of a Handheld Junkie -
power in the Palm of your hand
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.
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
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
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
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.
Glossary of Medical IT terms
1) PDA- personal digital assistant.
2) ASP- application service provider.
3) POC- point of care.
4) POE- physician order entry
5) CIS- clinical information system.
6) EMR- electronic medical record.
7) IT- information technology.
8) LAN - land access network.
9) WAP - wireless access protocol
10) WAN - wireless access network.
11) e-scribing - e-mail prescriptions.
12) OS - operating system
13) HIPAA - Health Insurance Portability and Accountability
14) ECS - electronic clinical services.
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;
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
Available at www.aishealth.com.
7. Medical Records Institute reports: Recent Statistics on Wireless
Heathcare Emergence, 2001. Available on-line at www.
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