Primary-care nurse practitioners and physician assistants are aware that managing patient care successfully requires both breadth and depth of clinical knowledge. The challenge of meeting patient expectations while implementing evidenced-based practice guidelines in a timely manner is inherent in each patient encounter. Certainly some encounters are more challenging than others. Skilled providers recognize the availability and accessibility of resources that support quality patient management, whether those resources are of the human variety (i.e., collaborators, colleagues, or referrals) or the nonhuman variety (i.e., handbooks, textbooks, or computer software programs).
Reference information commonly used by providers in the clinical setting for decades can now be easily accessed using handheld technology—specifically personal digital assistants (PDAs). If you are a clinician who has several guidebooks, a few algorithms, and a prescribing handbook in your lab coat pocket, you may be surprised to learn that your favorite clinical references are now available as handheld technology software bundles. If you bought a PDA many years ago and never really used it as originally planned, now is the time to dust it off and take a second look at what can be done with the handheld software now available.
Prescribing resources
Without a doubt, the primary reason providers purchase handheld computers is to take advantage of prescribing software. Having the ability to quickly double-check dose, side effects, contraindications, pregnancy categories, and pediatric indications before writing a prescription or recommending OTC medication improves efficiency and quality in the primary-care setting. In addition to providing drug reference information, prescribing software lets the clinician check for drug interactions, which allows invaluable risk/benefit analysis at the point of care. This multicheck functionality offers details regarding drug-drug interactions and enables the prescriber to make accurate clinical decisions.
A number of PDA prescribing resources are available to primary-care clinicians. Two of the top companies that market prescribing resources for PDAs are Lexi-Comp and Epocrates. Discussing the differences between these two companies' products is much like discussing the differences between a Mac and a PC; providers have distinct preferences and loyalties. Clinicians choosing a prescribing resource for the first time should be aware that both companies offer more than one option, both companies' databases have proven reliability,1,2 and both companies offer bundled software packages.
The bundled software available for purchase from Lexi-Comp and Epocrates includes clinical decision-making applications in addition to prescribing resources. Lexi-Complete On-Hand and Epocrates Essentials are two of the most comprehensive options available (Table 1). Software applications bundled together for purchase as a unit are of key importance to providers interested in acquiring clinical decision-making tools in addition to prescribing resources for their PDA.
Before companies like Lexi-Comp and Epocrates began bundling software, many providers looking to use a PDA in the clinical setting were a bit overwhelmed by the task of finding, reviewing, and purchasing clinical references. Now the best diagnostic guides, lab references, symptom assessment tools, dose calculators, and treatment algorithms can be purchased together in one package. Many of these applications are integrated into the prescribing resource database, which means that clinicians using the applications can easily access information as needed.
Even the process of downloading and updating prescribing resources has become easier. Providers who experienced the tedium of downloading handheld applications in the past will appreciate how much more streamlined the process is now. For example, software applications from both Lexi-Comp and Epocrates are downloaded from the Internet automatically onto desktop software and then onto a PDA after the handheld is connected. Databases can be downloaded directly onto memory cards or into the internal memory of the PDA. Versions of prescribing resources exist for almost every form of handheld technology using Palm or Pocket PC operating systems. Updating information is as easy as syncing he PDA to the desktop software. Online technical help and tutorials are available to take the new user through these processes.
Clinical applications
While the availability of bundled software packages has simplified the process of acquiring handheld clinical applications, the ability to download additional specific software based on individual provider needs is still an important part of using a PDA as a resource to manage patient care. Many providers first use the PDA as a basic prescribing resource and later add other clinical software applications. The process of adding software to handhelds is much easier today, as the memory capability and expandability of even the most basic PDAs have increased considerably in recent years.
What clinical applications do primary-care clinicians find most useful? A simple Web search uncovers thousands of choices. Table 2 lists examples of available PDA software and indicates whether they are available without charge or require payment. The evidence-based applications listed in Table 2 are the ones most used by providers in primary care.3,4 The following summary is meant as a helpful guide to clinical applications for the PDA.
• Billing and coding: Stat E&M Coder, Stat ICD-9 Coder
— StatCoder provides a number of tools to help with accurate coding and billing in an easy-to-use format. Free trials of the software can be downloaded.
• Cholesterol guidelines: STAT Cholesterol or ATP III Guidelines
— Either of these programs allows individualized patient management based on national cholesterol guidelines. Patients can see how changing lifestyle behaviors can decrease risk factors when the application is used with a team approach.
• Continuing education: Prescriber's Letter, Medical Letter
— The PDA versions of these unbiased, well-known newsletters are free to subscribers. Included with subscriptions are opportunities for pharmacology continuing education.
• Dermatology reference: DermMeister
— A dermatology reference with photos available in a handheld format is a rarity. (The fact that this one is free and user-friendly is quite a bonus.)
• Dosage calculations, IV rate calculations: MedMath and MedCalc
— These medical calculators allow easy access to countless formulas. The ability to quickly perform common calculations (e.g., dose based on weight, spirometry values, or cardiac output) makes either of these calculators a must-have. These programs are often part of bundled software but can be downloaded separately as freeware.
• Electronic prescribing and/or electronic records: iScribe, RxNT, EMR lite, Allscripts
— As the trend toward electronic prescribing systems and electronic medical records continues, user-friendly computer applications that incorporate handhelds are more widely available. The software applications listed offer various levels of integrated prescribing systems.
• Emergency response resource: .911
— The CDC offers free guidance for disasters, epidemics, and outbreaks. Download this free application to the expanded memory of a PDA, and detailed emergency preparedness and disaster information will be readily available if needed.
• Geriatric reference: Geriatrics at Your Fingertips
— This reference is the PDA version of the pocket guide from the American Geriatric Society.
