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Guest Editorial
Psychiatry, Technology, and the Corn Fields of Iowa
Harry Karlinsky
(PDF)

In Review
The Internet’s Impact on the Practice of Psychiatry
Rima Styra
(PDF)

Clinical and Educational Telepsychiatry Applications: A Review
Donald M Hilty, Shayna L Marks, Doug Urness, Peter M Yellowlees, Thomas S Nesbitt
(PDF)

Portable Computing in Psychiatry
John Luo
(PDF)

Original Research
Assessing and Monitoring Antipsychotic-Induced Movement Disorders in Hospitalized Patients: A Cautionary Study
Leonardo Cortese, Mandar Jog, T Jeffrey McAuley, V Kotteda, Giuseppe Costa
(PDF)

Sociodemographic Factors Associated With Comorbid Major Depressive Episodes and Alcohol Dependence in the General Population
JianLi Wang, Nady El-Guebaly
(PDF)

Delineating the Population Served by a Mobile Crisis Team: Organizing Diversity
Janet Landeen, Julie Pawlick, Steven Rolfe, Ian Cottee, Melanie Holmes
(PDF)

Detecting Women at Risk for Postnatal Depression Using the Edinburgh Postnatal Depression Scale at 2 to 3 Days Postpartum
Frédérique Teissèdre, Henri Chabrol
(PDF)

Review Paper
Ethics in Psychiatric Research: Study Design Issues
Gordon DuVal
(PDF)

Brief Communication
The Prevalence of Psychological Morbidity in West Bank Palestinian Children
Tanya L Zakrison, Amira Shahen, Shaban Mortaja, Paul A Hamel
(PDF)

Book Reviews
(PDF)

Beyond Technique in Solution Focused Therapy.
Reviewed by
Llewellyn W Joseph, MD, FRCPC

The Epidemiology of Schizophrenia.
Reviewed by
Mary V Seeman, MD

The Private Self.
Reviewed by
Paul Ian Steinberg, MD, FRCPC

Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical Care.
Reviewed by
Gilbert Pinard, MD, FRCPC

Pharmacogenetics of Psychotropic Drugs.
Reviewed by
Gustavo Turecki MD PhD

Psychotherapy and Counselling in Practice. A Narrative Framework.
Reviewed by
Paul KB Dagg

Oedipus and Beyond: A Clinical Theory.
Reviewed by
Paul Ian Steinberg, MD, FRCPC

Letters to the Editor
(PDF)

Modafinil Treatment of Excessive Sedation Associated With Divalproex Sodium

Ziprasidone in Parkinson’s Disease Psychosis

Combined Oral Venlafaxine and Intravenous Clomipramine-A: Successful Temporary Response in a Patient With Extremely Refractory Depression

Doxepin Increases Serum Cholesterol Levels

Re: Suicide: The Persisting Challenge

Reply: Suicide: The Persisting Challenge

Depression and a History of Alcoholism

Gains in Speeded Information Processing Following Clozapine Treatment of Schizophrenia

Problems With Crystallizing Phenomenology and Nosology in Adolescent Psychiatry

Serotonin Syndrome With Prolonged Dysphagia

In Review

Portable Computing in Psychiatry

John Luo, MD¹

It has been over a decade since personal digital assistants (PDAs), or handheld computers, were introduced in the early 1990s. At that time, these devices offered only basic functions, such as a calendar, an address book, and a to-do list. With increasing computer power, memory, and several additional functions, PDAs are now a mainstay in the practice of medicine. Although the medical literature on PDA use has increased dramatically in recent years, few articles exist on their use in psychiatry. Perhaps psychiatrists have yet to embrace this new technology because they do not understand how helpful these devices can be. This article reviews the many capabilities of these devices in the practice of medicine.

