Critical Care Plus-Handheld Computers Making Life Easier in the ICU

Mini-Computers are Becoming a Doctor’s Best Friend

By Julie Crawshaw

Frank s. becker, md, assistant professor of medicine and a pulmonary and critical care physician at Northwestern University in Chicago, used to laugh at people who carried palmtop computers. "Then a friend lent me his PalmPilot and within 10 days I became completely addicted," he says.

Becker now owns his own Palm, and he says it assists him with his "normal life" as well as with his practice of medicine. "When I’m in the intensive care unit, I don’t have access to my calendar or my patient list. Now I use my PalmPilot as my away-from-the office-database."

Becker observes that critical care medicine before the miniature computer revolution involved carrying around books with tables, equations, and lists of side effects, many of which are now accessible from his handheld device.

"In the ICU, we used multiple drugs, all of which have potential interactions," Becker says. Formerly, physicians had to look up the side effects and interactions in hard copy reference material. "Now," he adds, "when we’re on rounds and a question arises about using a drug in a patient with a certain condition, everybody immediately whips out their PalmPilot and looks up the answer."

The PalmPilot uses ePocrates qRX software, which provides physicians with information on more than 1600 drugs. Updated versions of the data can be periodically downloaded in the small device.

Another program Becker has downloaded is Medmath, a free downloadable application for medical equations. "When I used to carry a calculator to figure parameters like cardiac outputs, I’d look up the equation and try to do the hand calculations. There was always potential for hitting the wrong key and entering data that gave you the wrong answer."

With the Medmath system, Becker enters the data and the software automatically does the calculations. In addition to a lower potential for error, Becker thinks critical care physicians are doing more calculating these days. "Because it’s easier to do an AA gradient, people will do it," Becker says. They’ll do a cardiac output calculation as a quality control measure to see if the reading they’re getting on their Swan-Ganz catheter is accurate."

Medmath currently has the following formulas:

• A-a O2 Gradient

• Absolute Neutrophil Count

• Anion Gap (Serum)

• Anion Gap (Urine)

• Basal Energy Expenditure

• Body Mass Index

Body Surface Area (Dubois)

Cockcroft-Gault Equation

Corrected QT (QTc)

Corrected Serum Calcium

Corrected Serum Phenytoin

Corrected Serum Sodium

Creatinine Clearance

Fractional Excretion of Sodium

Henderson-Hasselbalch Equation

Hepatitis Discriminant Function

Ideal Body Weight

Mean Arterial Pressure

Osmolality (Serum)

Osmotic Gap (Stool)

Reticulocyte Index

Transtubular Potassium Gradient

Water Deficit

Winters’ Formula

Becker estimates between 80-90% of physicians in his division use a Palm V. "Some of the Medmath programs can be downloaded from the Internet to your main computer and hot sync to the Palm, which will upload them," Becker says. "I got some of my programs from the infrared beaming, in which you point your Palm at somebody else’s Palm that’s got a program you like, hit a button, and the Palm with the program beams to the other Palm."

Becker syncs both at home and at work so all his computers are always up to date. "Let’s say I enter some data on my home computer and the next day I do something at my work computer that involves the Palm software," he says. "When I put the palm device into the cradle and hit the button it will update everything, so that the most recent entry takes precedence over the prior ones. My address book, my schedule at home, and what’s in my palmtop will be the same as what’s in my office computer."

Many Palmtop Applications are Free

Writing in the Internet Journal of Anesthesiology,1 J. Garman, MD, MS, notes that many of the downloadable software applications for the PalmPilot are free and almost all of them feature a free trial period.

He observes that though there are several drug programs available, physicians might as well get the free ePocrates first. The program takes up 0.9 MB and the developers of the website promise to keep the database current. "One good thing about this drug database is the ability to add your own notes to the drug entries. I am using it now and highly recommend it,"Garman says.

