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International Journal of Medical Informatics (2005) 74, 409—422
REVIEW
A review and a framework of handheld computeradoption in healthcare
Yen-Chiao Lua, Yan Xiaoa,∗, Andrew Searsb, Julie A. Jackoc
a Department of Anesthesiology, University of Maryland School of Medicine, 685 W. Baltimore Street,MSTF 534, Baltimore, MD 21201-1192, USAb Department of Information Systems, UMBC, USAc School of Industrial and Systems Engineering, Georgia Institute of Technology, USA
Received 16 November 2004; accepted 3 March 2005
KEYWORDSAdoption;Handheld;Personal digitalassistant;Mobile computing
Summary Wide adoption of mobile computing technology can potentially improveinformation access, enhance workflow, and promote evidence-based practice tomake informed and effective decisions at the point of care. Handheld computers orpersonal digital assistants (PDAs) offer portable and unobtrusive access to clinicaldata and relevant information at the point of care. This article reviews the literatureon issues related to adoption of PDAs in health care and barriers to PDA adoption.Studies showed that PDAs were used widely in health care providers’ practice, andthe level of use is expected to rise rapidly. Most care providers found PDAs to be func-tional and useful in areas of documentation, medical reference, and access to pa-tient data. Major barriers to adoption were identified as usability, security concerns,and lack of technical and organizational support. PDAs offer health care practition-ers advantages to enhance their clinical practice. However, better designed PDAhardware and software applications, more institutional support, seamless integra-tion of PDA technology with hospital information systems, and satisfactory securitymeasures are necessary to increase acceptance and wide use of PDAs in healthcare.© 2005 Elsevier Ireland Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4102. A framework for review articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
2.1. Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4102.2. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4102.3. Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4112.4. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
* Corresponding author. Tel.: +1 410 706 1859; fax: +1 410 706 2550.E-mail address: [email protected] (Y. Xiao).
1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ijmedinf.2005.03.001
410 Y.-C. Lu et al.
3. System characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4113.1. Operating systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4113.2. Types of devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4113.3. Common applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
4. Adoption and barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4124.1. Benefits of handheld computers in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
4.1.1. Cost saving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4124.1.2. Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4134.1.3. Time saving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4134.1.4. Errors reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4144.1.5. Clinical impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
4.2. PDA adoption in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4144.3. Barriers to handheld computer adoption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416Appendix A. Summary of selected articles regarding the use of personal digital assistants in health care . 417References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
1. Introduction
Despite the differences in practice environments,the information needs of health care profession-als at the point of care are universal. Most clin-icians would benefit from mobile computing re-sources (such as evidence-based guidelines, medi-cal reference, drug reference and patient informa-tion) to meet their information needs. Mobile com-puting adds value to clinical practice in a numberof ways, such as by giving clinicians access to clini-cal information where and when the information isneeded, by improving the exchange of information(thus, reducing medical errors resulting from inad-equate access to clinical data), and by providingclinical decision support to give clinicians feedbackat the point of care [1—4].
Personal digital assistants (PDAs) are light-weight, compact handheld computers that literallyfit into one’s palm or pocket [5]. The terms ‘‘PDA,’’‘‘handheld computer,’’ ‘‘handheld,’’ ‘‘Palm Pi-lot,’’ and ‘‘pocket PC’’ all refer to similar deviceswith comparable capabilities.
Mobile computing allowed by PDAs is becomingan important tool in health care and has grown in
care. For example, Fischer et al. [9] assessed theliterature for evidence of the impact of handhelddevices in terms of patient outcomes. We also sys-tematically reviewed the literature on the use ofhandheld computing devices, but focused on theissue of their adoption in health care practice. Weexamined the potential benefits of PDAs as factorsthat will promote their adoption and identified bar-riers to their acceptance in health care.
2. A framework for review articles
2.1. Sources
We used Medline, the National Library of Medicine’ssearchable database of peer-reviewed publica-tions; the published proceedings of one primaryconference (Proceedings of Healthcare Informationand Management Systems Society [HIMSS]). In ad-dition, to assess the types of application availablefor different platforms, we used Internet searchengines (Google and Yahoo) and electronic re-sources (Download.com, CNet.com, Microsoft.com,PCG
2
W1rnctc
popularity among health care professionals duringthe past 5 years [6—8]. A wide range of mobile de-vices is used by health care professionals to im-prove efficiency and effectiveness in the delivery ofpatient care. These devices are designed to assistusers in both everyday work and off-duty activities.
As more health-care-related applications are in-troduced and used, a growing body of literaturehas been established that can guide the future de-sign and deployment of mobile computing solutions.Those published reports also provide insight intobarriers to the wide adoption of mobile computingsolutions and the effect of these devices on health
alm.com, Blackberry.com, ePocrates.com, Med-alc3000.com, Lexi.com, MDeverywhere.com,Ehealthcare.com, and Handheldmed.com).
