the Digital Divide in Medically Underserved Areas with PDAs
By: Michael J. Rice Ph.D., ARNP. BC.
Michael has been employed by the Washington
State College of Nursing, Spokane Washington since
1989. An associate professor, he teaches in the Psychiatric
Nurse Practitioner Program. He received his Master's Degree
in Psychiatric Nursing from the College
of Nursing at the University of Nebraska Medical Center,
Omaha Nebraska in 1976. He received his PH.D in Clinical
Nursing Research from the University
of Arizona College of Nursing in 1988. He has been
board certified by ANCC in Psychiatric Mental Health since
1995 and is licensed as a Psychiatric ARNP in Washington
State. He also has a private practice at the Suncrest
Wellness Center which is located in Steven's County
Washington, a federally designated medically underserved
rural community. He is a strong advocate for the use of
technology to meet health care needs in rural communities
and the recipient of the prestigious EDUCAUSE
2002 Award for Excellence in Technology Solutions.
Health care practitioners in rural areas have limited access to
expert consultants and resource knowledge bases. The opportunity
to become informed on the use and application of the newest medications,
essential patient and family teaching and to check potential drug-drug
interactions is hampered in rural and medically underserved communities
because specialists often reside in more urban settings. While many
knowledge bases are available on line, there are limitations in
rural and medically underserved areas because of the digital divide,
or a lack of access to information technology resources in rural
communities. The advent of Personal Digital Assistants (PDAs) and
their use in health care possess the potential for resolving many
of these resource problems. Yet, health care professionals familiarity
with PDAs must begin in their educational programs.
Washington State is sparsely populated with a total population
of fewer than two million who reside in an area of over 100,000
square miles. The vast distances have a negative impact on health
care and thirty-six areas in 39 counties are federally designated
as medically underserved or suffer from health professional shortages.
When compared to the eastern seaboard, Washington State's land mass
covers 7-8 states (Figure 1).
Washington State Compared
to Eastern Seaboard
Addressing these issues is difficult due to the distances which
hamper access to clinical experts and educational resources. These
problems are being addressed by the Intercollegiate College of Nursing/Washington
State University College of Nursing, which has the mission of preparing
graduate and undergraduate students in multiple locations throughout
The ICN\WSU College of nursing has received national and international
recognition for its excellence in design and support of distance
education. One of the more innovative projects, has been the Medically
Indigent Rural Area (MIRA) Psychiatric Nurse Practitioner Program
funded by the Health and Resource Services Administration. The MIRA
program has been has been addressing these issues through the innovative
use of technologies to bridge the digital divide and offer graduate
psychiatric nursing education to rural and medically underserved
communities. The MIRA program was awarded to prestigious EDUCAUSE
2002 award for Excellence in Technology and has had an increase
in enrollment by over 900 percent. The effect of the innovative
distance education technology has had a significant impact on rural
communities and over 90 percent of all graduates now practice in
rural areas. As ICN's distance education programs for mental health
professionals has advanced, graduates have identified that they
do not have easy access to expert information and consultation,
as do providers in more urban areas. Often, access to this information
makes the difference of treating and keeping clients in the rural
community near jobs, families, and friends. The absence of current
information often results in patients transported to locations,
facilities, and services hundreds of miles from their homes. The
MIRA program is now addressing the issue of current medication information
using PDA's during the student's education.
MIRA Psychiatric Nurse Practitioner students in clinical settings
will receive one of 33 PDA devices with a drug database and extensive
training on clinical applications. The College of Nursing MIRA program
received the grant sponsored by Suffolk County Community College
and Symbol Technologies,
manufacturer of the PDA. The grant provides 33 Windows CE based
PPT 2700 Series, a member of the family of Pocket PC-based terminals
from Symbol Technologies. The PDA's are rugged PDA's using a Pocket
PC platform with a simple, fast touch screen interface, and Internet
browsing capabilities. The PDA's use Intel StrongARM SA 1110 processor,
running at 206 MHz and come with 16 megabytes of memory. The PDA's
are ideal for students in rural settings as Symbol's drop; sealing
and temperature specifications are excellent.