History

The early PDA devices, such as the Casio Business Online Scheduling System (Casio BOSS), had limited memory and input methods. They did not offer more than a paper-based personal information manager. With the development of software that could be installed on the device, the Apple Newton MessagePad and eMate provided more capability. However, the Newton’s rather large size and poor recognition of handwriting were significant shortcomings. These devices were not widely adopted by either the general public or the medical community. Palm Computing deserves credit for starting the phenomenon with the introduction of the Palm Pilot in 1996. This well-designed device was small, easy to use, could backup information on the desktop computer, and offered character recognition.

Currently, there are several devices available in different operating systems. Just as desktop computing power improves dramatically each year, PDAs have increasing capabilities: sharper screens, more powerful processors, and external memory. Some devices even have built-in cameras, MP3 players, cellular phone service, and wireless Internet capability.

Today, most PDAs are based on either the Palm operating system (Palm OS) or the Pocket PC operating system (starting in 2003, it has been changed to Windows Mobile). Devices running Linux operating systems are available, but they are not popular for medical use and are only suitable for physicians who can write their own software. Palm had the luxury of being the market leader but has seen its market share shrink as devices with the Pocket PC operating system have become just as affordable as the Palm OS devices (Table 1).

Several factors should be considered prior to choosing a PDA (1). Processor speed, internal memory, type of external memory card, screen size, weight, and battery life are just some of the important hardware specifications to evaluate. Most medical software has been developed for the Palm OS; however, more software developers are now developing medical applications for the Pocket PC. It is important for first-time buyers to determine with whom they will be exchanging data and to what computer systems they will be connecting. Novice users may want to attend a class such as those offered at the Annual Meeting of the American Psychiatric Association or by a local computer retailer. All users should learn how to back up data on their computer via synchronization. The synchronization procedure installs new software and manages data between the desktop and the PDA. Other resources for learning about how to use a PDA include CD-ROM instruction guides (for example, see www.powerbyhand.com), Internet discussion forums (for example, Brighthand at see www.brighthand.com and the PalmInfocenter at www.palminfocenter.com), and books (Table 2).

General Uses

The basic organizer functions of the PDA lend themselves well to just about any psychiatric practice. The calendar or date book can set up regularly scheduled appointments and prevent double booking. Reminder alarms provide prompts for appointments, and the ability to attach notes provides additional information at a glance. One advantage is that administrative assistants can use Microsoft Outlook to schedule appointments that will appear in the PDA upon synchronization. Numerous software programs can provide organizational tools in addition to the calendar.

Other basic functions of the PDA include a to-do list, an address book, and a memo section. These basic organizational features can be used to store patient information, referral sources, task lists, and short notes. They appear to be sufficient for most psychiatrists, but additional software offering many more options can be installed.

Document Editing

Documentation of psychiatric encounters is primarily text-based and needs very few figures and graphs. PDAs are therefore practical for creating documents (2). Other medical specialties usually document a significant amount of additional information, such as laboratory results and trends, drawings or pictures of lesions or injuries, and figures that may require more sophisticated software. Several years ago, document editing on PDAs was limited to a specific format that required several steps for conversion to popular office applications (3). Now, Microsoft Word documents can be easily edited on PDAs and synchronized to desktop computers.

Although the small screen size of PDAs is a drawback, their portability assists convenient document editing in various locations on the hospital ward. With regard to actual text entry, most PDAs use an onscreen keyboard or standardized character recognition. However, these integrated methods are slow, and text entry is best done using a collapsible, but full-size, keyboard. Capturing a voice file is an alternative available to those using Pocket PC devices. Here, a voice message is uploaded and transcribed by software such as Dragon NaturallySpeaking. Voice recognition on the PDA itself is not quite ready, although it will likely be more robust in the near future. Pocket PC devices also offer voice command to read schedules and run applications while driving.

Databases or Spreadsheets

It is handy to store patient encounters in databases or spreadsheets, which are then uploaded to the desktop computer. This information can be used to generate billing lists or, in training, to document patient encounters. The Department of Psychiatry at the University of California, Davis, is currently using a PDA with a system that organizes the consultation service and captures information on patients seen by the resident physicians. Indeed, PDA-based patient tracking has become popular in many residency training programs (4,5). For example, Grasso and Genest describe how a PDA medication- information database has led to decreased medication error rates (6).

