Nursing Informatics - It's in your Palm
By Robert Eager email@example.com
assistance from Yvonne Stolworthy MSN, RN and Sylvia Suszka-Hildebrandt MSN, RN.
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.
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.
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).
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
These documents then become easy to update, are searchable and most
importantly, are instantly available at the point of care.
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.
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.
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.
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/).
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
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
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
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.
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).
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).
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).
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.
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.
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).