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Nursing Informatics - It's in your Palm

By Robert Eager informatics@cyber-nurse.com

With assistance from Yvonne Stolworthy MSN, RN and Sylvia Suszka-Hildebrandt MSN, RN.

This article was based on research conducted for an on-line forum guest hosted by Yvonne Stolworthy and Sylvia Suszka-Hildebrandt (RNpalm) on 5th Aug. 2000 at the Health Informatics Forum (http://www.cyber-nurse.com/cgi-bin/chats/chat7.cgi) and archived at http://www.cyber-nurse.com/robbie/infolinks/archives/forum01/forum01b-arch.htm.  The author is the volunteer moderator of the forum.


This article looks at the emerging use of handheld computers in the health care arena.  Concentrating on the Palm platform, it reviews current and future capabilities while acknowledging limitations.  Summarizing the current use within commercial areas, the article draws the conclusion that there are similarities to be found in the information flow within health care.  The recommendation is then made, based on current literature, that this is an appropriate and viable alternative to current data gathering practices and a way of bringing information to the point of care.  Finally, the suggestion is made that nurses should involve themselves in the design, development and implementation of software solutions for this platform, thereby not only allowing them a say in how applications are developed, but also in how they work, thereby ensuring that they are of maximum value to the nursing discipline.


When the first handhelds came onto the market, they were capable of little more than storing a few names and addresses.  Today however, the latest devices are capable of much more than this.  The usual memory is between 2 - 8 MB of RAM and processor speed using the Motorola "Dragonball" microprocessor is 33 MHz (http://ebus.mot-sps.com/ProdCat/psp/0,1250,MC68VZ328~M934310090795,00.html#parametrics).  This is comparable with a desktop computer system manufactured only 10 years or less ago.  The newer chips in development promise speeds approaching 1Ghz (http://www.intel.com/design/xscale/benchmarks.htm) and built in video-streaming and wireless connectivity capabilities (http://www.qualcomm.com/cdmatechnologies/about/documents/QCTOverview.pdf).


The PDA (Personal digital assistant) of today, and even more so in the future, is capable of storing large drug databases such as the one produced by ePocrates (http://www.epocrates.com/products/qRx/), running custom-built applications such as the ABG decoder from RNpalm (http://www.rnpalm.com/software.htm) and, through the use of wireless technology, connecting with an intranet (http://www.wavesync.com/system.htm) or mail account (http://www.eudora.com/internetsuite/eudora4palm.html).  Other uses pertinent to nurses include the ability to easily store reference material such as treatment protocols, and procedure manuals, extending to the placement of whole books, as evidenced by the conversion of the Merck manual to Palm format, on handheld devices  (http://www.handheldmed.com/prodmore.php?PRID=22).  These documents then become easy to update, are searchable and most importantly, are instantly available at the point of care.


Entry of data can be achieved through the use of the built-in keypad, the handwriting recognition function (Graffiti) or by connecting to an external keyboard, allowing for the documentation of care given and the updating and maintenance of patient records.  This is accomplished in real time and at the point of care.  Ample evidence exists in the commercial arena for the realization of substantial benefits in terms of decreased documentation time.  From this, a consequent benefit of increased time with the patient as well as reduced costs could be realized.  The health research that has been conducted supports this conclusion.


To get the best use out of these devices, custom applications need to be created specific to the area and type of work to be considered.  This has already started to happen in the medical arena, however nursing specific applications have largely been ignored.  This situation is being addressed by RNpalm (http://www.RNpalm.com) - a consortium of volunteer nurses involved in researching, developing and testing Palm-based, nursing specific applications.


Depending on application requirements, a number of development tools and environments are available.  A significant use for the Palm is database access ability.  In fact, the Palm was specifically created to use databases and all applications are located on a built-in database.  There are a number of database design tools available, one example of this being Pendragon Forms (http://www.pendragon-software.com/forms3/product.html) which allows design of user-interface forms based on Microsoft Access or other ODBC (Open database connectivity) compliant databases.  Database and form design can be done at the desktop and the finished application loaded via serial port, wireless or infrared sychncronization onto the Palm for use.


Another method for application development, is to use traditional programming languages.  At the time of this writing, C/C++, Java and BASIC are supported in a Palm compatible form and it is anticipated that more languages will become available in the near future.  Again, development tools are available, with Metrowerks producing a development kit for C/C++ (http://www.codewarrior.com/products/palm/) and Sun Microsystems a development kit for Java (http://www.sun.com/software/communitysource/j2me/).


A third way in which applications for the Palm might be created, is by the creation of a wireless server and the use of wireless markup language (WML) to create Palm viewable web pages and forms.  A variation of extensible markup language (XML), WML allows data types to be specifically defined.  When based on a wireless server, the utility of the PDA can be combined with the power of server technology and scripting languages such as Perl and VBS (Visual BASIC scripting) can be used to provide server-side input forms and content on the fly.


While the PDA has the potential to provide healthcare information in real time at the point of care, it is acknowledged that there are limitations to be considered.  These limitations can be generalized under the headings of speed and size.