Presentations

One of the newest PDA innovations is their ability to deliver PowerPoint presentations (7). A 6-oz PDA is much lighter and more portable than a 6-lb notebook computer and delivers a sharp presentation. Today’s PDAs have greater hardware capabilities and more software features and are able to sort and hide slides, display speaker notes, and allow limited transition effects. That said, this capability requires the purchase of additional hardware and software, and editing slide content must still be done on desktop or notebook computers.

E-mail

PDA wireless capabilities have improved with advances in the availability of public Internet access. Several years ago, e-mail access was limited to slow speeds. Today, with increasing public wireless network “hot spots” (also known as “Wi-fi”), access is more widespread and faster. Even Web-browsing software has improved graphic capability and improved use of the small screen available. Many companies offer server technology with specialized data parsing and formatting for PDAs that assists access to documents, databases, and other information.

Medical Uses

Patient Tracking
As described above, PDAs can manage patient data in various ways. For individual users, it has been sufficient to use the built-in PDA functions (8) or a PDA-based database or spreadsheet program. Primary care physicians and other specialists have used customized software to track patient information; examples include Patient Tracker (www.handheldmed.com) or Medical Pocketchart (www.gemedicalsystems.com). For psychiatrists, patient-information managers specific to mental health include Virtual Briefcase-Psych (www.thevirtualbriefcase.com) and Pocket Psychiatry (www.ddhsoftware.com).

In the past, these software programs were designed for single users. Now, many products integrate with such existing hospital information systems as Patient Keeper (www.patientkeeper.com). These systems serve as a bridge to parse data for viewing on the handheld platform.

With the development of wireless local area network (LAN) access in hospitals, a newer trend is to use the PDA as a terminal to access the medical information system. Cedars-Sinai Hospital in Los Angeles, California, uses the Palm VII and newer devices to wirelessly and securely access the clinical information depository from any location (9).

Medical Texts
Previously, PDAs had limited and unsatisfactory capacity to carry and read medical information. As recently as 2000, these devices did not have colour, and it was difficult to read information on monochrome screens. Similarly, they did not have much internal memory. Consequently, only a limited amount of information could be stored: the most medical information available at that time comprised tables and clinical pearls entered into spreadsheets and portable document formats (PDFs) found on Memoware (www.memoware.com) (3).

PDAs today benefit from brighter colour screens, faster processors, and the ability to access external memory. Many pocket guides can now be accessed with PDAs, including the DSM-IV-TR and the 5-Minute Clinical Consult (10). This contrasts happily with the past, when resident physicians and students had to carry numerous pocket guides on rotation or on call. Now, their lab coats need no longer be burdened with several pounds of portable guides: they can be replaced with a PDA carrying electronic versions. This portability is an advantage for physicians on the move, especially in the inpatient setting.

Most medical texts are available from several publishers via proprietary reader programs. Content publishers such as American Psychiatric Publishing and Lippincott Williams and Wilkins have partnered with companies such as Skyscape (www.skyscape.com) and HandheldMed (www.handheldmed.com) to distribute their texts using their reader software.

Currently, many Web sites have helpful medical information; however, only a small (but growing) number of hospitals have wireless Internet access. Nevertheless, even without an active Internet connection, information can be captured in several ways for viewing on PDAs at the point of care. Avantgo (www.avantgo.com) is a popular off-line Web site viewing program. Further, many companies have created channels or specific Web pages with abridged content designed for viewing on PDAs, including several journal publications. This information is updated whenever the PDA is synchronized with a desktop computer and active Internet connection. In a similar fashion, iSiloX (www.isiloX.com) and Plucker (www.plkr.org)—both of which are free programs—also provide off-line viewing of Web sites. These programs work by using desktop-based software to condense and save relevant Web pages for viewing on the PDA. The iSilo viewer must be purchased to use the hyperlink capability, but it has the advantage of supporting many document types, especially those found on Memoware. Another option is to capture Web sites using Adobe Acrobat (www.adobe.com). Most physicians are familiar with this software, because many journals provide Adobe Acrobat PDF versions of articles for download to view on the computer or to print, but few are aware that Adobe also offers a free Adobe PDF Reader for the Palm and Pocket PC PDA. This reader requires a desktop program to adapt the PDF document for PDA viewing.