.2. Scope
e limited our search to items published since998. The search was performed in March 2004 andepeated in May 2004. We summarized some of theon-empirical articles in Tables 2—4 to present aomprehensive picture of handheld computer adop-ion in healthcare. Articles addressing all healthare professionals (physicians, nurses, pharmacists,
Handheld computers adoption 411
and others) and their uses of PDAs and mobile com-puting devices were identified.
2.3. Framework
We applied Davis’s Technology Acceptance Model[10] as a reviewing framework to categorize arti-cles. As a result, we used the following sections:(1) system characteristics; (2) benefits; (3) adop-tion and (4) barriers, to present and summarize ourfindings.
2.4. Search strategy
For our searches, we employed the following terms:handhelds, handheld computers, handheld comput-ing, personal digital assistants, palm pilot, mobilecomputers, and pocket PCs.
More than 200 articles indexed on those termswere identified on Medline. Ninety-five of themwere reviewed, based on their relevancy to theadoption of PDAs.
3
3
MoomftattaWraosttab
bihnse
OS [14]. The authors reported high acceptance ofthe technology and reduction in total time for dataentry; however, no specific numbers were pro-vided. It was indicated that the system has severalunspecified limitations that preclude its implemen-tation outside experimental settings. The majorityof the problems were related to data security[14].
3.2. Types of devices
The four leading types of handheld devices that arecurrently available to consumers are:
1. Palm OS-based PDAs: Many manufacturers, suchas Palm, Sony, and Handspring provide PDAs thatrun on Palm OS. Generally, these devices are af-fordable, easy to use with a long battery life[15].
2. Pocket PC (Window CE based): Manufacturers,such as Toshiba, HP, and Zayo and others pro-vided PDAs that run on Window CE OS. Microsoftanticipated that users would someday be able todomany of the same things on a pocket-sized de-vice that they can do on a desktop PC; therefore,
3
4
. System characteristics
.1. Operating systems
ost PDAs run either a Palm OS® (operating system)r Window CE/Pocket PC OS. Each system has itswn strengths and weaknesses, but the two haveuch in common. Based on our manual searchesrom Download.com and PDA Cortex.com, morehird-party applications and medical applicationsre available to the Palm OS (approximately 1450hird-party applications and 527 medical applica-ions) than Window CE (900 third-party applicationsnd 306 medical applications) as of June 2004.e used these two websites as examples to giveeaders a basic idea of what to expect regardingvailability of the PDA hardware and software;ur intention, however, is not to conclude whichystem is superior. Currently, Palm OS dominateshe PDA market; however, there is an increase inhe popularity of Window CE-based PDAs [11]. Inddition, more healthcare-related applications areeing developed and introduced [12,13].A less commonly used PDA operating system is
ased on the open source Linux, with a graphic usernterface. The manufacturers using Linux OS do notave to pay a royalty because of its open sourceature, unlike those using commercial operatingystems [14]. One study described a handheldlectronic medical record (EMR) based on the Linux
Window CE was built to support that functional-ity [15]. The hardware requirements for WindowCE are higher; and as a result, the cost for apocket PC device is also higher.
. Smart phones (PDA/cellular phone combo): Thisis a device that integrates a full cell phoneand full wireless data connectivity into a full-function pocket PC that uses Global System forMobile Communication (GSM) for voice and Gen-eral Packet Radio Service (GPRS) for data [16].Microsoft is in the process of introducing a Win-dows mobile-based smart-phone. These phoneshave a high-resolution, graphical, color screensmall enough to fit on a compact phone yetbig enough to comfortably play games, view e-mails and images, and browse the Web. Theyalso offer users full personal information man-agement and e-mail functionality through Out-look, a Web browser in Pocket Internet Explorer,instant message capabilities with MSN Messen-ger, and even the ability to listen to musicand play video with Windows Media Player (Mi-crosoft.com).
. BlackBerries: These devices provide the abilityto send and receive messages without a phone,modem, or desktop computer. Several modelsare available from Research In Motion, the de-veloper of the devices. The difference betweena BlackBerry and a PDA, such as Palm or PocketPC is that with BlackBerry the wireless connec-tion is always on and connected. As soon as the
412 Y.-C. Lu et al.
Table 1 Selected example of the most commonly reported medical applications in the literature
Programs Functions
ePocrates Drug reference application that provides over 2600 drugs information (including adults andpediatrics) on dosages, indications and contraindications, drug interactions, adverse reactions,manufacturer, pricing, route of metabolism and pregnancy safety class [60]. Available athttp://www.epocrates.com.
MedCalc3000 Medical calculator that provides many medical formulas that can perform a number ofcalculations. Available at http://www.medcalc3000.com.
LexiDrugs Drug reference database that provides information about drugs commonly prescribed bydentists and physicians. Available at http://www.lexi.com.