Although the Palm may have a processor speed roughly equivalent to an early 486 desktop computer, with this set to increase substantially in the near future, the developer needs to be aware that this is not a desktop and manipulations that are available for getting around hardware limitations on a desktop, may not be available on the PDA.  For example, swap space is not available as currently no hard-drive is included.  This may change in the future as micro hard-drives become smaller and more available.  An example is the latest IBM micro-drive.  This hard-drive, the "size of an American quarter" (http://www.storage.ibm.com/press/hdd/micro/20000620.htm) currently holds 1GB (Gigabyte).  The current lack of swap space means that poorly designed, "bloated" software will run slowly.  Likewise, overly large databases, although possible, will extract a penalty in both memory availability for other programs as well as in search times.  These limitations require the developer to critically examine the required information to be entered or retrieved, leaving out data which may be superfluous.


Developers are also confined to a display size of 160 x 160 pixels and, while text entry is available as previously mentioned, it should be limited as much as possible, with data entry made using check boxes or drop-down selections where possible to speed up data entry.  While full length text entry is possible, it is slower on the Palm than on paper.  It should be noted however that the author uses his Palm Vx for note taking in class and wrote this paper almost exclusively on it!  Like most things, practice will increase both speed and accuracy.


Modern nursing is increasingly becoming focused on data administration.  Becoming obsessed with ever expanding information availability, in a litigious environment that demands that this information be used, nurses find themselves more often focused on caring for the information than caring for the patient.  This can perhaps best be illustrated in the areas of charting and assessment where the nurse is often required to enter the same data repeatedly, albeit often unnecessarily and usually manually. Martin, Hinds and Felix (1999, 345-352) found that nurses spent an average of 12% of their time performing documentation in their study of documentation practices in a long term setting.  They further identified that nurses needed to complete as many as 12 separate forms during the course of their shift.  This data is often unusable due to problems with legibility, time constraints or the data being simply missing.  These problems were traced directly to the fact that the data needed to be entered manually in the first place.  Martin et al, recommend that "duplicating and time-consuming aspects of the present system for documenting nursing care should also be addressed" and found that, due to missing data, the "level of progress in resolving patients' problems [was not] readily identifiable, nor...their current health status" (1999, 345-352).


Attempts at solving these problems have, to a large degree, been unsatisfactory, often requiring the nurse to leave the patient bedside to enter or retrieve information using a desktop-based system.  This break in real time, point of care, itself causes problems in time management and patient care.  It is obvious that a solution needs to be found; one which allows rapid entry and retrieval of information, allows the nurse to stay at the side of a critically ill patient and allows the information collected to be used by those who need it and integrated into any existing IT (information technology) system.  The Palm handheld is one possible solution.  In fact, Jeff Hawkins the creator of the Palm, had nurses in mind when he invented it, stating that the GRID (the forbear of the Palm) was targeted at "field data collection in warehousing and transportation applications, as well as police, census takers, nurses; essentially anyone who usually used a form to collect data" (Barnett, S. 2000).


The PDA is well established in the commercial arena as an aid to rapid and timely data entry.  Sales representatives use them to document calls made to customers, reference new product information and process new orders.  Managers use them to allocate resources where needed and track warehouse stock levels while stock brokers use them to keep a constant eye on the market.  The principles at work in these settings, can also be applied to the management and utilization of  health care information.  For example, rapid charting and documentation can be done at the point of care, instant referencing of drug information or protocols can be available when needed and bed or resource allocation can be streamlined.  Furthermore, vital information can be made available to the clinician in a timely manner resulting in reduced delays in lifesaving interventions.  Shabot and Lobue for example, developed a system whereby alerts about life-threatening patient conditions could be sent via a satellite relay to a PDA carried by the clinician, resulting in real time alerting of the required staff (1995 pg 174-177).


Another use in health care is in the area of data collection for research.  In a trial of handheld verses traditional pen and paper data collection, Robinson found that the main benefits of using a handheld were; "rapid data analysis" with rapid feedback, "ease of use", "considerable savings in time", "reduction of data input errors" and "capture of qualitatively rich data".  He continues on to suggest that there was a "potential for use in all areas of audit and research data collection" (Robinson D, 1994, pg 127).  Due to the relevant infancy of their use within the health care setting, nurses have a unique opportunity to play an active role in the development and implementation of these devices within the health care setting.  If we choose not to do so, either by action or inaction, we run the risk as a profession of once again having technology thrust upon us, without our consent, knowledge or input.


This paper has looked at the handheld computer and specifically at the Palm system.  Both the capabilities and limitations of the platform have been discussed and the implications these have for development.  Finally, the use of these systems within the commercial arena has been summarized and the conclusion drawn that the principles of a need for  rapid data access, entry and information utilization are just as valid in the health care setting.  This conclusion, supported by the current literature, leads to the recommendation that further research and development is required and that this is an area where nurses have an opportunity to be involved in on the ground floor.



The author is the Chief technical officer (CTO) at RNpalm - an unpaid technical support and development position which he accepted after first approaching RNpalm to guest host the August 5th forum (see above).