• Immunizations: Shots 2008
— This free application allows quick access to the immunization schedules for pediatric, adolescent, and adult patients; catch-up schedules and high-risk considerations are included. Having the most recent recommendations from the Advisory Committee on Immunization Practices (ACIP) available as a handheld reference is invaluable.
• Infectious disease reference: Johns Hopkins University Antibiotic Guide
— Search by diagnosis, pathogen, or antibiotic with this application to review evidence-based treatment guidelines. This is helpful for cross-referencing when a patient has more than one infectious disease diagnosis. The Antibiotic Guide is often bundled with other software, although it can be purchased separately as listed.
• Medical calculators, assessment tools, formulas, flow charts: Stat Growth-BP, BMI, Glasgow Coma Scale, Peak Flow Rate, arterial blood gases, and hundreds of others
— Almost any chart, graph, formula, table, or algorithm used in primary care is available for the PDA. Downloading these free applications to the handheld helps eliminate the assortment of notes that were once stuffed into a lab- coat pocket and will limit the need to search through office files or bookshelves to find that long-lost guidebook or reference.
• Mental status tool: MentStat
— Allows the provider to administer and score the Mini Mental Status Exam
• Pediatric references: Bright Futures, Red Book
— The American Academy of Pediatrics has PDA versions of references available.
• Pregnancy calculator: OB Wheel
— Allows the provider to calculate the estimated day of confinement, gestational age, and Bishop score
• Prescribing resources (with and without clinical software): Epocrates, Lexi-Comp, Clinical Pharmacology, Micromedex, Monthly Prescribing Reference, and Pepid
— The drug database from Monthly Prescribing Reference is available to medical professionals as a free download for mobile devices, as well as desktop and laptop computers. The MPR Mobile & Desktop Edition is compatible with Blackberry, Palm, Microsoft Mobile, Microsoft XP, and Microsoft Vista.
— Epocrates and Lexi-Comp offer versions of their prescribing software bundled with and without clinical references. Clinical Pharmacology, Micromedex, and Monthly Prescribing Reference have online and PDA versions. Pepid is an excellent clinical decision-making reference that includes prescribing and clinical software and is now available for mobile and wireless devices.
• Provider-specific references: NP Toolbox, PA Toolbox
— The “Toolbox Series” now includes a bundle of software specific to NP or PA practice. An excellent resource, the Toolbox includes numerous pediatric references.
• Symptom assessment: Diagnosaurus
— This free application generates lists of differential diagnoses for various signs, symptoms, and diseases and is an excellent tool preceptors can use to spark discussions with students.
• Sexually transmitted disease treatment: CDC Guidelines 2006
— The CDC provides the most recent evidence-based treatment guidelines for sexually transmitted diseases in a free PDA version.
• Symptom assessment and disease management: 5-Minute Clinical Consult, Harrison's Manual of Medicine
— These comprehensive and respected clinical references allow for quick review of symptoms, workup, diagnosis, and treatment. Both are available as part of software bundles or separately as listed.
Web sites for clinical software
The list of clinical applications provided in this article is far from exhaustive. If you're looking for a specific handheld reference not listed or wondering if a frequently used guideline or algorithm exists in PDA format, the Web sites shown in Table 3 serve as excellent resources. These Web sites offer comprehensive listings and reviews of available handheld computer applications pertinent to patient management. Freeware and point-of-care applications are included.
Barriers to use
Providers often wonder if patient confidentiality is compromised with PDA use. When handheld technology is utilized to manage patient care through clinical decision-making, no patient information is entered into the PDA, so confidentiality is not violated. Be careful when using a handheld computer as part of an electronic medical record, however. When entering patient-identifying information (e.g., name, birth date, or identification numbers) into your PDA, think of the handheld device as a patient chart. In many hospital settings, providers are required to register their handheld computer for permission to access patient records. Encryption and password protection can be used to safeguard patient data.
Financial barriers to PDA use can be significant for the student as well the practicing provider who doesn't want to make an investment in software that might seldom be used. Before downloading applications (even free software), consider its potential for use. Used efficiently in the clinical setting, computer applications can have financial benefits attributable to improved patient flow, fewer errors, and patient satisfaction. Before purchasing handheld software, be aware that discounts are frequently offered to national conference attendees, as part of group purchases, and through universities. Special offers for purchasing a PDA bundled with clinical applications are available. Some companies offer trial downloads, which allow providers the opportunity to determine the application's usefulness before finalizing their purchase.
Of course, for many providers, technology itself has inherent barriers. Anyone who has ever lost part of a document when a computer program freezes, has had trouble installing new computer software, or has had difficulty explaining a problem to technical support knows well the frustration that is inherent in using new computer tools. On a positive note, handheld applications that can be used as clinical references are not so new anymore. Companies offering clinical decision-making tools also offer technical support and have streamlined the downloading and updating processes. As the availability of software has expanded, the benefit to patient-care management has increased. Handheld applications have become a valuable resource in clinical practice.
Ms. Teall is a nurse practitioner with MinuteClinic, Ohio South, in Columbus.
References
1. Clauson KA, Polen HH, Marsh WA. Clinical decision support tools: performance of personal digital assistant versus online drug information databases. Pharmacotherapy. 2007;27:1651-1658.
2. Perkins NA, Murphy JE, Malone DC, Armstrong EP. Performance of drug-drug interaction software for personal digital assistants. Ann Pharmacother. 2006;40:850-855.
3. Lin AB. The top PDA resources for family physicians. Fam Pract Manag. 2006;13:44-46.
4. Craig AE. Personal digital assistants: practical advice for clinicians in 2007.
All electronic articles accessed May 15, 2009.