MD Everywhere Includes EveryCharge (provides electronic charge capture), EveryNote (digitally records voicedictation notes and links them to coded patient encounters), EveryReference (providesmedical references) and EveryOrder(enables clinicians to capture and convey orders andprescriptions on the handheld device). Available at http://www.mdeverywhere.com.
PocketChartTM Provides the ability to capture demographic data, symptoms, diagnosis, creation of care plan,and scripting of medications. Available athttp://www.gehealthcare.com/it solutions/pocketchart.html.
Patient Tracker A comprehensive patient database that keeps track of patient’s vital signs, labs, andmedications, and allow creation of to-do lists. Available at http://www.handheldmed.com.
user enters a coverage area, the BlackBerry willstart pulling or sending mail automatically [17].However, an emerging trend in the handheldcomputing development is the offering of wire-less networking functionality.
3.3. Common applications
A keyword search on Google on 20 May 2004 for in-formation about medical programs for PDAs yieldedapproximately 269,000 results. A search on PDACortex.com resulted in approximately 527 Palm-based medical applications and 306 Window CE-based medical applications available in the market.While the numbers obtained from Google and PDACortex results do not equal the number of the ap-plications available, they do provide an estimate ofthe abundance of PDA resources available to clini-cians and relative availability across different plat-forms. Table 1 lists some of the applications mostcommonly reported in the literature. In general,medical PDA applications can be grouped into thefollowing categories:
1. Decision support: The applications include ac-
capturing and tracking [25], reimbursement[26], and data collection for tracking and an-alyzing services and communications [27,28].
3. Documentation: Documentation functions in-clude note generation [22], dictation [22],charting [29],and printing [30].
4. Professional activities: These activities includepersonal information management [31], profes-sional monitoring and reporting [32], implemen-tation of guidelines [33], laboratory test or-dering [23], communication [23], patient datatracking [25], electronic prescribing [23], drugdelivery management [22], and recording andretrieving data and information at the point ofcare [34].
5. Education and research: Educational and re-search support include providing education ma-terials to patients, using handheld computers asa teaching tool for medical education, providingaccess to evidence-based medicine and medicalresearch [35—37].
4. Adoption and barriers
4h
4Supad
cess to patient information [18,19], medical cal-culation [6], medical reference [6] (e.g., drugreference [20]; electronic textbooks [6]), andclinical computational programs [6]; real-timeinformation access [21]; diagnostic data man-agement [22]; laboratory result retrieval [23];and wired or wireless access to Internet re-sources [23].
2. Administrative support: The applications in-clude scheduling [18], billing [24,25]; charge
.1. Benefits of handheld computers inealth care
.1.1. Cost savingilva et al. [26] reported using PDAs to doc-ment the services offered by pharmacists tohysicians (such as providing drug informationnd pharmacotherapy consultation). The cost re-uction associated with electronic documentation
Handheld computers adoption 413
totaled $662,335 during a 6-month period for thefour pharmacists and four residents who partic-ipated in the study. Potential claims for phar-macists’ cognitive services recorded with PDAsamounted to $1,025,834 during the study period[26].
4.1.2. EducationLeung et al. [35] evaluated the use of a hand-held clinical decision support tool to assess its edu-cational effectiveness on learning evidence-basedmedicine and reported improvement in partici-pants’ educational experience [35].
4.1.3. Time savingRothschild et al. [38] examined the clinical con-tributions of a handheld drug database in March2000. They found that physicians reported thatePocrates Rx saved time during information re-trieval, could be incorporated easily into theirworkflow, and improved drug-related decision mak-ing [38]. d’Hemecourt [39] also reported positiveoutcomes (from an average 33-day reimbursementtime to 1 day) after PDA technology was used forbilling and reimbursement: reimbursement timewas reduced from an average of 33 days to 1 day[39].
Table 2 Advantage of personal digital assistants
Advantages Summary (EB, evidence-based; OB, opinion-based)
Mobility OB: In the healthcare environment, PDAs allow the clinicians to have access to patientinformation whenever and wherever they prefer, to record patient data in real-time, tolook up medical references, and to communicate with colleague [5,65].
Real-time access OB and EB: Some articles commented that although small, PDAs have high functionality.One important feature is their ability to monitor patient data. Clinicians can tracklaboratory values instantaneously. Patient information, medical records and medicalreference libraries can also be uploaded, downloaded and accessed [16,66,67].
Cost-effectiveness OB: In addition to providing the opportunity to greatly improve patient care, PDAs offerg core p; thefewt is eerm].videed ainfraal cliing pvantnted
high benefits relative to reducinconforming to how the healthcaan increased capture of charges[25]. Although currently only aimproving clinicians’ practice, iby health care professionals in ta point of care device [41,69,70
Communication OB: PDAs have the ability to prointegrated PDA phone can be usother team members. Wireless/computing devices allows severefficient communication regard
Increased safety orreduce medical
OB and EB: One of the major ad[2,4,71,72]. Errors can be preve
errors is provided, (2) the most up-to-datesupports are provided.
