Technology, Information & Handhelds Stephen Lapinsky Mount Sinai Hospital & University of Toronto Toronto

One ICU patient generates up to 236 variable categories Morris, Crit Care Clin 1999, 15:523 Humans capable of managing 5 to 9 variables adequately Miller, Psychol Rev 1956, 63:81 Data overload - patient information

 Textbooks  Journal articles  Review articles  Association Guidelines  Hospital protocols  Pharmaceutical company information  Electronic Medical literature Data overload - reference information

Data overload - communicating info

 Evaluation of New Technologies in Medicine Information Access in Critical Care

Automated Paging Alert System  Software agent scans hospital database  Filters: eg.  Location = ICU  Hgb < 70 g/L or 20% drop  Generates automated page  Ongoing evaluation: - time to intervention - satisfaction: physician nurse

Digital Wireless Area Network  IEEE b Wireless LAN at 11 Mb/s  Wireless cart allowing bedside access to:  hospital system (eg. labs)  PACS radiology images  Internet searches  Order entry  Teaching  Potential for:  video transmission  wireless handhelds  wearable computers

Handheld Computers

Roles for Handheld computers access to patient information tracking patient symptoms, signs tracking patient symptoms, signs access to medical reference information access to medical reference information tracking educational experience tracking educational experience research data entry research data entry scheduling, contacts scheduling, contacts non-synchronous communication non-synchronous communication

Roles for Handheld computers D Roles for Handheld computers Demonstration

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

 Data entry & transfer:  on admission  update on rounds  IR beaming between staff  Reports  Daily report  Discharge summary  IR beam to HP Laserjet 6P Methods

Results Evaluation of Palm Computers in Critical Care  6 month study period: June - November 1999  24 palm handheld users (84 user-months):  3 Focus group meetings at 2 month intervals

Results Evaluation of Palm Computers in Critical Care  Physical attributes of Palm IIIx  Patient Management database  Medical reference database  Suggestions: hardware & software  Suggestions: process

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

Methods  Paper database: Critical Care Handbook of the Massachussetts General Hospital Study 2 Comparison of paper & electronic databases

Methods  Paper database: Critical Care Handbook of the Massachussetts General Hospital  Palm database: Electronic version of the Mass Gen handbook Mount Sinai ICU handbook Searchable database Treatment guidelines Comparison of paper & electronic databases

Methods  Crossover study: 3 weeks control (paper), 3 weeks handheld  Subjective assessment: Survey, interview  Objective assessment: Test clinical ICU scenarios, time-constrained Standardized on a separate group of trainees  Results: No significant difference But: Palm could carry 5x the data Comparison of paper & electronic databases

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

Surgical Procedure Logging System  69 General Surgery residents  Data entry on Palm  Internet download of procedure data

Reports Allow evaluation of - individual trainees - teachers - hospitals - trainee years - etc Surgical Procedure Logging System

ICU Procedure Logging System

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

 Comparison of features & content  Pharmacopoeias  Mobile Micromedex  Epocrates qRx  Dr. Drugs  A2Z Drugs  Lexi-Drugs  Moby Drugs & Interactions  PDR Comparison of Handheld Pharmacopoeias Results: Essential parameters: - Physicians identified 9 - Pharmacists identified 14 Content: A2Z9/913/14 Functionality Cost Updates

Evaluation of Palm Computers in Critical Care  Study 1: Qualitative evaluation of handheld computers in the ICU  Study 2:Comparison between “paper” and electronic medical reference database  Study 3: Evaluation of Surgical Procedure logging using handheld devices  Study 4: Evaluation of handheld Pharmacopoeias  Study 5: Ontario Critical Care Information Network

Dr. B. Kashin Dr. H. Clasky Dr. T. Rogovein Dr. D. McRitchie Dr. S. Lapinsky Dr. T. Stewart Dr. R. Wax Dr. S. Fischer

INFORMATION DATABASE content determined by user’s needs evidence-based management guidelines regularly updated according to feedback Internet Synchronisation from office, home, ICU Palm Handheld Reference Resource mobile, point-of-care access to medical information optimal formatting to facilitate rapid data retrieval hyperlinked text, tables, images, calculators online feedback re: content, format

 Does the handheld resource work? - videotaped "think aloud" analysis of the technology in action  Do community intensivists find the content and technology helpful? content and technology helpful? - Surveys downloaded to users’ handhelds - Moderated focus group meetings  Does the network improve resource use? - Clinician performance pre/post with a computer-controlled human simulator - Comparison of ICU mortality, duration of mechanical ventilation and length of stay, patient transfers Evaluation

Acknowledgments Current studies supported by: