The Hand-to-Handhelds Basics in Medical Practice

by Aura Bland
Ms. Bland, a former California Physician managing editor and CMA Alert editor, is now editor for a consumer-directed health care Web site.

If you’re one of the dwindling number of physicians who practices without a personal digital assistant (PDA), you may not be able to hold out much longer. These pocket-size devices have established a foothold in medicine, and their proponents say they are transforming how physicians practice.

No medical student today would dare do without one, and some medical schools require their use. When medical centers, such as Cedars-Sinai and UCLA, move to wireless networks, physicians and nurses need handheld devices to access patient records. Researchers are beginning to use them to manage data collection in clinical trials, and public health officials employ them to track and control disease outbreaks.

“Even many of the technologically impaired physicians are starting to use PDAs,” says Michael McCoy, M.D., chief information officer of UCLA Health Care, who is spearheading the development of UCLA’s new “digital medical center,” scheduled to open its doors in 2004. “I find that doctors and nurses are demanding this stuff and can’t get it fast enough.”

That’s not exactly what polls show, but PDA use among physicians is growing fairly rapidly. Harris Interactive, the online version of The Harris Poll, predicts that about half of all physicians will be using PDAs within the next two to three years. The number of physicians who have made PDAs an integral part of their practice rose to 18 percent from 10 percent between 1999 and 2001.

Some surveys put the numbers even higher. A June 2001 survey of 44 medical practice managers conducted by Forrester Research Inc. in Cambridge, Mass., predicts that in 2003 use of handheld computers will jump to 86 percent for electronic prescription writing and to 77 percent for charge capture to improve billing efficiencies. Results of a Modern Physician/PricewaterhouseCoopers technology survey published in the November 2001 Modern Physician found that 60 percent of physicians used PDAs in 2001, more than double the 26 percent who said they used handheld devices in the magazine’s 2000 survey.

Whatever the exact percentages, more and more physicians are buying PDAs. Why? “They make medicine better,” says San Diego family physician Robert Hogan, MD of the Southern California Permanente Medical Group. A former medical software developer, Dr. Hogan started the Journal of the American Medical Association’s software review column in 1983. “It’s awfully handy to reach into my pocket rather than running to a desktop computer,” he says. “It’s fast, convenient, and it works.”

Handhelds in Action
By now, most physicians know how these devices work. If they don’t yet own one themselves, they certainly have seen colleagues pulling them out of their pockets, taking hold of a pen-like device called a stylus, and tapping or writing on the miniature screens. Some doctors may simply be checking their appointment schedules, but many are looking up drug information using a program called ePocrates Rx 4.0, (known until recently as qRx) probably the most popular medical software program developed for handheld computers. In November 2001, Epocrates, a software maker based in San Carlos, Calif., reported more than 350,000 users for the program, including nearly 225,000 physicians.

Part of Rx 4.0’s popularity may lie in the fact that it’s free. Physicians can go to the company’s Web site and download the latest version of the software, which contains drug reference information for all of the most commonly prescribed medications. You may search for a drug by generic name, trade name, or class and can get information on adverse reactions, cost, and adult and pediatric dosing. One of the most popular features with physicians is “MultiCheck,” which enables you to enter up to 30 drugs at a time and check for interactions.

“Even the busiest clinician will find the speed and convenience of [Epocrates’] qRx loaded in a Palm Pilot a valuable means of fact finding with the least aggravation, the greatest ease, and the dandiest simplicity—…a remarkable advance over older methods of keeping reference [sic]up to date,” Dr. Hogan wrote in the July 11, 2001, JAMA.

The information is updated as necessary, and most physicians return to the ePocrates Web site every five days for the latest information, says company cofounder Richard Fiedotin, MD, who completed his general surgery internship at Emory University in Atlanta in 1994 but never practiced. Instead, he decided to get his MBA at Stanford, where he and a couple of classmates came up with the idea of developing a PDA software program for physicians that would save time and improve efficiency. His days as a medical student showed him where some health system improvements were needed. “You become very aware of those inefficiencies as a medical student or resident because you bear the brunt of them,” Dr. Fiedotin says. “When other people can’t get the information they need, you have to run around to the appropriate department and get the appropriate information for them.”

Since the software’s debut in October 1999, the company has released several new versions and has added both an infectious disease program and drug formulary information for certain U.S. health plans. Physicians visiting the ePocrates Web site can look at the list of health plans for their particular region, select the plans relevant to their practice, then download that data into their PDA. “In two seconds, you know what is covered and what isn’t, and whether there are any prior authorization requirements,” Dr. Fiedotin says.

This latest version will not only help physicians keep track of drugs covered by their patients’ health plans, but will also generate revenue for the company: Since it doesn’t charge for the software, ePocrates collects money from companies that want to deliver information to physicians via the program. In addition to health plans that send formulary and coverage information, pharmaceutical companies pay ePocrates to relay bulletins called DocAlerts when physicians download the frequent data updates. (Epocrates also publishes unpaid DocAlerts provided by the FDA, CDC, and other government agencies.) Physicians do not have to read these drug-company-sponsored bulletins, but they read them 60 percent of the time, Dr. Fiedotin says.

“We take great pains to make certain that it is very clear to users when they are looking at pure clinical content and when they are looking at a message,” he says. “You never see a message from a pharmaceutical company pop up when you are using our clinical application, and we’ll say no to a message that we think is going to undermine the perceived quality of our application.”