Drug Reference Guides
By far the most popular medical use of the PDA is to access drug reference guides (11). PDAs are well suited to this task, providing salient information at one’s fingertips. For example, ePocrates RX, one of the more popular drug reference guides, has been downloaded by more than 250 000 physicians and 500 000 users since it was made available in November 1999. Drug guides provide information on adult, geriatric, renal, and pediatric dosages; on common side effects, drug interactions, contraindications, and metabolism; on pricing; and on pregnancy impact (12). Physicians surveyed on-line reported that ePocrates saved time in the practice of medicine, increased drug knowledge, and contributed to drug-related decision making (13). Many drug-reference guides also provide information on their formulary availability, which helps physicians know when to contact drug benefit programs or seek patient-assistance programs from pharmaceutical manufacturers. However, most of these references carry the US brand name, although DrDrug and Lexi-Drugs Platinum offer Canadian brand names and availability (14). An advantage of a PDA-based guide is that its information can be regularly updated from the Internet. In addition, many software programs also offer interactive drug-interaction guides, which may facilitate warnings to patients about potential toxicity.

Medical Education
PDAs are quite popular with medical students and resident physicians. In 2001, the University of South Dakota School of Medicine became the first school of medicine to require palm handhelds for first-year medical students (15). Medical students at the UCLA School of Medicine are required to purchase a PDA. The school uses PDAs to distribute such information as emergency guidelines and clinical rotation handbooks from its Web site via an AvantGo M-Business Server. In addition, the school collects a log of patient encounters from each student’s PDA, as well as clerkship and faculty evaluations (16). Using PDAs also maximizes patient contact reports, since these devices can go to all clinical settings (17). Further, additional software can be installed, providing reference materials to be accessed during training (18). At Georgetown University School of Medicine, clinical pearls written on PDAS by students are part of the collaborative learning model and encourage integration of classroom material (19). Classrooms themselves are also a venue wherein PDAs enrich the learning experience. At Stanford University School of Medicine, students answer survey questions during lectures that include real-time compilation of results for discussion (20).

Residency training programs are also increasingly implementing PDAs. For example, the program directors of all American Academy of Family Physicians (AAFP) and American College of Osteopathic Family Physicians (ACOPF) residency programs in the US were surveyed; two-thirds of the 50% who responded indicated that they already used handheld devices in their residency program, and 14% indicated that they planned to introduce PDAs in the following 24 months (21). The University of California at Davis Psychiatry Residency Training Program has been a pioneer in using PDAs (22). PDAs are used for electronic sign-out and in the consultation service, for documentation and medical applications (2,8).

To assess how trainees are being exposed to different spheres of their specialty, the University of British Columbia Division of Urology developed a PDA-based system that documents all clinical and academic activities of urology residents. Customized pick lists allow residents to document all their activities, which are synchronized into a central database on a stand-alone server. Such information as location, diagnosis, and type of activity are recorded, allowing the training director to determine areas of curriculum weakness (23). Similarly, third-year medical students at the Indiana University School of Medicine and the Medical College of Wisconsin used a PDA to track their exposure to basic clinical skills, an exercise that highlighted significant gaps in this area (24,25).

Prescription Writing
Electronic prescribing has been touted as a potentially essential PDA tool. It has been suggested that sending prescriptions from handheld computers would decrease time spent and avoid prescription errors (26): illegible prescriptions and transcription errors would be avoided with machine text and transmissions via either wireless networks or fax. However, this market has not done well because the relevant companies, such as ePhysician, ScanRX, and Parkstone, no longer exist. Two other companies, iScribe (www.iscribe.com) and PocketScript (www.pocketscript.com), are under new ownership and appear to offer newly designed software. A research study on the impact of PDAs on medication errors is ongoing, funded by the Agency for Healthcare Research and Quality (27). When completed, it may offer compelling data that support changing existing prescribing methods.