Time-saving OB: Several articles reported that thIntegration OB: The consensus among authors re
technology (e.g., wireless transmissusers do not need to carry additionasystems perform functions, such asflow sheets. Also, there are systemscare on handheld computers [29]. Gachieved if data capture or data ent
Customization OB: Various functions or programs ca[75]. Therefore, PDAs offer solutionwhich are more realistic than thosemedical records [6].
Evidence-basedpractice support
EB: PDAs can provide quick access tin the right direction for medical de
Enhancedproductivity andquality of care
EB: McAlearney et al. reported thatimproved productivity and interactioquality of patient care and services
st and potential risks, while giving the convenience ofrofessionals work [68]. For example, one study showedrefore, the PDA had an important economic impactempirical studies support the effectiveness of PDAs invident in the literature that PDAs are highly regardeds of portability, functionality and values they provide as
and promote communication. For example, ans a mobile phone, allowing clinicians to contact withred transmission of data from PDAs to other mobilenicians to access and transfer relevant data, promotingatient care [16,28].ages of PDAs is their potential to reduce medical errorsif (1) data are captured at the point of care when care
medical information is available [50], (3) decisione use of PDAs can save time [7,73,74].garding the usefulness of PDAs is that all necessaryion) should be integrated into one device rather, so thatl equipment [16,49,50]. In addition, few existinggenerating and printing progress notes, sign-out, andthat allow information to be entered at the point ofreater efficiency and increased error reduction will bery are permitted wherever and whenever it is available.n be added to support different medical specialtiess to administrative and information management needs,offered by desktop computers and traditional electronic
o evidence-based screens that can point care providerscisions [76,77].doctors perceived that handheld computer applicationsn with patients. The physicians also perceived thatwere enhanced when PDAs were used [56].
414 Y.-C. Lu et al.
4.1.4. Errors reductionCarroll [29] conducted a pre/posttrial study in anacademic neonatal intensive care unit to deter-mine whether a point-of-care PDA-based patientrecord and charting system could reduce the num-ber of discrepancies in residents’ progress notes.They reported an overall decrease in the number ofdocumentation discrepancies, but the results weremixed [29].
On the other hand, Grasso et al. examinedwhether using PDAs to create discharge order listsinstead of transcribing the lists manually would re-duce errors. They documented a decrease in errorsfrom 22% to 8% at 4 months after implementation[4].
4.1.5. Clinical impactHow will PDAs improve the quality of medical prac-tice? The literature suggests that utilization of PDAssaves clinicians time in regard to accessing, retriev-ing, and recording data [6,22,30,32,40] and, there-fore, frees clinicians from spending time in docu-mentation, allowing them to do more direct patientcare. It can helps health care providers to bettertake care of their patients by improving their per-
cess to patient data. Furthermore, clinicians canmake educated decisions when they are offered ac-cess to the most up-to-date patient data and med-ical references, such as evidence-based practiceguidelines and the most current medical informa-tion. However, more research should be conductedto evaluate the effect of PDA technology on thequality of medical practice.
4.2. PDA adoption in health care
Most health care professionals perceive PDAs asuseful tools that can enhance their practice by of-fering mobility and functionality in a small devicethat fits into one’s pocket [41—43]. As summarizedin Table 2, PDAs have many advantages in the worldof health care. These attributes are likely to con-tribute to the continued acceptance of handheldtechnology not only in the practice of medical care,but also in the administrative functions that supportit.
Numerous studies have demonstrated awidespread adoption of the handheld computersin health care, and many information technologylco
iscip
, op
roximmpathat[6].more
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eld c
of al [62n of
ed timpd coent aatio
to d
tion
sonal and professional information management,providing medical decision support via access toevidence-based materials, and allowing remote ac-
Table 3 Adoption by of personal digital assistants by d
Specialties Examples of use (EB, evidence-based; OB
Medicine EB: Smithline’s survey revealed that apptheir organizations used PDAs in 2001, coEB: Criswell and Parchman also reportedresidency programs in the United StatesEB: Carroll and Christakis reported thatPDAs in their practice [7].EB: Gillingham et al. found that 60% of rPDAs in their organization [8].EB: Garvin et al. reported uses of handhprocedures [61].EB: Fu et al. described, implementationinformation for anesthesia quality controEB: Giammattei reported implementatioPDAs [63].
