# Presentation: 132813

## How to get the Whole Medical World in the Palm of your Hand

**Scott Hamstra, MD, **
**      ****National**** ****Medical Info****rmatics**** ****Consultant**
**LT Christopher C. Lamer****,**** ****PharmD, CDE**

## Objectives

**At the end of this presentation, you will:**
**Be able to differentiate and recognize various PDA (personal digital assistant) hardware and operating system technologies available.**
**Understand and be able to illustrate how PDA reference information software programs are used in clinical practice and to incorporate PDAs into a variety of practices and work settings.****	**
**Review initial survey data on the use of PDA hardware/software by IHS clinicians and discuss various roles for PDAs throughout the IHS. **
**Discuss the advantages and disadvantages of PDAs and appraise necessary resources needed to implement a PDA program.**

## Evaluation of PDA EffectivenessPDA vs. PDR vs. Internet

## The Question

**A 45 year old male comes into the ER complaining of chest pain radiating to his jaw and arm. ECG and lab results confirm a diagnosis of Myocardial Infarction. He weighs 72kg. You decide to use a thrombolytic...  **
**    ****The newest addition to the formulary is TNKase...**

**What dose do you give?**

## Step 1

**Turn on your PDA and select ePocrates by tapping on the icon.**

## Step 2

**Drugs**

- All

**Drug**
**Drug**
**Drug**
**TNKase**
**Drug**
**Look Up:_____________**

**tnk**

**Write the drug name using graffiti or tap on the ‘abc’ to get a keyboard that you can ‘type’ on using the stylus.**
**Select TNKase.**

## Step 3

- Tenecteplase
- (IV)
- Myocardial infarction, acute
- [wt<60kg]
- Dose: 30mg IV x 1; Max 50 mg
- [wt 60-69kg]
- Dose 35mg IV x 1; Max 50mg
- [**wt 70-79kg]**
**Dose: 40mg IV x 1; Max: 50 mg**

**Read answer.**
*It’s that simple!*

## The Winner...

**Updated Daily**
**Easy index**
**Easy search capabilities**
**Fast results**

**The Loser....**
**Updated yearly**
**Difficult index**
**Time consuming to flip through pages**
**Must read passages to find information**

## ePocrates highlighted in the Wall Street Journal as being faster than the PDR 

- "The study, published in the most recent Journal of the American Medical Informatics Association, indicated that 50% of ePocrates physicians who were surveyed reported that the devices and guide prevent one to two errors a week, and help doctors keep track of the constant barrage of new drugs and changing treatment guidelines. The study also showed that doctors can look up drug information much faster using ePocrates than with traditional sources such as the Physicians' Desk Reference; 60% of physicians surveyed reported that it took them 10 seconds  or less to find information using ePocrates compared with one to five minutes for traditional methods."

## Anatomy and Physiology of the PDA (Personal Digital Assistant)

- Anatomy and Physiology of the PDA (Personal Digital Assistant)

## Palm OS and Windows CE

## Palm and Handspring

## Clinical Applications

**ePocrates**
**ePocrates QID**
**Tarascon**
**ePharmacopoeia**
**ACLS2000**
**5-Minute Clinical Consult**
**BMI Calculator**
**Mobile Micromedex**
**Shots 2002**

**Lexi Comp**
**MedCalc**
**Pregnancy Wheel**
**Do-in**
**Growth Rates**
**MedRules**
**Obesity Calculator**
**ATP III**

## Epocrates

## Updatable Daily

**Hot sync PDA daily to obtain the latest up-to-date medication information**
**PDR is updated yearly**

## Searchable by class or drug

## Adult Dosing, Pediatric Dosing, Contraindications, Cautions...

## Drug Interactions

## Adverse Reactions

## Cost & Other Information

## Multi-Check

## Customizable Notes

## Non-Clinical Applications

**Address Book**
**Calendar**
**Date book**
**Appointments**
**Reminders**
**Alarms**
**Calculator**
**Memo pad**
**To do list**
**Mail**
**Expense Log**

