From pdaMD.com

Feature - Handheld Computers in Pediatric Education
by Thomas Courtney, M.D.

The purpose of this article is to provide detailed insight into the development of a handheld computer initiative at a large pediatric teaching hospital. It is hoped that our experiences will be beneficial to others interested in medical handheld computer usage and education. Overview Children's Hospital of The King's Daughters is a large regional pediatric medical center located in Norfolk, Virginia.

>We are associated with Eastern Virginia Medical School and educate 47 pediatric residents, as well as, medical students and pediatric infectious diseases and emergency medicine fellows. Recently, we began a handheld computer initiative to explore their impact on education, efficiency, patient care, cost reduction, research, and medical error reduction. Currently, very little research is available in the medical literature on the impact of this rapidly growing medical tool. Last year, we chose to equip each of our pediatric residents with a Palm IIIxe handheld computer and purchased Lexi-comp's pediatric drug reference for them. Also, we converted a series of reference cards to "memo" format for use by the residents.

We found the general response from the residents to be very positive. They reported that using their Palm devices saved time. Even before we started to add to the programs they use, many had gone out on their own and found useful resources. Indeed some residents have reported that they now dread a "crash" of their Palm because it means a return to the "old" methods of getting the information needed to learn and take care of patients. Infrastructure Over the past year we have concentrated on building infrastructure. We are fortunate that our children's hospital is already equipped with existing DHCP (Dynamic Host Configuration Protocol) compliant networks.

We also already have a Microsoft exchange server, which provides Microsoft Outlook compliant data for scheduling, contact lists, memos, and task lists. We recently purchased a handheld computer server from Aether systems. In addition to supporting Palm handhelds, this server also supports Microsoft PocketPC based platforms and will likely soon support the RIM Blackberry platform, should either of these platforms become a dominant market player.

The Aether server is the same enterprise server that is resold by Palm, Inc. as their Palm enterprise server. It is part of a line of products from Aether that includes ScoutBuilder, (a Palm program development tool which we purchased as well for custom program development), and Scoutweb, a package similar to AvantGo, which allows for the conversion of web based materials for viewing on the Palm. The server has an excellent monitoring program, ScoutIT, that allows the administrator to monitor server and Palm usage and to control programs placed on the user's Palm. For an additional price, Aether provided us with Exchange conduits as well. These allow for direct synchronization to our Exchange server. Installation was relatively straightforward and the handheld computer server has been reliable with excellent technical support provided by Aether.

To provide access to this server, we purchased several Palm Ethernet cradles and an infrared sync system by Clarinet Systems. We found the latter to be the most convenient independent link to the server because it allows the user of any Palm OS device to sync to the server, including users of the Sony Clie and Handspring Visors. The Palm Ethernet cradle supports only use of the Palm III and VII computers, as well as the Palm V computer with the use of a special "bridge" adapter. Although we initially were hopeful that these cradles would provide significant increases in synchronization speed, we found that this speed is essentially rate-limited by the serial port connector on the bottom of the Palm and the speed of the infrared port on the Palm devices. Both of these provide similar speeds. Routine synchronization to the server generally takes a couple of minutes.

Syncing can also be done via the desktop proxy conduit that Aether provides for use on desktop computers, simply by pushing the usual hotsync button on the desktop cradle. This method seems only slightly slower than the other independent cradles. The server also supports RAS (Remote Access Services) and wireless syncing. Wireless access via an 802.11b network is appealing, but there are current concerns of wireless interference with existing medical equipment such as IV pumps. Software So far we have purchased two pieces of additional software for the residents. Blue Nomad's WordSmith program allows relatively robust document manipulation on the Palm with tight integration to Microsoft Word. We are converting "clinical pearls" from morning report and grand rounds to ".doc" format so they can be viewed and manipulated on the Palm. The second program, STATcoder, a HCFA (Health Care Financing Administration) compliant coding aid, will help teach the residents accurate coding of pediatric visits. There are many other programs we are assessing. PatientKeeper, MDeverywhere, and several other programs will possibly link to our legacy systems to provide improved charge capture, patient information documentation and retrieval. Several other vendors offer support for electronic prescription writing. Pediatric reference programs and calculators are becoming increasingly more sophisticated, and in the near future they will rival the venerable Harriet Lane Handbook as a treasured reference source.