Research
PDAs’ portability and customized software make them helpful in data collection. Data can be entered either by physicians or by patients who, in a study by Tseng, preferred handheld devices over desktop computers (28). In that study, self-rating scales on mood and “computer anxiety” demonstrated that anxiety related to using a PDA did not affect visual search time, when compared with use of a desktop computer.

Clinical trials increasingly use PDAs to collect data on adverse reactions to medications being tested (16). In one study, the total time needed for data collection on a PDA, with transfer to a computer, was 23% faster than that needed to record data by hand and showed 58% fewer errors (29). Remote data collection infrastructure can be set up with the existing cellular phone network. This system transmits clinical trial information using wireless markup language and has the potential to provide almost real-time data collection at the point of service via PDA or cellular phone (30).

In a related issue, PDAs are also used to collect medical history data at the point of service. A comparison of acute pain assessment on paper vs PDA demonstrated that PDAs were more likely to contain complete documentation regarding pain and side effects and that the overall encounter time was shorter (31). Goldstein illustrates PDA mobility for real-time collection of data on pain and disability in the operating suite, in the office, and in the hospital (32). Even patients use PDAs to track medical history in the form of electronic diaries (33); patients with rapid-cycling bipolar disorder are using PDAs to transmit mood-related data wirelessly to a centralized database (34). Biometric monitoring devices such as blood pressure cuffs, scales, pulse oximeters, and spirometers can be linked to a PDA to transmit data via the Internet or modem (35).

Data capturing can be as simple as using the PDA’s built-in features, such as the memopad. Alternatively, with the development of handheld databases using mobileDB (www.handmark.com) or HanDbase (www.ddhsoftware.com), it can be more complex. For large-scale data collection, a more robust solution is to develop applications with form software, such as Pendragon Forms (www.pendragonsoftware.com) or Satellite Forms (www.pumatech.com/sf_mad_main.html). These programs synchronize data collected on the PDA with desktop databases, such as Microsoft Access, for analysis. Larger-scale database vendors such as iAnywhere (www.ianywhere.com) also offer mobile database solutions integrated with such device- management and enterprise-level collaboration and communication software as Microsoft Exchange.

Psychiatry-Specific Applications
PDAs have several applications specific to mental health. The Mini-Mental Status Examination (MMSE), a common screening tool for dementia, can be conducted with prompts from a Palm OS PDA (Table 3). Several psychiatry reference texts, including the DSM-IV TR, are available at Skyscape (www.skyscape.com), PDAMD (www.pdamd.com), or Handheldmed (www.handheldmed.com).

Various diagnosis-assistance pearls for the Palm OS are available at PocketPsych (www.pocketpsych.com/Resources/ downloads.htm) and Memoware (www.memoware.com). Medical Piloteer (www.medicalpiloteer.com) sells a program called PsychDx that summarizes the DSM-IV TR criteria in a structured format. This site also offers DepressQ and ManiaQ, which are checklist-based programs for the Palm OS that assist in diagnosing mood disorders. There are no specific mental disorder diagnosis programs for the Pocket PC, but DiagnosisPro from Medtech (www.medicalamazon.com) offers differential diagnoses based on different signs and symptom entries. MedRevu (www.meddrevu.com) offers Psychiatry Recall, which has diagnosis and treatment information designed for medical students. Compendica (www.compendica.com) has a psychiatry specialty module for its Palm OS-based SpeedReader reference tool. This module covers epidemiology, history and examination findings, diagnostic information, therapeutic information, and patient information. The American Psychiatric Association practice guidelines are available at Handheldmed (www.handheldmed.com).

