Newton received many revisions over the years with steady improvement, but was recently discontinued by Apple Computer in 1998.
The Newton Messagepad 2100 was the last revision before it was discontinued. Appealing features of this model included it's large screen, and full handwriting recognition. Connectivity software between the Newton and desktop computers, however, was very limited.
Palm
Palm, Inc.
http://www.palm.com
The PalmPilot was the first commercially successful handheld computer and was released in 1995 (?). The Palm Pilot was a simpler device than the Newton Messagepad, which may have contributed to its success. The primary built-in functionality of the Palm Pilot revolves around its organizational applications. These include the notes, datebook and contact applications.
The functionality of these built-in applications is appealing and easy to use for consumers. The Palm Pilot also provides excellent connectivity to desktop PCs, allowing you to transfer your information back and forth with relative ease. As the most popular handheld computer on the market, predictably, medical applications and references were soon migrated to the Palm platform. Limitations of Palm devices, however, include limited storage and a small screen. Storage issues are being addressed with new Palm Pilot clones. Screen size, however, is still a limiting factor.
Windows CE
Microsoft, Inc.
http://www.microsoft.com
Microsoft soon followed with their addition called Windows CE. Introduced in 1996 (?), Windows CE was not a single product, but a flexible operating system designed to provide 3rd party manufacturers a framework to build their own handheld devices. As a result, Microsoft allowed for an entire family of devices ranging from handheld "pilot-like" devices up to small laptop-like devices.
Early criticism of these devices primarily revolved around the fact that Microsoft adapted their popular desktop Windows 95 interface and moved it to their handheld devices. While providing their Windows 95 users with familiar functionality, Palm and Newton users felt it an inappropriate interface for a handheld device. In April 2000, Microsoft has revised and is rebranding their Windows CE line as "Pocket PC". Their new operating system simplifies their interface, addressing many of the early criticisms. This Pocket PC, however, focuses primarily on the Palm-sized devices, leaving the future of other sized devices in question.
Franklin Medical Book
Franklin
http://www.franklin.com/medical/
Franklin's Medical Book System is a small keyboarded device that accepts their proprietary Medical Book System Cards. These cards must be purchased separately but are available with many popular books including, the PDR, Washington Manual, Merck Manual and many more. The screen size, however, is limited and there is no additional functionality beyond this one specific function. The simplicity, however, is also it's advantage. You do not need a desktop computer or any real computer experience to use this system.
Issues
1) Form Factor / Input Method
Form Factor refers to the size and shape of the handheld device. The introduction of Windows CE has allowed for a lot of diversity amongst handheld form factors. Intimately associated with form factor is input method. There are basically 2 types of input: keyboard and handwriting recognition.
a) Handwriting Recognition
Early on, Handwriting Recognition was seen as an enormous step forward, and carried much appeal to the masses as a familiar way to enter data. The Newton Messagepad was introduced with much hype and the promise of "true" handwriting recognition. Performance, unfortunately, fell short of expectations, and the Newton received much criticism and a bad reputation that it was never able to lose. This remained true, even years later, when its handwriting recognition had improved significantly.
The Palm Pilot was introduced later, incorporating "one-stroke" character based recognition called Graffiti. The user is required to learn a special alphabet where each letter is composed of a single stroke of the stylus. Limiting the alphabet like this dramatically improved recognition, and to the surprise of many, people were actually willing to adapt their writing to Graffiti. By also providing a small "writing" area for the user to enter their characters, the Palm was able to comfortably incorporate a smaller screen, which ultimately meant a smaller device. Handwriting recognition also allowed for more comfortable standing-usage of these devices. One limitation of both character based and full handwriting, however, is it tends to be slower than a skilled typist.
Microsoft will also be including both character based and full handwriting recognition in their newly released Pocket PC, so users can decide which works better for them.
Handwriting recognition handhelds can come in various sizes, but, the most popular, is the mini-tablet size of the Palm Pilot. The portability of such a small device appeals to most consumers, including physicians.
b) Keyboard
Keyboarded handhelds are often referred to as "clamshells". These can also vary in size, from pocket to laptop-sized. As mentioned above, skilled typists will find that even using the smaller keyboards provided, they are often able to enter data more quickly and accurately than with the handwriting recognition.