Skeptical physicians who spoke with CP wonder whether ePocrates releases confidential information about its physician users to outside companies. The answer: yes and no. The only companies that see specific information about individual physicians, according to Dr. Fiedotin, are market research firms that crunch the numbers and analyze aggregate user data. “We are not telling an insurance company what information a doctor is looking up,” he says. “We don’t violate that trust.”

Pocket Expense
The drug guide from ePocrates is one of hundreds of medical software applications available for PDAs. Physicians can not only write prescriptions, capture charge data, and access drug information and lab values with handhelds, but can also maintain electronic medical records, calculate complex formulas, conduct Medline searches, access the Web, and check e-mail.

The most daunting task is deciding which application to use and, in some cases, such as electronic prescription writing, identifying cost-effective solutions that work with your office’s practice management system.

Part of that decision-making will depend on the type of PDA you use. The ePocrates drug guide, for example, relies on the Palm operating system. Palms still dominate the PDA market, Dr. Hogan points out; other PDAs, developed by Handspring and Symbol, also use the Palm OS. The main Palm competitors are the “pocket PCs” made by Compaq, Hewlett-Packard, and Casio that use Microsoft Windows software. PDA prices range from about $200 to $600.

If you aren’t ready to buy a PDA, you might find a company that will give you a discount or provide one free, as long as you use whatever application it is marketing to physicians. Medical students, staff, and faculty at Stanford University School of Medicine receive discounts on Palm devices they purchase through ePocrates—which of course come loaded with the company’s drug reference guide. When ePhysician, a Mountain View, Calif.-based company founded by gastroenterologist Stuart Weisman, MD, was launched in May 1999, it offered free Palm handhelds to the first 10,000 physicians who registered for its prescription-writing service (a service that several vendors are marketing to physicians).

With that application, called ePhysician Practice, doctors write prescriptions on their Palm device and then transmit the information to the company’s server via either a local Internet-connected PC or a wireless modem. The company then sends the information to the patient’s pharmacy of choice, either electronically or by fax.

The basic service—prescription writing, charge capture, patient scheduling, and drug-information access—costs $50 a month plus a $400 setup fee. The setup establishes a one-way interface with your practice-management system, because you have to export information on patient demographics, insurance, and appointments into the ePhysician database. (The company says it uses “industry-leading” security measures to ensure protection of information.)

Joseph Goldberg, MD, a San Francisco internist and clinical professor of medicine at UC San Francisco, received his first Palm device and a wireless modem from ePhysician when he agreed to test the company’s product. After using the service for about a year, he gives it rave reviews. “One of the problems in an internal medicine office is callbacks from the pharmacy,” he says. “They can’t read my writing, or they don’t know how many tablets I prescribed. We rarely get those callbacks anymore. If you interview my office staff, you will find that their workload has decreased tremendously because I’m doing the prescription writing and refills on my Palm.”

Although Dr. Goldberg receives the service free of charge, he says he has no other economic interest in the company. He advocates electronic prescription writing because he believes it reduces errors. “Doctors’ handwriting is notoriously sloppy, which gives the pharmacist an enormous challenge when trying to interpret what the doctor has written on the prescription pad,” he says. “My goal is to have more and more physicians use this process or a rival process that is just as good in order to ensure accuracy of prescriptions.”

The Security Promise
The needs for increased efficiency and improved productivity are driving the demand for digital doctoring. Coupled with wireless technology, PDAs enable physicians to be truly mobile. If they work for a so-called digital hospital, they can look up test results, notes from physical evaluations, findings from consultations, emergency room reports, surgical reports, admitting histories, and other patient information anytime, from any location, as long as they have their wireless PDA.

“If you’re a patient, you want your physician to have quick access to your results, particularly if they’re abnormal,” says Michael Shabot, MD, vice chief of staff and medical director of enterprise information services at Cedars-Sinai Medical Center, which developed a wireless, Web-based system using a handheld. “We’re trying to make it very easy and quick for doctors to get all the information they need.”

Access to the system is highly secure, Dr. Shabot says. The entire system, including its wireless link, is encrypted. Physicians can’t enter the system without a name and password, and each PDA has a unique number for the system’s transmitter. “We record that number in our authentication database,” he says. “If a doctor loses his Palm, we deny that particular Palm access to the system. This is strong authentication, similar to the type that banks use.”

As an extra security measure, the medical center has built a firewall that is monitored by an outside company. “That’s what hospitals have to do to keep hackers out of the system,” Dr. Shabot says.

But are most hospitals ready for this new technology? Probably not, says Ann Geyer, who chairs the Mobile Healthcare Alliance, which is working to identify and promote solutions for security and data management in wireless systems, and of which CMA is a founding member. Because wireless technology is new to the health care industry, many hospitals don’t understand the security risks and aren’t even aware that the Health Care Financing Administration has developed security standards for wireless technology, Ms. Geyer says. “Wireless technology is not going away,” she says. “It offers real benefits to the health care process. But it’s still emerging. The more you use it, the more the security threats become visible.”

Dr. McCoy of UCLA Medical Center, however, believes a wireless, Web-based system makes patient information more secure than ever. “No data is stored on the PDA itself,” he says. “All of the data comes over the network and the Web and then it’s gone.”

At UCLA’s new medical center, every doctor and nurse will carry a wireless PDA. The PDA will be a phone, a pager, and an information terminal. It will also act as a remote controller to coordinate viewing of X-rays, MRI scans, and other medical images. “The disadvantage of computers in fixed workstations is that you are tied to a machine and a place,” Dr. McCoy says. “The PDA will dramatically improve productivity because it fits less intrusively into the normal work flow of taking care of patients.” cp