Saleh Elgiadi, Director of IT
Testing Symbol PDA
In addition to the basic Windows CE programs, the PDA's contain
an extensive drug data base program called Dr. Drug's. The Dr. Drugs
program is published by FA Davis, powered by Skyscape and includes
brand names, dosing, detailed mechanisms, toxicity, and pharmacodynamics
for more than 3900 mediations. Dr. Drugs was selected for the students
because the program is very detailed and has an extensive database
on natural compounds, costs, generic availability, and patient teaching.
The program has also been rated as superior to many other popular
programs (PDARounds, 2002).
The project investigators, Dr. Michael Rice, MIRA program administrator,
and Saleh Elgiadi, Director of Information Services feel that providing
PDA devices will give the students the confidence to practice in
these underserved areas once they have graduated. The graduate students
will use PDA's during their clinical training in medically underserved,
rural communities and clinics serving migrant/ethnic populations.
Clinical training on the use of the PDA's will teach students how
to directly access medical information and databases used in clinical
decision making that otherwise would not be available in the rural
clinical settings because of a lack of clinical experts and the
lack of current technologies in these medically underserved geographies.
The students will be oriented and trained in the use of the PDA's
through established MIRA videoconference sites in one-hour seminars
conducted by the project investigators. The effectiveness of the
use of the PDAs for teaching and supervision in rural and medically
underserved communities will be evaluated using three tiers of data.
Each Tier of data is unique and offers some insight into the use
and effectiveness of the PDA's as an educational tool in rural and
medically underserved communities.
The first tier of data will be evaluated using a traditional pre-post
test design. Students will initially be screened prior to training
on the PDA's using instruments developed for this project. The two
instruments developed based on the Flashlight programs Current Student
Inventory (CSI). The CSI is currently licensed and in use by over
120 institutions around the world. The CSI is a construction kit
for creating surveys, interview protocols, and focus groups that
gather information from currently enrolled students, on or off-campus.
Each instruments is a mirror instrument designed to measure the
change in the students' attitudes about the use of the PDA's. The
initial measure "PDA Utilization and Cost Assessment: Time
1" will assess the student's beliefs and attitudes prior to
use of a PDA in a clinical setting. The second instrument "PDA
Utilization and Cost Assessment: Time 2" will measure their
reactions to the PDA's when they complete their last clinical rotation.
Each of the two instruments is composed of items that address areas
of interest in the use of the PDA's. The instrument will gather
student data on; 1. Participation (A), 2. Research (S), 3. Feedback,
(F), 4. Time, Using Productively (D) and 5. Real world problems
A second tier of data will be gathered on the application and use
of the PDA resources used by the students during their clinical
training. Each of the PDA's is programmed with an Excel spread sheet
entitled "PDA Client Contact Activity". This spread sheet
will enable the students to complete the simple questions after
each client visit. This data will be automatically downloaded on
a periodic basis from the PDA's. A web site operated by the College
of Nursing will provide the students with access to weekly information
updates of the primary drug database. Students will connect their
PDA's to their home computers and simply log on to the established
web site. Once connected, the PDA's will be automatically synchronized
and the information databases will be updated.
The third tier of data will be gathered on the use of "Dr.
Drugs". The Dr. Drug data base program provides automatic
updates on all of the latest medical and pharmacological information.
Each week, when in the process of downloading new information, the
College web site will automatically upload and retain information
on the areas of the database that have been used in the prior week.
This information is then complied and sent to the investigators
as a formal report. The information provided in these reports will
indicate areas of interest in the clinical experiences and used
to help tailor the curriculum.
Use of PDA's will be systematically monitored using the established
MIRA videoconference sites in one-hour seminars. Funds for videoconferencing,
web site development and staff/faculty time are provided through
the MIRA project funds from HRSA. The opportunity to learn the use
of PDA, accessing resources and making clinical decisions based
on accessible data bases will reduce the rate of errors due to drug-drug
interactions, medical complications and will enhance the student's
professional skills for post graduation practice in rural and medically
underserved communities. Training the students in the use of PDA's
during their educational programs provides them will skills and
resources that they can continue to use after they graduate regardless
of their location and distance to expert consultants.
Michael can be reached by email