While the Palm Pilot is limited to the familiar mini-tablet form factor, Windows CE devices have come in all shapes and sizes, so the majority of clamshells you will run across will be Windows CE. There are also keyboard options available for the Palm Pilot, however. These keyboards have been developed by 3rd parties but do add some extra bulk when carrying your Palm Pilot around.
Keyboarded handhelds tend to be slightly larger than their mini-tablet cousins. This extra size is required to accommodate a reasonably sized keyboard. However, depending on the specific model, you can still comfortably fit most models in a white coat pocket.
2) Battery Life
If you’ve ever used a laptop or cellular phone, you realize how essential it is to be aware of your battery life. Fortunately, PDAs have been designed to be truly portable devices. As a result, their battery lives tend to be much more generous than laptops and early cellular phones.
Early handheld devices were almost always powered by off-the-shelf double or triple-A alkaline batteries. The largest advantage of using alkalines were that they were easily replaceable. If traveling or on the wards, you could always keep an extra set handy, and swap them out as you needed them.
However, as technology advanced, more features were being included in smaller packages. As a result, many companies have moved to built-in rechargeable batteries. The Palm V and Palm IIIc both use a rechargeable lithium ion battery, as does the new Pocket PC from Microsoft. The advantage to a lithium ion battery is primarily that it provides more power in a smaller package. This extra power allows companies to include faster processors and color screens.
You should be aware of these issues when purchasing a handheld device. Features such as a Color screen and Compact Flash harddrive will draw more power and decrease your usable battery life.
3) Screen
a) Resolution
A screen’s resolution refers to the number of distinct dots (or pixels) that it can display. The higher the resolution, the more pixels you can display. All text and graphics displayed on your handheld is composed of these pixels, so the higher the resolution, the more you can fit on your screen. The Palm Pilot has the lowest resolution of these devices at 160 by 160 pixels. The Pocket PC’s have a resolution of 240 by 320 pixels, and the clamshell and laptop-sized devices can have resolutions up to 640 by 480 pixels.
For medical purposes, the amount of screen space can be a very important factor. Extra screen resolution allows you to display more data at once, whether it’s reference material or patient tracking information. Even with the Palm’s more limited screen space, references and patient tracking software are readily available for it. The Pocket PC’s are relatively new, but as reference materials and tracking software are migrated to it, the extra screen space may prove to be useful.
b) Color
Color is a new feature in handhelds. Color screens tend to draw more power and increase the cost of the units. At this time, the largest advantage of color screens will come from Microsoft’s ClearType technology. ClearType is a method for displaying crisper/sharper text on a color screen. Microsoft has incorporated this technology in their new Pocket PC’s. This technology seems well suited for medical applications which involve large amounts of textual information.
4) Storage
The number of references and applications you can store on your handheld device is dependant on how much storage you have. For day-to-day contact and schedule management, most people will never need more than the “standard” amount of memory provided by the manufacturers of these PDAs.
If you plan on added many additional references and applications to your handheld, then you will need to plan ahead. The Palm Pilot’s available are not easily user expandable. Some models (such as the Palm V) come in 2 different configurations (2MB vs 8MB). If you do plan on installing many additional references, you should purchase the higher storage model from the beginning. Of note, Palm Pilot also licenses their operating system to 3rd parties. These companies include Handspring (http://www.handspring.com) and TRG (http://www.trgpro.com). Both of these are functionally identical to the Palm Pilot, but have slightly different form factors and expandability options. Additional storage can be added to both of these models at a later date.
Windows CE devices all have storage options available. In general, WinCE software requires more memory than their PalmPilot counterparts. As you add software, you may find the need to add additional storage.
Uses of Handhelds
1) Day planner
Providing appointment scheduling and contact management is built-in to all handhelds on the market today. This functionality is often the one which convinces people to purchase a handheld computer. Many people use their handhelds for this one purpose. Physicians may find that they want to utilize their handhelds for medical purposes as well.
2) Reference Materials
Due to the large amounts of information involved in medicine, using handheld computers as a quick reference has perhaps been the most popular application. Computers have been very good at storing large amounts of textual information. The natural extension of this is to provide electronic forms of the reference books that physicians often carry around with them.
Searchable references are available for both Windows CE and Palm, with a slight advantage to Palm due to it’s popularity. The largest distributor of these references is HandMedical (http://www.handmedical.com). Other companies include:
PDR for Palm
http://www.franklin.com/medical/pdr_palm.asp
ePocrates qRx for Palm
http://www.epocrates.com
K2's Library for Palm and WinCE
http://www.skyscape.com/k2new/nindex.html
Handmedical's library for Palm and WinCE
http://www.handmedical.com
2) Medical Calculators
Another popular application available for both Palm and WinCE devices are medical calculators. These simple programs provide fill-in-the-blank calculators for common medical equations.
MedCalc for Palm
http://netxperience.org/medcalc/index2.html
MedMath for Palm
http://mail.med.upenn.edu/~pcheng/medmath/index.html
Medicalc for Palm
http://www.angelfire.com/ms/medicalc/
SynCalc for Palm
http://www.syncalc.com
Stat Cardiac Risk for Palm
http://www.statcoder.com/prod04.htm
Ranson Calculator for Palm
http://www.thenar.com/Ranson
PregPro for Palm
http://www.thenar.com/pregcalc
Archimedes for WinCE
http://www.skyscape.com/k2new/nindex.html
3) Patient Tracking
Patient Tracking software is the most ambitious use of handhelds in medicine. Patient H&Ps, progress notes, and daily lab values essential information for physicians to generate and track. Naturally, migrating this information to a handheld computer is an obvious step.
This application was recognized early on, and Physix (http://www.physix.com) created the first handheld tracking software (Pocketchart) for the Newton platform. PocketChart still exists and is available for WinCE, and a number of other solutions have also emerged. There are some challenges in using patient tracking software on your handheld:
a) Screen Size
When trying to track patient data on Palm and WinCE devices, the screen size is a significant restriction. Unlike notecards, and looseleaf paper, far less information can be contained on one screen. As a result, “flipping” through screens may be required and tends to be more tedious than “flipping” through notecards. At this point, screen refresh speed and processor speed become very important.
b) Input
Ideally, you would like to enter data from a patient during the interview. Unfortunately, handwriting recognition and typing may not be able to keep up. Various methods exist to try to speed up this data entry - including pop up menus, and on screen keypads, which work to an extent. However, by using these techniques you are required to follow a set path of questions, and it is very difficult to enter data you are not yet ready for.
As well, it is difficult to generate a generic H&P pathway that can handle any general medical situation.
c) Connectivity
How well you can utilize your handheld computer in your hospital setting depends on that particular hospital’s charting and computer system. Ironically, as hospitals move towards more computerized patient tracking, you may find it impossible to connect your handheld to the hospital’s system. If your notes must be placed on the hospital’s computer system, then the advantage of entering data in your handheld is lost.
Even with a paper-based hospital system, you still need some computer resources. Most importantly, you will need reliable access to a printer to print any progress notes or H&P’s.
Unfortunately, Patient Tracking software is one of the most difficult applications for handheld computers and requires a time commitment on the part of the physician to learn how to use the software. In more specific situations or specialities, it may be more realistic to utilize pregenerated pathways to input data, but even this would require personal customization.
Software:
Patient Tracker 3 for WinCE
http://www.handheldmed.com/code/ce/code/software/pt30announced.htm
Pocketchart for WinCE
http://www.physix.com
Ward Watch for Palm
http://www.watch.aust.com/pilot/wardwatch/
Patient Keeper for Palm
http://www.PatientKeeper.com
Raphael for Palm
http://www.pdamed.com
Upcoming Technologies
Anoto
http://www.anoto.com
Smart Quill
http://www.bt.com/innovation/exhibition/smartquill/whitepaper.htm
Other Resouces
- Handheld Med
http://www.handheldmed.com
- Smaller.com
http://www.smaller.com
- Medical Piloteer WebRing
http://healthypalmpilot.hypermart.net/webring/
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