AppUsage is another program we are reviewing. It tracks which Palm applications are employed and how they are used so that we may further document the usefulness of handheld computers in a clinical practice. We recently completed our first custom program. It is a pediatric procedure log that is compliant with the residency review committee standards. By using the user's HotSync name and point and click entering of the procedure type, date, and time - the log minimizes the need for extensive user input. The log also records the supervising physician, the patient medical record number, and whether the procedure was a success or failure. Soon, conduits will be finished to synchronize the log with a Microsoft Access database. Custom reporting screens will allow our residency director to periodically review resident procedures in a variety of views to ensure quality resident education. A custom report will aid residents after graduation when they apply for hospital privileges. The procedure log is easily customizable to accommodate any procedure list so that it can be used in other residency programs (e.g. Family Practice, Surgery, or OB/GYN). It is also easy to modify it to record a list of the types of patients our residents are seeing so that we can remain sure that their educational experience is diverse. The procedure log program will soon be available for purchase through pdaMD.com and Dr. Courtney.

Other custom programs being developed will act as front-end access programs for the variety of programs we have installed on the Palms. Randomly we will use this front end to question the users on how they are using the programs. In the near future we will develop a program to document phone triage based on the guidelines developed by Dr. Barton Schmidt to help educate the residents in this important area of clinical pediatrics. We are also developing a pediatric "Jeopardy" program to quiz the residents. Prizes will be given on a regular basis and at the end of the year. Both of these programs will sync to our handheld server to allow easy access to the data. Handheld Education and Support Dr. Courtney has developed a local intranet web site accessible throughout the hospital and affiliated clinics that is also available through the Eastern Virginia Medical School Internet site at www.evms.edu.

This site includes news on the progress of the handheld initiative, tutorials, reviews, handheld class schedule, and annotated links to hardware and software vendors, E-libraries (with downloadable reference "docs" for pediatrics and other medical fields), other academic handheld sites, evidence-based medicine sites, and a multitude of other useful sites relating to handheld computers in medicine. It also contains email links for support from Dr. Courtney. Classes vary from individualized sessions and small groups to "Palm Pizza" nights and monthly noon conferences for the residents. Educational presentations to other groups in the medical school community are ongoing. Research Residents are able to participate in research projects using the Palm. Currently, one motivated resident is preparing to give a grand rounds presentation. Custom programs are being developed to aid in several areas of pediatric research. A custom program will soon help nurses enter data for a research study on pain relief in sickle cell patients. Andy McCraw, a computer programmer, has developed a program for EMS tracking at the hospital. He is currently working on a patient encounter program with a pediatric hematologist. Dr. Courtney has developed a program to provide calculations to predict occult bacteremia in children 3-36 months based on an article by Dr. Dan Isaacman, the director of the pediatric emergency room.

Other projects are being planned. Future Plans Quantification of the benefit of handheld computers is elusive. Our infrastructure will allow us to study usage, cost savings, efficiency, and augmentation of educational progress by handheld computers. These data should provide objective evidence of their utility. Proof of utility will aid in grant writing for financial support for further studies and infrastructure development. Join a discussion about this article

If you would like to join others in chatting about this article or sharing a similar experience, join our discussion board at this thread:www.pdamd.com/vertical/forums//read.php3?num=5&id=295&loc=0&thread=295 Personnel Our staff currently encompasses: one pediatrician, Dr. Courtney, who coordinates the initiative with support from our former chairman Dr. Arno Zaritsky, our current chairman Dr. David Oelberg, our pediatric residency director Dr. C.W. Gowen, our CIO Debbie Barnes, our web master Jessica Munday, and our director of information services Joe Hooks. Dr. Zaritsky and Dr. Oelberg have been supportive mentors for the project financially as well as through active planning and consultation. Dr. C.W. Gowen has guided our project through financial support and has worked directly on reviewing custom programming for the residents and third party software purchases.

His time and support have been invaluable. Our excellent information services department led by Joe Hooks in consultation with our CIO Debbie Barnes spent considerable time in helping us to install the current server and provided us with that computer. In particular, network technician Mark Gingell worked diligently late hours to get our server up and running and help us with the initial evaluation. Jessica Munday, the web master for our children's hospital was instrumental in ensuring that the "look and feel" of the web site was consistent with the rest of our corporate intranet. She has made valuable suggestions and posts the updated site in a timely manner. We have been the beneficiaries of a unique group of people who have dedicated their time, and in many cases without compensation, to help make the project work. In particular we have been fortunate to have a close working relationship with Aether systems.

Mr. John Teeples at Aether has worked hard to ensure our success. Dr. Courtney works half time as a general pediatrician and works the other half of his time on our handheld initiative. He is charged with overall coordination of the initiative. Dr. Courtney trained as an engineer (B.S. in electrical engineering and M.S. in biomedical engineering). He has worked with handheld computers since the early 1990's and presented several lectures at the American Academy of Pediatrics national conference. He is a member of the executive committee of the AAP section on computers and other technologies. His broad responsibilities for the initiative have included teaching, web site design and programming, handheld computer repair, server administration, custom programming, and research coordination.