David Rovner, MD

Family physicians generate many questions as they care for their patients.^1-3 Some are urgent information needs (“What is the dose of naloxone for an infant with respiratory depression?”); some are important but less urgent (“How do I interpret a negative troponin blood test result in a patient with chest pain?”); and others represent expressions of curiosity or frustration (“Why did this patient develop asthma late in life?”).

Unfortunately, physicians who want to answer their questions in time to have an impact on patient care face several barriers. These include the unavailability of high-quality medical information at the point of care and a lack of time. Both are especially problematic for family physicians who have less time with each patient than do consultants. They also practice in a variety of environments: office, hospital bedside, emergency department, nursing home, and house call. Although Sackett and Straus⁴ have described an “evidence cart” with a computer and references that is pushed through the hospital while on rounds, this is expensive and impractical for most physicians and does not solve the problem of access to information at multiple locations.

One solution is to put medical references on a hand-held computer (Table 1). These devices have become very popular among a wide variety of professionals and are characterized by:

• light weight (5 to 17 oz)
• immediate start-up and shutdown
• relatively low cost ($300 to $1000)
• high durability with few or no moving parts
• long battery life (7 to 30 hours)
• a natural pen-based interface that is similar to a clipboard or chart

These characteristics make hand-held computers a good fit for the demanding medical environment. There are drawbacks, however, such as:

• slower microprocessors
• less memory for storage
• a small screen that may be hard to read in bright sunlight, low-light conditions, or both
• no keyboard or a small keyboard that may make typing difficult

A previous article⁵ examined the advantages and drawbacks of hand-held computers for physicians. Recent advances in technology have begun to address some of the drawbacks and have made these units even more useful for physicians. The newest models have 16 to 32 megabytes for storage, color screens, and a full suite of programs. They also have faster processors than the earliergeneration of hand-held computers, and although not as fast as desktop computers, they now provide quicker performance for most programs. Also, some units now have keyboards that allow touch-typing, although this comes at the price of increased size and decreased portability.

In this article we describe the latest generation of hand-held computer hardware. We also describe the medical software available, including both record and reference software.

Computers without keyboards

Palm Computers

Palm computers (Figure 1) are highly compact and measure 3.2 inches wide by 4.7 inches in height and weigh 6 ounces. The screen displays 4 shades of gray and measures 160 by 160 pixels. All Palm computers provide an excellent battery life of 20 to 30 hours’ continuous use. Most users enter text with a built-in handwriting-recognition software program called Graffiti. The letters and numerals are very close to standard script; most people need 20 to 30 minutes to learn the anomalies. An on-screen keyboard can also be used for inputting data.

The Palm III is the basic model and has 2 MB of memory. It has a built-in flip-top, and an infrared port allows it to communicate with other Palm computers. The screen can be backlit for low-light applications. The Palm IIIx features an improved screen that is easier to view in low-light situations. It also has an expansion slot for accessories such as pager and memory cards, supports synchronization with networks and Microsoft Outlook, and comes with 4 MB of memory built in.

The Palm V is even thinner (only 0.4 inches) and sleeker than previous Palm units. It has 2 MB of random-access memory (RAM), a rechargeable lithium ion battery, and the same improved screen as the Palm IIIx. The Palm VII was recently released. In addition to all of the functionality of the Palm III, it offers 2-way wireless access to the Internet through Palm.Net (www.palm.net). This network is designed around the BellSouth Wireless Data network to provide extensive coverage and customer support. Although it will not allow full Web browsing, it will enable users to download “Web clips,” such as stock quotes, directions to the nearest automated teller machine, weather reports, travel directions, and E-mail. The Palm VII costs approximately $600, and the Palm.Net service is $10 per month for the most basic level of service. It is only available in selected metropolitan areas.

