PDA No Means Physician Digital Assistant
Glenn Fink, Andre Schiller · Emergency Medicine News · 2003
Emergency physicians are exquisitely time sensitive beings. We want our information short and to the point, and thumbing through an index or a textbook is the last thing we want to do. Those who design software for ED use know that even an extra click or tap is annoying. Having to walk over to a PC, log on to the web, and enter a password also can seem next to impossible. Fortunately, much of the data needed by a busy emergency physician can be found on a Pocket PC or Palm OS handheld, downloaded in the comfort of your home and available within seconds during your shift. In the real world of PDA (personal digital assistant) use, we are regularly looking up drug dosages, forms, interactions, and indications. The sight of a physician thumbing through a PDR in the emergency department has become a curious anachronism. Current recommendations, such as blood exposure algorithms, stroke and tPA contraindications, and treatment options are readily available and repeatedly accessed on our PDAs. The original Palm Pilots held telephone number lists, to-do lists, and schedules. The small memory of these early units required very concise programming for the Palm Operating System (OS). Large user and programmer groups formed centered primarily on Internet web sites. Small programs were offered for free or for small fees. The Internet played (and continues to play) an important role for this group because it served as an inexpensive distribution channel for inexpensive products. Without the software support of thousands of small programs, the PDA environment would not have experienced the explosive growth we see today. For emergency physicians, the recent increases in processor speed, color screens, and most importantly, the development of large capacity memory storage devices fulfills our need for quick access to large medical databases. Portable Computers Many of us recall our first computer's capacity: 16 MHz speed, 4 megs of RAM, and 50 megs of hard drive storage space. Today's PDAs have processor speeds of 400 MHz with 600 MB of memory. With this capacity, PDAs are truly portable computers. Although you can profitably invest a lot of time becoming facile at extending the desktop computers' functionality into the PDA environment, rest assured that an inexperienced user can purchase a PDA off the shelf, make a few simple downloads from the Internet, and be fully functional with medical databases at your fingertips. If the initial medical database offerings on the early Palm Pilots represent the infancy of point-of-care access, the current editions probably represent the late adolescent phase. The drug databases convert to the handheld format more easily than do medical textbooks. Rendering large textbooks to contain just what information you need and to present it in a useable format is a challenge that has not yet been completely mastered.Table: Sites Offering PDA Medical SoftareThe Internet format addresses this situation effectively because you can download trial versions of fairly large programs and compare them before you make your purchasing decision. Compare, for example, how each offering describes malignant hypertension. Does it have the right amount of detail, do the suggested medications link to companion drug databases, do the drug databases provide you with the information you need to know, e.g., doses, drug interactions, adverse effects, mixing instructions, etc.? On the fly, you will want quickly accessed information with a strong emphasis on treatment details. Patient satisfaction really soars when you do a high-tech computer search at the bedside, usually checking drug interactions. Sometimes this bedside tactic can backfire. A recent patient complained that “the doctor had to check his Palm” when the physician made a show of conscientiously checking if a controversial drug was approved for use in the first trimester of pregnancy. The Palm operating system is still the most heavily used PDA OS in the emergency department, and it is a rare resident or medical student who is not seen tapping away. Palm, Sony, and Handspring are the usual brands seen. Most Palm OS users started with Epocrates, the popular drug program available at Epocrates.com. Mysteriously available for free for many years (if you don't count that Epocrates sells each physician's drug query data), Epocrates is now charging $49.99 per year. You can still download the free version, but this does not offer herbal drug interactions and the many useful tables, which include relative steroid and opioid potencies, ACLS algorithms, formulas and hypertension guidelines. More importantly, the free version does not have qID, Palm's infectious disease treatment guidelines. Mac owners, always heavy users of the Palm OS, were strangely left out, unable to get