By: Randall L. Nord PA-C Randall is a CVT Surgical Physician Assistant at the Asheville Cardiac and Thoracic Surgeons, P.A. Asheville, North Caroline. He He has eighteen years experience as a CVT PA. From 1998 to 2001 Randall served as Senior CVT PA at Duke University where he collaborated on several Medical Informatics projects including wireless handheld and tablet PC implementation. He is a strong advocate for computerized standardization in healthcare and is available as a consultant on handheld implementation for medical settings.

Editors note: This article originally appeared in the January 2002 issue of Surgical Physician Assistant Journal.

We all share mental markers from the past. For many of my generation the JFK assassination or the Beatles on the ED Sullivan Show come to mind. I have been hearing of the coming "Computer Age" since elementary school and recall several mental markers specific to computer technology.
As a Surgical PA I have seen progress in patient care thanks to the new technology. In my personal practice I resisted many new computer related innovations because I could not appreciate the reward vs. the learning curve. Over the last three years I have come to a different perspective. Learning endoscopic vein harvest (EVH) for saphenous vein harvest taught me the value of a new clinical skill and the technology. I believe this approach is superior to methods used previously and it marks an important transition for cardiovascular/Surgical PAs. Those of us who work with this technology have become innovators instead of imitators. We have gained new respect from patients, surgeons, nurses, and the industry that provides these new tools.
In the new millennium there is another opportunity unfolding where we as PAs can demonstrate our skills-adapting information technology to patient care. We see the integration of computer technology into every aspect of our lives. The medical sector has many stellar examples, including computerized tomography, magnetic resonate imaging, and robotic surgical technology. Yet other areas of patient care have lagged behind. How many of us have experienced the lack of routine items in the operating room? Have you ever tried to dictate a discharge summary but find vital documents missing? In my practice it is common practice to hand write the History/Physical Exams forms, pre-operative consultations, daily progress notes and orders. At discharge I average 8 hand written prescriptions per patient. Did you think of who might take care of that mountain of paperwork?

Over the past 15 years there has been a dramatic increase in medical care regulation. As I write this paper our Federal government is in the throes of heated debate about patient rights. This year the Health Insurance Portability and Accountability Act (HIPAA) has added yet another regulatory layer to those with which we must comply. What does this mean? I like to define it as added cost that detracts from monies spent at the point of care. Over the last five years I have visited several CVT surgical practices. Every single one is concerned with costs. Patient care providers are concerned with increasing numbers coupled with increasing acuity but fewer caregivers to serve patients. Now consider the financial side of the issue -- soaring costs, decreasing reimbursement --how do you construct fiscally competent health care with that formula? One approach I have observed, unfortunately, is the decrease in the number of caregivers, which is where increases are needed.

So what can we as PAs do besides complain and talk about the good old days? I believe the answer lies in reducing the need for hospital employees not involved in patient care. How do we do that? Computers at the point of care could provide part of the answer. If applied with skilled planning these new tools may evolutionize patient care to a new level.

In August of 2000, under the direction of Peter K. Smith MD, chairman of CVT Surgery here at Duke University Medical Center, I began a trial to improve data capture at the point of care. Simultaneously I purchased a personal digital assistant (PDA) in the form of a Palm Vx. For Dr. Smith's project I used Internet based software to record the history and physical, pre-operative consultations, progress notes, and discharge summaries for selected surgical patients. This type of project involves the capacities of an Applied Service Provider (ASP), DataCritical in this case. My PDA purchase was made after 6 months of research to begin exploring ways of implementing the PDA as a clinical tool. Initially I wanted to use the device for data collection on EVH cases, and as an electronic handheld resource repository. My next goals were to find methods to record the history and physical, pre-operative consultations, and progress notes on the PDA, and print the output in the medical record format. My last goal is to do something similar for medicine prescriptions. In February of 2001 I was invited to assist James Tcheng MD with design and implementation of the PDA as a clinical tool at the point of care for the entire Duke Heart Center (cardiology and cardiac surgery). I will have more to report on this project in the near future.

Many of us may have similar stories to tell concerning the implementation of computer technology into the clinical setting. The application of information technology in the clinical setting presents a great opportunity for PAs to produce positive changes in patient care. Our clinical role gives us a unique perspective. We know how vital applying the "human touch" in this modern technological era of medicine is needed. Unless we find ways to save money and improve care this will be difficult to accomplish.