With the increasing awareness of complications secondary to psychotropic medication use, various medical calculators and medical resources are helpful. The National Heart, Lung, and Blood Institute (NHLBI) has developed a calculator of body mass index, clinical guidelines on overweight and obesity in adults, and adult-treatment panel cholesterol management guidelines (http://hin.nhlbi.nih.gov/palmapps.htm). Medical calculators can also check absolute neutrophil count and corrected QT interval. Medcalc (medcalc.med-ia.net/desc.html) is a well-known calculator available for free, but only in the Palm OS. Kent Willyard, MD, lists various medical calculators for the Palm OS (http://pbrain.hypermart.net/ medapps.html) and the Pocket PC (www.medicalpocketpc.com/software/calculator.shtml).

Security
Those using PDAs must take into account security measures related to its portability, especially in regard to sensitive mental health information. The Health Information Portability and Accountability Act (HIPAA) of 1996 was developed to improve the efficiency and effectiveness of electronic information, but it is better known as the mandate for protecting health information in the US. Steiner describes how PDAs have enhanced point-of-care access to health information but carry significant risk because they can be lost, stolen, broken, or used fraudulently (36). Pancoast observes that physicians who download patient information have ultimate responsibility for safeguarding its confidentiality and describes how the requirement to track the use of information stored in physician PDAs can be avoided by carefully defining the HIPAA- designated record set (37).

Several existing mechanisms protect information on the PDA. Password protection is a simple method to prevent access to the device, but security should also include the use of encryption software such as PDASecure (www.trustdigital.com) or PDADefense (www.pdadefense.com). An advantage of using these packages is that specific protected health information can be encrypted, leaving medical reference texts and other applications alone. Using coded patient identifiers (17) or the last 10 digits of patient social security numbers is another strategy (38). A key element of PDA security is the ability to automatically lock out after a defined period of inactivity. Passwords are often forgotten, but such alternative methods as signatures, button combinations, and numeric keypads exist.

Discussion

PDA use in medicine has dramatically increased in recent years, with more literature published every year. The Arizona Health Sciences Library no longer maintains a bibliography of PDAs in health literature (http://educ.ahsl.arizona.edu/pda/art.htm) because the National Library of Medicine has added “computers, handheld” to MeSH terms available in Medline. This makes it easier to search for articles on this growing topic.

In discussion, one of the cofounders of the popular ePocrates RX program said that he felt psychiatrists have yet to join the trend to PDA use, as suggested by the low numbers registering to use this software (personal communication, J Tangney, 2003). It may be that the small number of PDA articles published in psychiatric journals also reflects this and indicates either limited PDA needs or a lack of interest among psychiatrists. However, the large numbers of psychiatrists who attend workshops and courses at the American Psychiatric Association Annual Meetings suggest that interest does exist.

One of the issues is that, although more software and newer hardware are available, they may not be yet optimized for the medical environment (39). Technological limitations such as their fragility, small size, and lack of voice recognition restrict their usefulness. In particular, lack of integration with the myriad information systems available today, as well as lack of connectivity options, limits their implementation. Human factors also make it difficult to implement new technology, and advance preparation is needed to ensure that technology solves “real-world problems” with “room to grow” (40).

Nevertheless, the growing capability and number of PDAs in the consumer and medical sectors indicate that these devices are here to stay. Wireless technologies such as “wireless LAN” and “Bluetooth” enhance the usability of PDAs with easy access to hospital information systems (41). These technologies are steps toward convergence, where all information needed by physicians arrives on a device with seamless access to the main information system. This concept represents one of the situations in which PDAs would enjoy more system- wide implementation (39).

Conclusion

PDAs are increasingly able to support to busy physicians managing complex information in the practice of medicine. Medical literature describing successful implementation of these devices is increasing every year. With the improving software interfaces and greater hardware capacity in a small form, the mobile computer will become the essential tool in medicine.

References

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Author(s)

Received and accepted September 2003.

1. Assistant Clinical Professor of Psychiatry, UCLA Neuropsychiatric Institute and Hospital, Los Angeles, California.

Address for correspondence: Dr J Luo, UCLA Neuropsychiatric Institute and Hospital, 760 Westwood Plaza, Los Angeles, CA 90024

e-mail: jsluo@mednet.ucla.edu

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