the paid version until enough protest finally created availability for them this coming spring. Another popular and successful drug program is Tarascon Pocket Pharmacopoeia, PDA edition. You can find the prerelease, still-free beta version at Tarascon.com. Although not as robust an interface as Epocrates for finding drug interactions and much worse for drug cost data, Tarascon has a more complete pediatric weight-based dosage system and a more complete description of the relative doses for various indications of antibiotics. More recent drugs and drug indications, such as Cardene IV for malignant hypertension, are on Tarascon. This program also has a very useful array of tables, with “Drugs in Pregnancy” topping the list.Table: Sites for Palm OS PDA UsersMedical packages that integrate/link several databases save you time and increase your productivity. “Nipride” in the treatment section of the malignant hypertension chapter from the textbook database will link to “nipride” in the drug database and also to “nipride” in the drug interaction database. The utility is obvious and necessary. There are currently three contenders. They do not all measure up. Drug Databases The Lexi-comp package ($175) includes Griffith's 5 Minute Clinical Consult, the Lexi-drug information database, and Interact for drug interactions. Lexi-comp was the first company to put medical databases on the PDA, and their experience is obvious in the product quality. The PEPID program ($109.95 for a one-year subscription) has all the appearances of a high-powered application, but in the medical program you must back out of each chapter section to move on to the next section, which can be frustrating. The indexing of the drug section is confusing. You cannot simply write in the name of the drug in which you are interested. These programs are not ready for prime time. Skyscape's 5mEmerg (The 5-Minute Emergency Medicine Consult) with the A2Z drug program and iFact drug interaction package ($164) is another tempting set of programs. Although the 5mEmerg section on ectopic pregnancy provides a link to methotrexate in the companion A2Z drug database, the methotrexate listing there actually has no mention of ectopic pregnancy as an indication for methotrexate use, and therefore would not help you at all. This package of programs needs more work. A host of PDA products are available from Lippincott williams & wilkins (www.lww.com), including the 5-Minute Emergency Medicine Consult, 5-Minute Pediatric Consult, 5-Minute Toxicology Consult, Emergency Medicine Recall (deliverable online), the Handbook of Fractures, Pocket Emergency Medicine, and the Wills Eye Manual and Drug Guide. Many emergency physicians turn to eMedicine on the Internet for information while seeing patients in the ED. eMedicine has PDA versions of its ebooks ($79). The concise Internet formatting of eMedicine content would seemingly make it very suitable for PDA use. It would be useful to be able download a trial version of the many ebooks available before making a purchase decision. Jeff Mann's EMguidemaps also are available for PDA download. The EMguidemaps are free, but you must purchase the iSilo reader. The operating system for the Pocket PC line is designed by Microsoft. These units are produced by HP (Ipaq), Toshiba, Dell, ViewSonic, and Casio. Pocket PCs have truncated but very functional versions of Word, Excel, and Outlook. Historically, the Pocket PC has had more memory and had color screens earlier than Palm devices, but were also more expensive. Although some differences remain, the functional capacity of both handheld lines is converging. windos desktop users who prefer to remain in the familiar Windos operating system will benefit from the impending convergence of the PDA and desktop PC/laptop digital environments. Unfortunately, PDA databases are relatively expensive. Although purchasing one database package may be reasonable, purchasing several medical databases becomes prohibitively expensive. The aggregate expense of all the programs you would like to have is the biggest obstacle to major growth in this market. Current e-publishers should learn from their predecessors. They will find more success (total income) in reducing the price of downloadable medical databases. After all, their download expenses are minimal. The handheld market will more than compensate for whatever cannibalization of the medical print market occurs. When looking to buy a handheld, shop around and visit web sites such as pdaMD.com and Palmgear.com. First make your decision on which operating system you want (Pocket PC or Palm) based on which software titles you want. Remember, Epocrates is still only on the Palm OS. If you are a Mac user, only the Palm OS makes sense. You will need a memory expansion card, and look for at least 16 MB RAM for those medical programs which are not yet memory-card friendly.