Enter the handheld computer in the form of the PDA. If you are not using one today, I hope this article will inspire you to start in the very near future. Here is a basic guide to get anyone started.

The first step is deciding what you want the device to do for you and with that in mind how much you want to spend. I have listed websites to assist you at the end of this article. The most basic device with several free software programs will place numerous clinical references in your hand. This basic capability may be adequate, especially because your institution/practice may provide more advanced devices in the near future. If your institution has a land access network (LAN) operating, you could take advantage of the most advanced technology. It will cost as much as a bare-bones laptop computer. Check the websites. Explore, and I think you will agree that PDAs as clinical tools are cool fun.

As an individual PDA user you can begin to reap the benefits of this technology within a few days after purchase. Regardless of the size of your practice, this handheld device and the technology can be applied within a few weeks, depending upon the level of implementation that you seek.
An entire hospital or health system would take several months if the right heads were working together towards a common goal. There are two very important and controversial issues: securing patient data from transmission to storage and the protecting patient data from being used by entities other than the health system that generates the information.

IT industry information I reviewed projects tens of billions of dollars will be invested/spent for medical informatics, including PDAs over the next 3 to 5 years. Area of clinical use that have been identified as potentially the most cost effective include electronic prescription generation, point of care data entry, charge capture/billing, electronic data retrieval in real-time mode, and the electronic medical record (EMR). Currently there is a large amount of money being invested in these areas. Smaller private companies have concentrated on providing products for the individual/small group market. These include database and reference programs, for example, Epocrates and Handbase.

Another battleground is the PDA operating system/device market. Of course, no area of the computer industry would be complete without a Microsoft story. PDAs are no different. Two years ago this was not even worth discussing but the climate has changed and Bill Gates is positioning his operating system to dominate the healthcare PDA market. Palm, at present remains the leader with several companies' devices utilizing the Palm OS, including Palm, Handspring, HandEra (formerly TRG), Sony, and recently Acer. These PDAs comprise over 90 percent of today's market. Pocket PC (formerly Windows CE) checks in with less than 5 percent, but many analysts predict a 50 percent share or greater for Pocket PC in the near future. Devices using this OS are the Compaq/Ipaq, Casio, and Hewlett-Packard models.

The future of medical informatics is bright. Within 2 years voice recognition software will simplify data entry, eliminating the need for human transcriptionists. We will be able to display visual data to our patients for education or even make house calls from anywhere with an internet-connected PDA. We as PAs can make a huge contribution to this arriving technology -- the power is right there in the palm of your hand.

Useful websites:

REFERENCE LIST:

1. Fisher J, Wang, R. A report on e-health "The Cure is at Hand: Bringing Information Technology to Patient Care." e-health report published by W.R. Hambrect & Co. Sept. 19, 2000.

2. Galbus, Andrew, his report: Wireless Computing at the Bedside. Available at www.rnpalm.com; April 2001.

3. Visotosky, Jeffery, Personal Digital Assistants in Clinical Practice: The Wave of the Future? Available at www.rnpalm.com; presented March 1, 2001: American Academy of Orthopaedic Surgeons 68th annual meeting.

4. Stammer, Lisa, A Show of Handhelds, from Healthcare Informatics 04/2001. Health Care Informatics. April 2001. Available at www.healthcareinformatics.com.

5. Thierry, Patty, a PDA Primer, from Advance for Health Information Professionals, 06/2001. Available at www.advanceforhim.com.

6. MD Practice Alert, a report: As Doctors flock to PDA Reference Tools, Group Practice Managers see Benefits, from AIS Physician Management.
Available at www.aishealth.com.

7. Medical Records Institute reports: Recent Statistics on Wireless Heathcare Emergence, 2001. Available on-line at www. medrecinst.com.

8. Briggs, William, reports: Getting Around with Handhelds, from Health Data Management, 2001. Available at www.healthdatamanagement.com; "Health Data Management"; March, 2001.

9. Paul, Norman, report Admission to Discharge, from Health Management Technology, 2001. Available at www.healthmgttech.com; "Health Management Technology; February, 2001.

Randall can be reached via email