All models use the Palm operating system and come loaded with these applications: date book, address book, to do list, memo pad, and calculator. The most current versions also support E-mail and basic Internet capabilities, although the optional modem costs an additional $120 and clips onto the bottom of the unit, increasing its size and weight and decreasing the battery life. Infrared transmission of data between devices (beaming) is also possible and is a built-in feature. In addition to the built-in applications, the user can add third-party software to the Palm. These software applications allow it to exchange information with many popular programs, including Lotus Notes, Meeting Maker, Act!, and Microsoft Outlook.

The ability to load information on a Palm computer is partially determined by the model. For example, the Palm III has 2 megabytes (MB) of RAM and a capacity for 6000 addresses, 3000 appointments, 1500 to-do items, 1500 memos, and 200 E-mail messages. Average users can add more than 25 third-party applications. With 4 MB of RAM, the Palm IIIx has approximately double the capacity of the Palm III. The less data stored, the more applications or programs can be installed. The size of the third-party applications used on the Palm will also influence the total number that can be installed. Application sizes can range from less than 1 to more than 100 kilobytes. If a user runs out of memory, the Palm III, IIIx, and V are all upgradable to 8 MB.

The Palm computer comes equipped with a docking cradle that attaches to a Windows-based personal computer (PC) or a Macintosh for data transfers using a HotSync session. The cradle allows easy synchronization of information between the PC and the Palm computer. Software that mirrors the Palm’s capabilities on the desktop computer is included with the product. This software allows users to edit or create data on the desktop computer and then transfer them to the Palm.

Windows CE Palm-Size PCs

Palm-size PCs (Figure 2) run the Windows CE operating system from Microsoft. Made by several different manufacturers, they are all slightly larger and heavier than the Palm III computer and use a variety of microprocessors. However, they all easily fit into a pocket. Palm-size PCs have a larger screen than the Palm units (320 by 240 pixels), and most units have color screens. Some of the newer models also have stereo headphone jacks for replaying MP3 audio files (including the Casio E-100 and E-105), and all have a compact flash slot for expansion. This can be used for additional memory (units come with 4 MB to 32 MB of RAM), and the newer units are shielded so a paging card can be inserted. However, these extra capabilities decrease the battery life to only 7 to 14 hours.

The Windows CE operating system is less efficient than the Palm and requires more memory. Thus, 4 MB on the Palm stores about the same number of programs as 16 MB on the Windows CE unit. Palm-size PCs come with the standard organizer software (address book, calendar, task list, and notepad). Pocket Streets (a street atlas program with detailed city maps) is available free online at the Microsoft site. Users who own Microsoft Streets 2000 can create custom street-level maps of any part of the country; a 20-by-20-mile square takes about 0.5 MB of memory. DeLorme Company has a similar product for the Palm computer that can link to a Global Positioning System receiver. Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT but cannot connect to desktop computers running the Macintosh operating system

Computers with keyboards

Windows CE Hand-held PC/Hand-held PC Pro

This is a heterogeneous group of hand-held computers. All run the Windows CE operating system; all have a keyboard; and they tend to have more memory and faster processors than their cousins the Palm-size PCs. The quality of the keyboard varies considerably, though. Some units (such as the Velo 500, Hewlett Packard 320, and Hewlett Packard 660) have small “chicklet” style keys that are only suitable for hunt-and-peck typing. Some of the newer units have keyboards that are between 76% (Hewlett Packard Jornada 680) and 90% (NEC MobilePro 770 or 800) of the size of a desktop keyboard and are more useful for touch-typists (Figure 3). All units now have color screens, and the screen size of hand-held PCs varies from 640 x 240 pixels in the more compact units to 640 x 480 and even 800 x 600 pixels in some of the larger units. The former typically weigh around 1 to 1.5 pounds, while the latter weigh 2 to 3 pounds and are really closer to subnotebooks in size. Most manufacturers of the hand-held PC now also have a model with a color screen.

Hand-held PCs come with an excellent selection of built-in software, including Pocket versions of Microsoft Word, Excel, Access, and PowerPoint. They all have a built-in modem and include Pocket Internet Explorer for Web browsing and an InBox program for E-mail. Pocket Streets can be downloaded at no charge, and as with the Palm-size PCs, users can create their own street-level maps if they have Microsoft Streets 2000. Manufacturers also bundle a variety of other programs, such as expense managers and Pocket Quicken with these units (Table 2).

Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT, so exchanging documents is as easy as dragging and dropping an icon on the computer’s desktop. Although the Pocket versions of the Microsoft Office applications use a file format different from the desktop versions to save space, translation occurs automatically as files are transferred from the desktop computer to hand-held computer and back. Although hand-held PCs cannot connect to desktop computers running the Macintosh operating system, they can connect to Macintoshes running an emulation of Windows as long as the user has a serial to parallel cable.

This category includes 2 interesting computers for the health care environment, the Sharp Tri-Pad and the Vadem Clio. These units open like a miniature laptop, revealing a nearly full-size keyboardand 640 x 480 color screen. However, the screen can flip around, concealing the keyboard and turning the unit into a tablet-style pen computer. The latter is particularly useful for environments like the office, where the large screen and long battery life make it a good unit to consider for electronic medical record applications.

Psion

The Psion is a very compact hand-held computer with an excellent keyboard for its size and a very long battery life (20-30 hours). It has a backlit 640-by-240 pixel screen that displays 16 shades of gray. It runs the EPOC operating system and can connect to both Windows and Macintosh desktop computers. The Psion comes with a full suite of software, including word processor, spreadsheet, database, and programming language. Although it is the most popular hand-held computer in Great Britain, the Psion has never achieved popularity in the United States, and the amount of medical software available is somewhat limited.

Choosing a hand-held computer

Which hand-held computer should a physician choose? There is no single answer. The best hand-held computer depends on individual budget and needs. If only a basic organizer is needed, the Palm IIIx is an excellent choice. If the user wants to be able to listen to music, recorded books, and other multimedia content, the Casio E-100 or 105 is a better choice. If the user will be doing a lot of touch-typing and using the hand-held PC as a partial replacement for a desktop or laptop computer, the NEC MobilePro 770 has a terrific screen and keyboard (although the larger size makes it less mobile). Finally, if the user wants the convenience of a keyboard, built-in modem, and Internet support and a highly portable device that fits in the pocket of a white coat, the Hewlett Packard Jornada 680 is an excellent value. One other caveat: For those using Apple computers, the best choice is a Palm or Psion unit since the Windows CE units do not communicate well with the Macintosh operating system (Table 3).

Hand-held computer software

All hand-held computers come with a broad array of software. Although not specifically designed for medical use, they can be easily adapted by motivated physicians. For example, the address book can be used to keep a list of patients, colleagues, and consultants; the task/to-do list can be used as a “scut list”, and the calendar can be used for office and patient scheduling. In fact, a member of the Information Technology Department for the Michigan State University Health Team has written a program that takes the patient appointment schedules from our mainframe computer and synchronizes them with the Microsoft Outlook calendars on our desktop computers. When I synchronize my hand-held computer, it updates my calendar, and I can view my clinic schedule from anywhere. For those of us who have difficulty keeping everything in our heads, this device can help keep life and practice in order.

The notepad software in all hand-held computers can be used to track key information about inpatients, which can then be beamed using infrared to other members of the inpatient team. It can also replace the “pearls book” developed by many physicians. Some physicians keep summaries of commonly used practice guidelines, advanced cardiac life support protocols, Mini-Mental State Examination questions, minimal criteria for diagnosis of various conditions, or commonly used drugs. The advantage over a paper version is that it can be kept up-to-date more easily and can readily be shared with colleagues who also have hand-held computers.

Database software comes with some hand-held computers and can be purchased as third-party add-on software for others. Many computer-literate physicians are using database programs to develop their own customized medical applications. For example, physicians can create databases of their patients, with key information such as current medications and diagnoses

We have summarized general-purpose software in Table 4, and medical software for hand-held computers in Table 5. Table 6 includes a list of Web sites for users of handheld computers, including sites that are focused on medical applications. Below, we briefly discuss some medical applications for each platform. The purpose of this section is not to review these software items but rather to make the user aware that they exist.