## PDA use in the IHS 

**Cherokee**
**Warm Springs**
**White River**
**Others...**

## PDA Surveys

**Provided to assess the use of PDAs in the Indian Health Service**
**Looked at:**
**PDA device used**
**Software used**
**Likes / Dislikes**
**Problems**
**Preliminary results are coming in...**
**A second survey will be released in ~6 mos**

## Survey Results

**Major uses:**
**Address Book**
**Treatment  Algorithms**
**Satisfaction****	****	****33 yes vs. 3 OK**
**Most used clinical applications**
**ePocrates (Rx and QID)**
**5 Minute Clinical Consult**

## Survey Results

**Benefits**
**Availability and accessibility of data**
**Easy to document information (coding)**
**Access to drug information**
**Faster than the internet**
**“****indispensable”**
**Time saving**
**Easy to use**
**Keeps you organized**

## Survey Results

**Problems**
**Transmission difficulties – ‘hot syncing’**
**Permission to use PDA software at work**
**Battery life**
**Difficulty writing with graffiti**
**Limited memory**
**Hard to carry – ‘clunky’**
**Screen too small**

## National Surveys	

**“****in a survey of physicians using (ePocrates) qRx, a set of knowledge resources available on a PDA found that:**
**60% used qRX more than twice a day**
**81% report improved drug-related decisions**
**46% report three or more drug decisions per week were affected**
**71% report improved inpatient efficiency**
**69% report improved outpatient efficiency”**
**Rothschild (Journal of Healthcare Information Management**

## PDAs and Patient Education

**Purpose**
**“****There are too many codes to remember them all!”**
**PDAs serve as a database containing patient education codes**
**To determine if PDAs would:**
**Increase the documentation of patient education on patient medical records**
**Increase provider accessibility to medication information**
**Increase provider satisfaction**

## PDAs and Patient Education

**Background**
**A proposal was submitted to the National Patient Education Program (Mary Wachacha) requesting PDAs to increase documentation of patient education.**
**Approval for a pilot project of 15 PDAs was granted **
**Cost per PDA $ 299.00**
**Total Cost ****	**** $ 4,485.00**

## PDAs and Patient Education

**Methods**
**Handspring Visor Prisms were purchased: **
**Competitive pricing in relation to Palm Handhelds.**
**Less expensive than Windows CE based PDAs. **
**Springboard Module Expansion slot makes exploration of various uses, functions, and upgradeability possible.**
**Color handhelds had not yet been evaluated ****	****	****by the National IHS PDA Initiative.**
**Computer operations ordered it.**

## A variety of applications suited to the provision of health care were added to the PDAs:
Epocrates
Epocrates ID
Medcalc
NHLBI guidelines (COPD, Asthma, ATP III (lipids), Obesity)
Pregnancy Wheel
Growth Charts

PDA users were encouraged to become 	
	familiar with their various applications.

**Epocrates**
**Epocrates ID**
**Medcalc**
**NHLBI guidelines (COPD, Asthma, ATP III (lipids), Obesity)**
**Pregnancy Wheel**
**Growth Charts**
**PDA users were encouraged to become ****	**
**	****familiar with their various applications.**

## Various database and document applications were evaluated to add patient education codes to the PDAs.

Quickoffice was obtained through additional funding from the National IHS Palm Initiative program.
Quickoffice is a productivity suite that allows PDA users to import Microsoft Word and Excel documents onto their PDAs.
Quickoffice enabled an easy solution to adding 	
	the Patient Education Codes to PDAs and by
	providing a simple means to add/update 		
	the codes.

**Quickoffice was obtained through additional funding from the National IHS Palm Initiative program.**
**Quickoffice is a productivity suite that allows PDA users to import Microsoft Word and Excel documents onto their PDAs.**
**Quickoffice enabled an easy solution to adding ****	**
**	****the Patient Education Codes to PDAs and by**
**	****providing a simple means to add/update ****	****	**
**	****the codes.**

## PDAs and Patient Education

**Design **
**15 PDAs were distributed to clinical staff including MDs, PACs, and FNPs.**
**PDAs were checked in by computer operations and approved software was “loaded” on.**
**PDAs were distributed and utilized ****	****for a number of weeks.**

## After a break in time, PDAs began to require Hot-Syncing to maintain up-to-date medication information.

Some difficulties arose
Problems hot-syncing - notably with ePocrates

ePocrates had to be loaded on each computer individually for auto-update to work appropriately. Batch loading was not productive.

ePocrates was reinstalled on problem PDAs and no further problems arose.

Quickoffice was installed on all (most) PDAs by Computer Operations.

**Some difficulties arose**
**Problems hot-syncing - notably with ePocrates**
**ePocrates had to be loaded on each computer individually for auto-update to work appropriately. Batch loading was not productive.**
**ePocrates was reinstalled on problem PDAs and no further problems arose.**
**Quickoffice was installed on all (most) PDAs by Computer Operations.**

## PDAs and Patient Education

**Measures**
**A primary survey was distributed to all clinical staff who utilized a PDA in the course of their work (15 providers who received PDAs and 4 pharmacists who are using PDAs).**
**Patient education “hits” were recorded in the Resource Patient Management System, (RPMS), database**

## PDAs and Patient Education

**Initial Results**
**Of the 13 returned surveys, 12 responders stated that they were familiar with the IHS patient education codes and one responder was not.**
**13 (100%) of responders have used the patient education codes in the past.**
**10 responders stated that they had access to a computer with Quickoffice installed**
**9 have Quickoffice Patient Education codes installed on their PDAs.**
**3 responders installed the codes from a CD**
**1 responder installed the codes from the hard drive**
**5 responders installed the codes through ‘beaming’**

## PDAs and Patient Education

**The PDA codes are used:**
**More than twice daily****	****	****	****3**
**Once a day****	****	****	****	****1****	**
**A few times a week****	****	****	****2**
**A few times a month****	****	****	****1**
**Never****	****	****	****	****	****4**
**The PDA education codes are used to:**
**Look up education codes****	****	****5**
**Increase documentation****	****	****5**
**See if an education code exists****	****	****4**
**Find more education codes****	****	****3**
**Not familiar with the education codes****	****3**
**Do not use patient education codes****	****1**

## PDAs and Patient Education

**Were the codes clinically helpful?**
**	****	****	****Yes****	****10****	****	****No****	****1**
**Have the codes increased your documentation?**
**	****	**** ****	****Yes ****	****7****	****	****No****	****0**
**What other applications help to increase patient education documentation?**
**	****	****	****ePocrates****	****	****12**
**	****	****	****Tarascon****	****	****5**
**	****	****	****Shots 2002****	****	****4**
**	****	****	****Micromedex****	****	****1**
**	****	****	****5 MCC****	****	****5**

## PDAs and Patient Education

**Patient Education ‘HITS’**
**2000****	****	****12,607 patient ed hits**
**2001****	****	****21,336 patient ed hits**
**2002****	****	****  8,888 hits for the first quarter**
**	****	****	****	****	****anticipated 35,552 hits**
**Why are they increasing??**
**	****PDAs, PCC+, Yellow tab cheat sheets, nagging...**

## Patient Confidentiality

**HIPPA**
**Warm Springs’ Policy**

## Setting up a PDA Program

**Some PDA Issues to consider**
**Hardware issues**
**Costs**
**PDA – which one? Expandability? OS? Memory? Color?**
**Cradle uniformity**
**Warrenties – broken or lost PDAs**
**Software Issues**
**Clinical and non-clinical – which ones to use?**
**Who pays for it? User or I/T/U**
**Who installs it?**
**Training – by whom? Group or one-on-one?**
**Personnel issues**
**Computer specialists for installation, troubleshooting**

## ITSC Home Page

**home.IHS.gov/ITSC-CIO/index.asp**

**www.ihs.gov/CIO/InfoTech_index.asp**

## Conclusions

**Questions?**