Untapped power: A physician's handheld

Richard Raborn, MD, a solo internist in Boynton Beach, Fla., is like a lot of physicians when it comes to his personal digital assistant. Since shelling out $400 for a Treo 600 from palmOne in spring 2004, Dr. Raborn has used the handheld device primarily as a communication rather than an office productivity tool.

"It's more of a phone and little bit of a reference tool to look up [physicians' and patients'] names, addresses, faxes and phone numbers," Dr. Raborn said.

He wants to use it for more clinical tasks eventually, but "I haven't had enough time to really do what I want to do with it," Dr. Raborn said, explaining that converting his practice into a concierge practice consumed most of his attention and energy in 2004.

When handheld devices hit the market, many experts predicted that physicians, even those who weren't early adopters of computers and health technology, would quickly find use for a device that seemed to fit right into their busy lives, their need to have access to information and their constant mobility.

And those predictions were correct. About 40% of practicing physicians owned a personal digital assistant in 2004, up from 19% in 2001 and more than four times greater than the overall percentage rate of consumer adoption, said Mark Bard, president of Manhattan Research LLC, a market research company in New York.

But the other end of those predictions hasn't held up -- that physicians would find PDAs useful as a clinical tool. Although physician adoption of PDAs in the past four years soared for various reasons, the devices have yet to come close to being used for their fullest potential in medicine.

Cost and lack of connectivity of PDAs with electronic medical records and physician practice management software systems are major deterrents keeping doctors from using the devices professionally. But there are others. PDAs are touted as useful for e-prescribing, but most pharmacies can't accept electronic prescriptions yet. The devices have a small screen and short battery life. In some cases, a lack of training and awareness of how PDAs can benefit physicians professionally, and a perception among some physicians that PDAs offer limited functionality, also pose barriers, industry observers say.

At this point, most doctors who own PDAs use them for personal rather than professional purposes. And when they use PDAs professionally, they typically use the devices to access drug and medical references, scheduling applications, and, to a much smaller extent, billing and prescribing systems.

Even those who use PDAs still gravitate to the good old-fashioned paper and pen, if that way appears to work more quickly than an electronic device.

"It's a combination of a cultural issue and technology [limitation], said Scott Tiazkun, program manager of U.S. health care information technology at IDC, a market research company in Framingham, Mass. Paper and pen are "the way [physicians] have done business in the past, and the technology is not compelling enough for them to change their way of doing business."

Going mobile

But some new developments are under way that could drive physicians to use and take advantage of what PDAs have to offer. For example, PDAs are evolving into a new class of mobile computing devices known as smart phones. Those devices combine cell phone functionality with the personal organizer functions -- address book, date book and to-do lists -- offered by other PDAs.

"You're kind of seeing saturation in the market for what was historically defined as a PDA," Bard said. Smart phones will continue to evolve into new mobile computing devices that will become more computer-like, easier to use and still fit in your hand or pocket, he said.

"These next-generation mobile devices will open up the field of mobile health to a new generation of physicians, including the ones who held out based on the limited value -- in their opinion -- delivered by current offerings," Bard said.

D. Bart Sills, MD, a family physician at a three-doctor family practice in Fort Smith, Ark., agrees that the new devices and their enhanced functionality will appeal to physicians who don't use PDAs in the office now.

He has noticed substantial improvement in the devices since 1999. "Since I first started using a Palm, the thing that has become amazing is the amount of memory that's become available," Dr. Sills said. For example, there are plug-in cards that make it easier to access a greater amount of information. So he uses a drug database and a medical reference on his PDA, as well as using the device for writing prescriptions. "I hardly even use any [hard copy] reference now because I have so many references available on my Palm."

Dr. Sills also keeps notes whenever patients contact him when he is on call, accumulating more than 1,000 call notes to date. "Quite honestly, I think most physicians would say that's needless work, but if it saves me one lawsuit or keeps me from losing a lawsuit, I think it will be worth it," Dr. Sills said.

Although physicians say PDAs have a lot of room for improvement, the devices still can provide immediate help if doctors take the time to learn how to use them and what handheld medical applications are out there, Dr. Sills said.

"When you buy a Palm off the shelf, it has very few things loaded into there except for the address book function, date book function and a few other things," Dr. Sills said.

"It's maybe not as intuitive as it should be. ... I have evolved the set of tools that I use over the last five years. It was not something that someone walked up to me and said, 'This is what you need to have. You need to have this, this, this and this.' I read a lot, I research a lot, I get a lot of things off the Internet, my listservs and things like that. So what I'm doing maybe is more than a lot of doctors are willing to do -- investing in time."

Doing more with more

While Dr. Sills is a PDA power user, Dr. Raborn is at the opposite end of the spectrum and knows he could be doing a lot more with his Treo 600 smart phone.

But now that he has trimmed his practice from 3,000 patients to 400 patients through the conversion to a concierge practice, he intends to take advantage of his smart phone.

For example, Dr. Raborn plans to store comprehensive patient physicals and consultant reports in PDF form on a memory card that he can insert into and access on the Treo, he said.

He also plans to download a medical drug reference onto his device because he had used one for years before upgrading from a PDA to a smart phone. "I do miss all the pharmaceutical help I got" on previous PDAs, he said.

Furthermore, he plans to write prescriptions electronically, because he believes that will take less time than calling a pharmacy or writing multiple prescriptions for a patient by hand, Dr. Raborn said.

That attitude is on the rise, helping boost usage of PDAs in physician offices, some say. "What I've seen in the last few years has been an increasing number [of physicians] using it," Dr. Sills said. "I really think every doctor I talk to, if they don't have [a PDA], is thinking about getting one."

Another factor that also will boost PDAs is that medical schools nationwide are increasingly requiring their use. As medical students and residents go into private practice, PDAs will be more widely used in physician offices, said Scott M. Strayer, MD, a family physician, assistant professor of family medicine and health evaluation sciences at the University of Virginia. He also is owner of PocketMed, a Charlottesville, Va., company that sells a handheld-based charge capture software to physicians.

Linking the PDA

As several health care organizations publish their research on handheld devices in coming months, doctors will become more educated about their usefulness, Dr. Strayer said.

For example, the Robert Wood Johnson Foundation is funding Prescription for Health, a multimillion-dollar research initiative. The health care philanthropy has funded 17 projects designed to improve counseling on unhealthy patient behaviors. Several of those projects involve PDA use.

"We still have a lot to learn as to how best to use those things in practice, but I think once that occurs and there's more outcomes-based data, then there could be an even larger swell [of physician adoption]," Dr. Strayer said.

The federal government's and industry's current focus on making electronic medical records more affordable and helping physicians implement them also will lift PDA adoption, experts say. Most EMRs aren't integrated with practice management systems, and data in those systems can't be accessed via PDAs, making physicians reluctant to use either EMRs or handheld devices in the office, Dr. Strayer said.

"As the pressure builds for efficiency, safety and EMRs, that is in turn going to drive a lot of the PDA adoption," Dr. Strayer believes, especially as the government, insurers and others in the industry offer financial incentives to entice doctors to implement clinical information technology. "I think over the next 10 years, all these forces will come together, and the funding will be there."