Palm OS

MedData, Raphael, and PocketChart are all basic medical record systems. Although all 3 packages have some limitations over desktop systems because of size and memory limitations, they offer a remarkably complete set of features. Medical references available for the Palm include the 5-Minute Clinical Consult and the Lexidrugs Drug Information Handbook. In addition, many Palm users have created their own references and collections of pearls. A good source for these is the Palm Central site (www.palmcentral.com) or one of the other Palm sites listed in Table 6.

Windows CE Operating System

Although the number of medical software applications for the Windows CE OS is small, it is growing rapidly. PocketChart is a fully-functional electronic medical record that can either run as a stand-alone program on a single Windows CE unit or be linked using wireless modems to a central server. K2 Medical makes several medical reference applications, including an extensive drug database (Lexicomp), an internal medicine reference (Outlines in Clinical Medicine), and a medical calculator (Archimedes). InfoPOEMs has released a Windows CE version of its InfoRetriever software that contains a variety of evidence-based sources of information, basic drug information, summaries of guidelines, and clinical rules and calculators.

Another option for Windows CE users is to run a program called Citrix WinFrame. This allows users to access and run (usually through a wireless modem) programs and data that reside on a central server computer. This expands the number of electronic medical record programs that can be run on the Windows CE hand-held computer.

EPOC Operating System (Psion)

There is one medical record package available, called MedPalm. It is full-featured and can share information with a desktop computer. We were unable to identify any medical reference software for the Psion, although this may change in the future.

Conclusions

Hand-held computers are finally achieving the combination of price, power, and portability to make them a useful tool. Physicians in particular stand to benefit from their use, and according to Microsoft, half of all Windows CE devices have been purchased by health care professionals. This is a good time to take the plunge and make it possible to access vital information whenever and wherever it is needed.

Acknowledgements

Work on this article was supported by a grant from the American Academy of Family Physicians to establish the Michigan Consortium for Family Practice Research and by a Generalist Physician Faculty Award from the Robert Wood Johnson Foundation. Dr Ebell is author of the InfoRetriever software and profits from its sale.

Family physicians generate many questions as they care for their patients.^1-3 Some are urgent information needs (“What is the dose of naloxone for an infant with respiratory depression?”); some are important but less urgent (“How do I interpret a negative troponin blood test result in a patient with chest pain?”); and others represent expressions of curiosity or frustration (“Why did this patient develop asthma late in life?”).

Unfortunately, physicians who want to answer their questions in time to have an impact on patient care face several barriers. These include the unavailability of high-quality medical information at the point of care and a lack of time. Both are especially problematic for family physicians who have less time with each patient than do consultants. They also practice in a variety of environments: office, hospital bedside, emergency department, nursing home, and house call. Although Sackett and Straus⁴ have described an “evidence cart” with a computer and references that is pushed through the hospital while on rounds, this is expensive and impractical for most physicians and does not solve the problem of access to information at multiple locations.

One solution is to put medical references on a hand-held computer (Table 1). These devices have become very popular among a wide variety of professionals and are characterized by:

• light weight (5 to 17 oz)
• immediate start-up and shutdown
• relatively low cost ($300 to $1000)
• high durability with few or no moving parts
• long battery life (7 to 30 hours)
• a natural pen-based interface that is similar to a clipboard or chart

These characteristics make hand-held computers a good fit for the demanding medical environment. There are drawbacks, however, such as:

• slower microprocessors
• less memory for storage
• a small screen that may be hard to read in bright sunlight, low-light conditions, or both
• no keyboard or a small keyboard that may make typing difficult

A previous article⁵ examined the advantages and drawbacks of hand-held computers for physicians. Recent advances in technology have begun to address some of the drawbacks and have made these units even more useful for physicians. The newest models have 16 to 32 megabytes for storage, color screens, and a full suite of programs. They also have faster processors than the earliergeneration of hand-held computers, and although not as fast as desktop computers, they now provide quicker performance for most programs. Also, some units now have keyboards that allow touch-typing, although this comes at the price of increased size and decreased portability.