Nursing EB: The data from Forrest Research showusing PDAs. Drug reference was the mostOB: Schneider reported use of a handhelOB: Bosma et al. reported the developmby an intravenous resource nurse consult
Pharmacy EB: Silva et al. reported the use of PDAspotential reimbursement [26].EB: Lynx et al. described the implementa
hospital [64].EB: Reilly et al. reported use of a PDA documeaders and executives have agreed that handheldomputers will have a significant role in the futuref health care [6,7,44]. According to a recent
lines
inion based)
ately 60% of respondents indicated that physicians inred with 26% in a 2000 survey [5].PDAs were used by two thirds of the family practice
than one third of pediatricians in the US were using
ndents said that physicians in their organization use
omputers to document family practice resident
mobile information system to collect patient].a total joint registry system to collect information on
hat in North America, more nurses, than physicians areortant use of PDA in nursing [45].mputer in an emergency nursing setting [40].nd integration of a PDA-based point-of-care databasen service [27].
ocument pharmacist cognitive services and estimate
of a PDA-based pharmacist intervention system in a
entation program to document interventions [42].
Handheld computers adoption 415
survey conducted by Forrester Research, physi-cians adopted mobile technology at a higher ratethan general consumers: in 2003, 40% of physiciansowned a PDA whereas only 8% of consumers werePDA owners [45]. The Forrester survey also foundthat, in 2003, more nurses than physicians inthe United States and Canada were using PDAs(559,800 versus 408,020) [45]. Pharmacists werealso among the early adopters of PDA technologyin health care. A pharmacist survey showed that
26% of the respondents used a handheld computeron a daily basis [46]. These data and the consensusderived from our literature review clearly show anincreasing trend of PDA adoption in health care(Table 3).
A driving force for PDA adoption is wirelessconnectivity. Wireless handheld devices are be-coming popular among physicians and nurses[47—51]. Wireless connectivity is achieved byspread spectrum or other radio technology with
Table 4 Complaints about personal digital assistants and barriers to their use
Complaints or barriers Findings (EB, evidence based; OB, opinion based; EMR, electronic medical record)
Personal factors [56] EB: Physical factors, e.g., large fingers (too big for the buttons) and poor eyesight(cannot read the small fonts)EB: Age: memory problem (forgot to carry the device).EB: Comfort with technology.EB: Comfort with the device.EB: Dependency or over-reliance on the device.
Ineffectiveness EB: Brody’s study showed that documenting pharmacists’ clinical interventions on PDAsdid not appear to be more effective or efficient than documenting on paper [78].
Non-integrated EMRs OB: Most medical facilities do not have integrated EMRs. Ideally, the handheld systemshould be integrated with the hospital’s electronic patient record system, to allow direct
ata
ith g
creecree
f ofty [7
vice
ut dt sec
entry and access of patient d
Data entry EB: Data entry mechanism w
Physical design EB: Size, weight, and small slighter but have the largest s
Maintenance EB: Brody et al. reported halwere no longer under warran
Delicate devices EB: Fears of breaking the de[54,56].
Security and speed ofwireless transmission
OB: An integrated input/outpshould be developed to mee
faster transmission [34,52,79,80]Technical difficulties EB: In a study of PDA use by interacceptance of the technology’s cas cumbersome modem cords, inaccess at times, and synchroniza
Negative patientperception
EB: Negative patient perceptionslimit the use. 23% of physicians rewith patients; 10% of patient did
Other barriers EB: Organizational Barriers, e.g.,issues [54].EB: Usability issues, e.g., limitedscreen size, and unease with datEB: Inadequate technology, suppoapplications [54].EB: Alternative methods used orwrite notes on paper rather thanEB: Lack of needs or motivation,money to get additional hardwarapplications [54].EB: Insufficient training [30,54].
[30].
raffiti was unintuitive and not easy to use [54,56].
n: most users think that PDAs should be smaller andn possible [7,54,56].
their PDAs malfunctioned in some way, and the products8]. Therefore, repair costs constitute another barrier.
make some users limit their uses to avoid damaging it
evice with data encryption at both ends of transmissionurity needs. Broadband wireless access is needed for
.nal medicine students, Beasley noted generalapabilities but documented technical difficulties, suchcompatible platforms, difficulties in gaining Internettion with home computers [81].
of physician’s use of PDAs in the examining room mightported reservations about using the handheld computernot like the idea of PDA use in the exam room [59].
lack of institutional support and concerns about legal
battery power, limited memory, perceived fragility,a entry using graffiti, difficult in use [54,56].rt or access barriers, e.g., unavailable features or
competing technologies, e.g., some physicians prefer toon PDAs [54,56].e.g., some physicians are unwilling to spend extrae or software for some particular functions or
416 Y.-C. Lu et al.
different coverage. Prospective applications ofwireless technology in health care span a widerange of disciplines and processes, and adoption isexpected to increase with improvements in batterylife and transmission speed [22,51,52].
One example of the influence of wireless con-nectivity on the adoption of PDAs is electronic pre-scription. Currently, less than 5% of physicians writeprescriptions electronically using a wireless device,but vendors seem optimistic about the trend [53].In fact, vendors are supplying doctors and nurseswith wireless devices, hoping that hospitals at somepoint will integrate the devices into their infras-tructure [51]. Hospitals in general are in the earlystages of adopting wireless networking [51,52]. Pri-vate physician practices are also moving towardthese systems [49]. Experts estimate that wirelesstechnology will become an essential component ofhospital operations within next few years, aftersome major issues, such as bandwidth, availability,and security are resolved [49].