Another drug and drug interaction database Garman lists is Apothecarium (www.skyscape.com/k2). This contains both LexiDrugs (1.7 MB) and Interact (1.0 MB) and sells for $110. This program, if fully installed, will take up 2.7 MB of memory. It is a complete drug and drug-interaction database that is easy to use. You can also buy the LexiDrugs database alone at the same site for $70. Garman considers AvantGo, a program that allows you to automatically download updated information from various web sites, to be one of the most exciting developments for handhelds. Avant’s list of downloadable sites is growing quickly, and synchronizing a Palm with a desktop computer, AvantGo automatically makes the newest information current while deleting the old.

Other free downloadable medical applications many palmtop users have found extremely useful include Tarascon, a drug resource found at Medscape, and Medcalc, which has some equations Medmath does not.

Additional handheld applications web sites commonly recommended are:

Synapsesoft, Inc., features ProcLog and Rounder procedure and patient tracking software, both of which are integrated on the same database structure to eliminate duplicate data entry for the Palm platform;

Pen Computer Solutions designs, programs, and integrates custom medical software applications for the PalmPilot, Palm III, IIIx, V, VII, and Symbol SPT 1500;

• e-MedTools medical software works for PalmPilot and Win95/98 and has several titles related to evidence-based medicine, microbiology, medical records, and common calculations;

PocketMD software, which enables a simplified and sophisticated patient database management system for students and physicians that includes 700+ drug database as a component of the program;

ePhysician enables health care professionals to order lab tests and prescriptions and can provide mobile access to patient information;

Medical Communication Systems produces Mobile MedData, which is a patient information manager application for the PalmPilot;

Handheldmed.com is a virtual community that is designed to help physicians, medical students, and other health care professionals that covers medical uses for both Windows CE and PalmOS devices and includes forums, software archives, and reviews; and

MobileMed Forum is a forum for Newton, PalmPC, PalmPilot, Windows CE, PSION, and other applications of medical mobile computer technologies.

Critical Care Physicians in Forefront

David Main, a partner in the health care group of the Washington, DC-based law practice of Shaw Pittman, says that physicians are generally slow to take advantage of new technology that changes their methods of practice. He finds an exception to this in critical care. As an example, Main points to the fact that many critical care physicians have used the Apache system and have had handheld devices for many years.

Violet Shaffer, Apache Systems chief operating officer, defines her company as a scientific and medical decision support company. "We provide information that helps physicians and nurses both predict patients’ risk and better manage high-risk patients." Shaffer says that physicians with a palmtop device can enter patient data and access a display about that patient’s risk.

"It gives information about the patient’s risk for ICU length of stay and hospital mortality, upon admission and then daily, which helps to manage the ICU more effectively." Shaffer says the information Apache provides is frequently used to inform patients and their families about progress and risk that lends comfort and helps them make necessary decisions.

Apache’s products range in cost from a few thousand dollars to six digit figures. All are routinely updated. "We continuously revalidate our science," says Shaffer. "Predictive equations need to keep up with medical practice."

Quick Date Means Good Decisions

More memory has bumped the information access benefits of palmtops, which completely outstrips their data-entry features. Richard H. Savel, MD, critical care fellow at the University of California and a hospitalist at St. Luke’s Hospital in San Francisco, Calif., has a long-standing interest in medical informatics and wanted to see what palm computers potential was to help physicians at bedside.

Savel says that he started using a palmtop to get rid of the little cards he had to carry around on all of his patients. "It worked but was difficult to use," Savel says. "It just wasn’t as fast as scribbling something on a piece of paper."

Like Becker, Savel uses ePocrates. "It’s very exciting to use a computer for something it can do well, which is storing data. I see patients from all over the country and they come in taking drugs prescribed for them elsewhere. I need to make sure those drugs don’t interfere with each other." Savel observes that because the screen set on the PalmPilot is so small, a lot of thought has to be put into how the data is retrieved by the physician.

"I had some experience with this when I was a resident involved in medical informatics at Cornell Medical Center. The thing I like about the PalmPilot is that information retrieval is instantaneous."

Savel sees free palmtop applications as posing a potential problem for physicians. "If it’s free, who’s subsidizing it?" he asks. "If it’s being paid for by a drug company, then it’s important that be explicitly revealed. The physician has to know that any information retrieved is unbiased."