BMJ clinical review

Originally published as "Handheld computers", BMJ, 2004 vol 328 p1181. This was part of the BMJ's theme issue on electronic communication and healthcare.

Summary points

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), 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

Author information

Originally published 2004 in the British Medical Journal

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