In conclusion, despite mixed reactions to PDAsin health care, mobile computing is generally wellreceived in the health care industry. The earlyadopters are optimistic about the handheld com-
riers can be eliminated by organizational changes(such as providing the necessary infrastructure forthe handhelds, technical support, and funding forthe devices and software applications) and moreeducation and training [54,56,58,59].
5. Conclusion
A number of benefits of the use of PDAs in medicalcare have been articulated and demonstrated inthe literature. These benefits include offering clin-icians mobility, providing real-time access to dataand information, reducing medical errors, savingtime, supporting evidence-based practice, enhanc-ing productivity and quality of care, and providing atool for communication. Along with technology ad-vances (such as wireless connectivity), these ben-efits contributed to the reported trend that healthcare professionals are adopting PDAs in increasingnumbers. Physicians, pharmacists, and nurses areall early adopters of handheld computers. Indeed,clinicians perceive the handheld computers as aportable, relatively inexpensive, integrated plat-fatFgibmiarht
aatie
rtoaatatpor
puters’ potential to improvemedical practice. Moreand more health care professionals, clinics, andhospital organizations are considering the purchaseand implementation of handheld technologic solu-tions to save time, improve medical data access,assist with medical information management, im-prove patient care efficiency, and reduce medicalerrors.
4.3. Barriers to handheld computeradoption
A number of user complaints (Table 4) about PDAshave been reported, such as uneasy data en-try, small screen size, and fear of breaking thedevice [11,54—56]. These complaints are poten-tial barriers for wider adoption of PDAs amonghealth care professionals. For example, Larkin[57] reported that if a PDA could not fit into aphysician’s workflow seamlessly or if it requiredextra effort, the physician was less likely to use thedevice.
Advances in technology and usability [54] helpovercome some of the barriers to adoption. Forexample, new batteries offer longer battery timeand memory cards with larger capacity could ex-pand memory storage easily. The latest PDA fromPalmOne Inc. offers a screen 50% larger than thepast models; in addition, screen resolution is be-coming better, with more clarity [58]. Some bar-
orm for point-of-care clinical reference, patientnd data management, and a communication toolhat can be used to enhance their clinical practice.urthermore, the advance of wireless technologyives clinicians access to Internet-based resources,ncluding evidence-based references and web-ased medical databases. In addition, more andore hospital information systems are integrat-
ng mobile technology to offer the convenientnd portable means to access patients’ medicalecords. From the literature, it is evident thatandheld computing is becoming an indispensableool in health care practice.The current PDA adoption rate for physicians is
pproximately 40% in the United States and Canada,nd even more North American nurses are usinghem. As the technology continues to mature andmprove, more use among health care providers isxpected.Wider organizational or institutional adoption is
elatively slow, perhaps because there is still rela-ively little published evidence of a positive impactf handheld computers on patient outcome. Inddition, numerous barriers could discourage PDAdoption by clinicians. These include personal fac-ors (such as age, eyesight, comfort with technologynd device, and concern of over-dependency on theechnology), ineffectiveness of using PDA in clinicalractice (use of PDAs does not improve workflowr process), non-integrated electronic medicalecord, usability barriers (e.g., data entry mecha-
Handheld computers adoption 417
nism, size, weight, screen size, perceived delicacyof the devices), maintenance and security con-cerns, wireless transmission technical problems,negative patient perception, lack of organizationalsupport, inadequate technology, competing tech-nologies, lack of motivation, and insufficient train-ing. While better designed hardware and softwareare more likely to promote greater acceptance andadoption of handheld computers in health care,
Appendix A. Summary of selected articles regarding the use of personal digitalassistants in health care
Usefulness and ease of use
Authors Summary
Garvin et al. Handheld devices were found to be an efficient way to document resident procedures. Mostresidents found the devices easy to use and used them regularly. Eighty percent of theresidents collected data on their handheld device. Those residents who responded to thesurvey (n = 19) indicated that handheld computer was very useful and 73% reported daily use[61].
Kiel The case study shows that electronic prescribing and drug reference applications are easyto install, intuitive, and reliable [75].
Lapinsky et al. Subjects (20 physicians and 6 medical staff) who used handheld devices found them to beggested more comprehensive training and improved searchs inceiase
atioer.icabe
icindemographics, hardware preferencegeneral, trainees reported more frepatient care, while attending physicand for calendar function [83].
Wofford Several advantages of using PDAs inthe handheld computers offer physicprocess. They allow physicians to crto reduce waiting times, paper pilestranscription of clinical documentat
Usability and barriers issuesAl Ubaydli The use of PDAs in health care was r
measures such as not storing sensititaken to address security concerns [
Bergeron It was concluded that the ideal PDAthe main hospital or the clinical datdecision making; and offer messaginnotification [43].
Brody Documenting pharmacists’ clinical ineffective or efficient compared withwas continued interest on the part oplatform for pharmacy students to dSuggestions for similar projects incluexisting programs, and economic im
increasing institutional support and sufficient train-ing could promote more individual adoption of thetechnology. Further investigations of the usabil-ity barriers of mobile computing in health careare recommended to reveal problems so that so-lutions can be proposed. More PDA evaluation stud-ies are also encouraged to explore expanding rolesand clinical impacts of the technology in healthcare.
users’ familiarity with the devices, the introduction ofved [30].suitable for daily use, useful during ICU rounds, and
n of a PDA-based pharmacist intervention system inThe primary benefit of the program was the generationl staff with data relative to physicians’ prescribingnefit was the pharmacists’ ability to download drug
e physicians to examine PDA use prevalence, user
functional and convenient but sufacilities. Despite the differencehandheld technology was well re
Lau Users found the handheld databpreferable to paper forms [82].
Lynx et al. This article describes implementMercy Hospital and Medical Centof reports that provided the medhabits and concerns. The seconddatabases into the PDA [64].
McLeod et al. This study surveyed internal med
s, and setting and application use frequencies. Inquent PDA use in the hospital setting and for directians reported more PDA use in administrative settingsclinical settings are discussed. It was concluded thatians autonomy and flexibility over the documentationeate documents during the process of clinical care, and, and excessive costs associated with dictation andion [84].
eviewed. Security was the biggest concern. However,ve data on PDAs, or using encryption software, could be85].would be pocket-sized; communicate seamlessly withabases; hold enough information to support clinicalg, cellular phone service, paging, and e-mail access and
terventions on PDAs did not appear to be moretraditional documentation methods. However, theref the UA College of Pharmacy in developing a PDAocument their interventions during clinical rotations.ded evaluation of PDA usability, compatibility withplications of future upgrades [78].
418 Y.-C. Lu et al.
Appendix A (Continued )
Usefulness and ease of use
Authors Summary
Criswell and Parchman Two thirds of the US family practice residency programs reported use of handheldcomputers in their residencies (use was mandatory in 30% of the programs). An additional14% of the programs had planned to implement this technology in 24 months. Reportedreasons for discontinuance of PDA use included: (1) lack of interest, (2) lack of support, (3)lack of budget, and (4) too complicated to use [6].
McAlearney et al. This focus group study examined physicians’ perspectives regarding their experiences withPDAs in clinical practice. It was found that doctors who used PDAs in clinical settings weregenerally satisfied with the devices and that patterns of use were diverse. Users perceivedthat the devices helped them increase productivity and improve patient care. Barriers touse included usability issues, such as size and data entry method, personal and perceptualconstraints, such as comfort with the technology, preference for paper, and the perceptionthat the devices were difficult to use. It was suggested by the participants thatorganizations can help promote PDA usage by providing support and training [56].
Monahan Some of the following barriers to PDA use were reported: insufficient memory, short batterylife, small screen size, clumsy options for data entry, and limitations or choices of softwareapplications. Other complaints included slow data transfer speed and the perception ofimproper etiquette in recording data into a PDA in front of the patient [11].
Shiffman et al. This study evaluated clinicians’ satisfaction and frustration with the use of a handheldcomputer system that implemented a childhood asthma management guideline. It wasfound that pediatricians generally appreciated the mobility of the devices. The users weredivided into two groups with regard to the guideline implementation software: those with apositive attitude toward the system and those who were more ambivalent toward it. Mostof the dissatisfactions reported by the second group were related to deficiencies in the user
consistencies and speed of printing), which can be resolved. The most serious complaint was the excessive timeclinical setting [86].iew, interview, observation, focus group, scenario, and userhe potential applicability of new information managementing. It was found that (1) most physicians who had tried they satisfied with the devices; (2) physicians without access tostem or an electronic record were more likely to use thea input was a bottleneck; and (4) physicians preferredompact, had a long battery life, and had a wireless
s that information technology can reduce errors: byvents, by facilitating a more rapid response after an adverseking and providing feedback about adverse events. Datalogy, including handheld computers, could reduce thetypes and probably the frequency of associated adverse
ians use PDAs in their practice. General PDA users wereing, practicing in a non-private setting, in an urbante of medical school. Screen size and system speed wereicians’ PDA adoption [7].ine whether a point-of-care PDA-based patient record ande number of discrepancies in resident progress-notetensive care unit. The system showed an overall reductionrepancies [18].opment of a wireless handheld computer system to preventoutcomes for adolescent patients with persistent severerge-scale randomized trials were suggested to determineping such a system [87].e outcomes after adapting PDA technology to help withreat improvement in reimbursement time—–from an averageed [39].
interface (such as navigation inwith better design of the systemrequired to use the system in a
Sittig et al. Multiple methods (literature revsurvey) were used to evaluate ttechnologies in the clinical setthandheld computers were highla good practice management sydevices for patient care; (3) datdevices that were easy to use, cconnectivity [55].
