Hand-held Computers in Geriatric Patient Care

I opened the door of my hospital locker and bent down to retrieve my AST 80386 laptop computer, equipped with 2 megabytes memory and a speedy 2400 baud modem. I looked again. It was gone! I thought about the Dilbert® cartoon where a company bought its workers laptop computers but then bolted them to their desks to prevent theft. Rather than swearing off mobile computing, I moved in a radical new direction. I bought a Newton Message Pad hand-held computer as soon as it came out in 1993.

Demographics

I am a general internist with a subspecialty in geriatrics and a clinical instructor at Northwestern University Medical School. Most of my time is devoted to my private practice with the Harbor Medical Group, an internal medicine practice in Chicago. We have two office locations and have admitting privileges at three area hospitals. In addition, I follow patients at two nursing homes. I'm always on the go.

Problem

I first became interested in computers in order to help organize my nursing home practice. The nursing home patients are very sick and often wind up in the emergency department. Late at night I found it difficult to remember details about their medical history. Was the atrial fibrillation new or old? What was the code status? What were the allergies? My first concern was having access to basic patient data outside the nursing home.

Nursing home medical records can be awful. Each time patients go out to the hospital they get new charts. The old records are difficult to obtain and are usually locked in the basement of the nursing home. For me, writing an admission note was a nightmare. Did the patient have a pneumococcal vaccine? Did I have all the diagnoses? Was the PPD positive last year? I needed access to this same data in the nursing home. To speed charting, I also wanted to have this data in a computerized form, so I wouldn't have to keep writing the same thing over and over again. I could just update the history and physical form with new data as needed.

Approach

I first used DOS-, then Windows-based, computers to create a nursing home database. I printed up a form for each patient, put one copy in the nursing home chart, and kept another in a notebook in my briefcase. When the fun of creating the database was over, the work of keeping it updated became tedious. My office staff was too busy to update the data, and after my laptop was stolen, it became impossible for me to keep up.

The Newton hand-held computer has several advantages over a laptop. First because it fits in my lab coat pocket, it goes where I go. Its four AA batteries last for over 2 weeks. It is easy to use at the bedside and on rounds in the hospital because it turns on in seconds and opens in the place you left off. It doesn't have to boot up and load Windows or other software. It has a pen interface that recognizes handwriting, so patients aren't intimidated when they see me using the device.

My first thought was to use the Newton as a front end to my Windows database. The first versions of the connection software were slow and hard to use. I quickly discovered that I didn't need my data on a desktop machine. The Newton gave me instant access to what I needed to know and I had enough memory to hold all the patients I wanted, plus appointments, address book, notes, and even a medical calculator.

As I was starting to use the Newton in 1994 and 1995, the Internet became a part of my computer use as well. The first Newton patient tracking program I used was MedNotes, written by John Burch. I downloaded a demo, (which was fully functional) from America Online's PDA (Personal Digital Assistant) forum. I had some questions, so I called the company. To my surprise John was very responsive to my suggestions. In a few days he e-mailed me new version of the software, incorporating the changes I had suggested. I started to beta test the software and had some influence on many of its features as it was developed. Through the Internet I was able to try new software and talk to other doctors using the Newton in their practices. I subscribe to a moderated mailing list, NewtMed, that links doctors, software developers and Newton Inc. (formerly part of Apple Computer).

My new Newton Message Pad 2000 is 10 times faster than my first Newton. It has more memory, and the handwriting recognition is excellent. I am using Palmedic patient tracking software for tracking my nursing home and inpatients (Figure 1). Palmetic's developer, J. Rick Adams, is an intern in the Internal Medicine program at Michigan State. Palmedic is simpler than Pocket Chart and Virtual Intern, the most popular patient management packages, but it does what I need. I am not using the Newton to write progress notes, which require the production of templates. Templates are useful for notes that, like x-ray reports, use the same language over and again. I just haven't found the time to create templates for my patients.

Results

I have begun to use the Newton to declutter my life of useless bits of paper. If I am on call I can jot a quick note to my office utilization manager about an HMO patient who was seen in the emergency department. I have software called Paperback that can take any text file on my PC and create a Newton book. I typed up the Northwestern Anticoagulation Guidelines, and now if I get a call about a protime I can instantly respond with the correct dose of warfarin or vitamin K.

I can go online and download Web pages. The most common use for this is to help decide what immunizations are needed for travel to exotic locations. In minutes I can plug my Newton into a phone outlet and download the information I need from the Centers for Disease Control and Prevention. I can even hand the computer to the patients and let them browse through the page.

One day I read an article in The Journal of the American Medical Association about "Emergency Contraception". It contained information on how to use common oral contraceptives to prevent pregnancy with in 72 hours of intercourse. Before I had the computer I would have ripped the article out and filed it away. The article referenced a web site maintained by Princeton University's Office of Population Research. I used my Newton to log in and then saved the page to cache. I can look up the information any time off line using the built in web browser. Any Internet web page or electronic mail message can be saved this way. I have lists of new HIV drugs, including drug interactions from the University of California at San Francisco's HIV Insite.

The newest use for my Newton is to write prescriptions. It takes a little longer than writing them out by hand but the advantages outweigh the few minutes extra it takes. Imagine a prescription pad remembers the spelling, SIGs, and doses of every drug you used. Then imagine it remembering the address and phone number, allergies, and all of the previous drugs prescribed for all of your patients. You can see how useful it can be. The software I use is called EZRX, written by Dr. Ralph Potkin. (Figure 2) I tap out the prescriptions in the exam room, then print them at the check-out desk in my office. I review the printed script for accuracy and then sign it and give it to the patient. I could fax or E-mail the prescriptions directly to the pharmacy but they don't yet have the capability to receive them. Writing prescriptions with the computer is so much fun I hate to write them by hand anymore. The prescriptions are readable and are less likely to result in errors.

The prescription writing module has become a mini electronic medical record. I use the phone numbers in the database to call these same patients about their lab tests a few days after their visit. I can replace a lost set of prescriptions in a few seconds without having to look for the chart.

Another idea I have is to have different managed care formularies on the Newton then the formulary that matched the HMO could be used to avoid the patient and myself from being hassled by the HMO's pharmacy management company. I was able to do this for Blue Cross HMO, but since I had a 95 percent compliance rate with the formulary before getting the Newton it makes little difference to me. If the HMO bought Newtons for all of the doctors in the network, then it may achieve a cost savings.

In the future I would like to use wireless features which would make the Newton an even more natural computer to use in the exam room or at the bedside. If the Newton could talk to my office billing computer or the hospital computer, then I could have access to information while talking with the patient or on call.

My partners don't have Newtons yet. They are waiting for me to work out all the bugs first. I have found that only by first having the computer can you develop new and interesting ways to use it. Some of us physicians must take the plunge, and then the computers and software will evolve to meet our needs.