Adoption and impactsBates and Gawande This article discusses three way
preventing errors and adverse eevent has occurred, and by tracshowed that information technofrequency of errors of differentevents [2].
Carroll and Christakis More than one third of pediatricmore likely to be male, in traincommunity, and a recent graduaidentified as barriers to pediatr
Carroll et al. A study was conducted to examcharting system could reduce thdocumentation in a neonatal in(from 61.7—51.2%) in these disc
Chang et al. This article describes the develemergency visits and to improveasthma. Outcome studies and lathe cost-effectiveness of develo
d’Hemecourt This case study reported positivbilling and reimbursements. A gof 33 days to 1 day—–was report
Handheld computers adoption 419
Appendix A (Continued )
Usefulness and ease of use
Authors Summary
Eastes The experience of one academic level I trauma program in implementing the use of PDAs forpoint-of-care documentation was reported. Generally, the trauma surgeons were pleased withthe project and believed it improved the efficiency of daily rounds and subsequent necessarydocumentations. Interns and nurse practitioners had more time to track and eradicateunnecessary medications and to evaluate patient laboratory results to adjust therapyaccordingly, owing to the elimination of the need to write daily notes [34].
Fischer et al. This study evaluated the feasibility of incorporating handheld computing technology in asurgical residency program, to log surgical procedures through the Internet to a centraldatabase. The survey found that 38% of the subjects were regularly using the procedure-loggingprogram successfully. However, the authors reported that user acceptance was not uniformand thought that continued training and support were necessary to increase acceptance [88].
Fischer et al. A systematic review of articles regarding the use of handheld devices in medicine wasundertaken by the authors, and the current literature was summarized. The authors concludedthat only a small number of articles have evaluated the use of PDAs in medicine. It showedthat handheld computers were being used widely in medicine, and various medicalapplications were discussed. Most publications consisted of reports of clinical experience withthe use of PDAs or innovative uses without significant substantiating data. More uses of PDAsand further evaluation of PDA applications are encouraged [9].
Goldstein et al. This article presents the development and application of a model for access to real-timeinformation at the patient’s side. It was perceived that the computerized data resulting fromthe model would provide valuable information for researchers, clinicians, and administratorsto improve quality, effectiveness, and efficiency in the health care setting [21].
Grasso et al. PDAs were introduced to create and directly print out discharge lists to replace manualge o% to
L s to evaluate whether handheld computers improve thehat, although few studies were available, recent reportsnce suggesting that the devices can facilitate practiceof care. Barriers to PDA adoption were identified [57].
L al effectiveness of two methods of learning evidence-basedproved participants’ educational experience with, although significant improvements were found in all
M tly uses web and wireless technology to give its physiciansilable inside and outside the building. The acceptance ofing staff and faculty has been excellent. However, there areice [89].
R ontribution of a drug database developed for PDAs.ved time during information retrieval (40.6% saved 0—30 ss; 20.8% saved 1—3min); improved practice efficiencyr inpatient practice); increased self-reported drug-related decisions (80.3%); and improved patient care (83%ients; 54% reported more patients satisfaction and 63.1%e drug effects) [38].
R f a handheld-computer-based support system forhis study showed that using handheld computer support forbe a feasible strategy to influence nursing care to be morees and to improve patients’ preference achievement [1].
S s to document pharmacist cognitive services and estimatel claims for pharmacists’ cognitive services documentedillion in 6 months. It was concluded that PDAs could providem for documenting pharmacists’ clinical services and6].
transcription of physicians’ discharmedications were reduced from 22
arkin The author reviewed several studiequality of care. It was concluded tseemed to support anecdotal evidemanagement and improve quality
eung et al. This study compared the educationmedicine. Handheld computers imevidence-based medicine the mostoutcome scores [35].
cShane Cedars Sinai Medical Center currenaccess to clinical records. It is avawireless applications among attendconcerns about security of the dev
othschild et al. This study evaluated the clinical cPhysicians reported ePocrate Rx saper encounter; 29.8% saved 30—60(86.3% for outpatient and 87.1% foknowledge (78.9%); improved drugreported better able to inform patreported reduced potential advers
uland This paper evaluates nurses’ use opreference-based care planning. Tpreference-based care plan couldconsistent with patients’ preferenc
ilva et al. The authors studied the use of PDApotential reimbursement. Potentiawith PDAs totaled more than $1 ma simple, efficient, paperless systegenerating reimbursement claim [2
rders in a psychiatric hospital. Errors involving discharge8% 4 months after PDAs were implemented [4].
420 Y.-C. Lu et al.
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