In this article we describe the latest generation of hand-held computer hardware. We also describe the medical software available, including both record and reference software.

Computers without keyboards

Palm Computers

Palm computers (Figure 1) are highly compact and measure 3.2 inches wide by 4.7 inches in height and weigh 6 ounces. The screen displays 4 shades of gray and measures 160 by 160 pixels. All Palm computers provide an excellent battery life of 20 to 30 hours’ continuous use. Most users enter text with a built-in handwriting-recognition software program called Graffiti. The letters and numerals are very close to standard script; most people need 20 to 30 minutes to learn the anomalies. An on-screen keyboard can also be used for inputting data.

The Palm III is the basic model and has 2 MB of memory. It has a built-in flip-top, and an infrared port allows it to communicate with other Palm computers. The screen can be backlit for low-light applications. The Palm IIIx features an improved screen that is easier to view in low-light situations. It also has an expansion slot for accessories such as pager and memory cards, supports synchronization with networks and Microsoft Outlook, and comes with 4 MB of memory built in.

The Palm V is even thinner (only 0.4 inches) and sleeker than previous Palm units. It has 2 MB of random-access memory (RAM), a rechargeable lithium ion battery, and the same improved screen as the Palm IIIx. The Palm VII was recently released. In addition to all of the functionality of the Palm III, it offers 2-way wireless access to the Internet through Palm.Net (www.palm.net). This network is designed around the BellSouth Wireless Data network to provide extensive coverage and customer support. Although it will not allow full Web browsing, it will enable users to download “Web clips,” such as stock quotes, directions to the nearest automated teller machine, weather reports, travel directions, and E-mail. The Palm VII costs approximately $600, and the Palm.Net service is $10 per month for the most basic level of service. It is only available in selected metropolitan areas.

All models use the Palm operating system and come loaded with these applications: date book, address book, to do list, memo pad, and calculator. The most current versions also support E-mail and basic Internet capabilities, although the optional modem costs an additional $120 and clips onto the bottom of the unit, increasing its size and weight and decreasing the battery life. Infrared transmission of data between devices (beaming) is also possible and is a built-in feature. In addition to the built-in applications, the user can add third-party software to the Palm. These software applications allow it to exchange information with many popular programs, including Lotus Notes, Meeting Maker, Act!, and Microsoft Outlook.

The ability to load information on a Palm computer is partially determined by the model. For example, the Palm III has 2 megabytes (MB) of RAM and a capacity for 6000 addresses, 3000 appointments, 1500 to-do items, 1500 memos, and 200 E-mail messages. Average users can add more than 25 third-party applications. With 4 MB of RAM, the Palm IIIx has approximately double the capacity of the Palm III. The less data stored, the more applications or programs can be installed. The size of the third-party applications used on the Palm will also influence the total number that can be installed. Application sizes can range from less than 1 to more than 100 kilobytes. If a user runs out of memory, the Palm III, IIIx, and V are all upgradable to 8 MB.

The Palm computer comes equipped with a docking cradle that attaches to a Windows-based personal computer (PC) or a Macintosh for data transfers using a HotSync session. The cradle allows easy synchronization of information between the PC and the Palm computer. Software that mirrors the Palm’s capabilities on the desktop computer is included with the product. This software allows users to edit or create data on the desktop computer and then transfer them to the Palm.

Windows CE Palm-Size PCs

Palm-size PCs (Figure 2) run the Windows CE operating system from Microsoft. Made by several different manufacturers, they are all slightly larger and heavier than the Palm III computer and use a variety of microprocessors. However, they all easily fit into a pocket. Palm-size PCs have a larger screen than the Palm units (320 by 240 pixels), and most units have color screens. Some of the newer models also have stereo headphone jacks for replaying MP3 audio files (including the Casio E-100 and E-105), and all have a compact flash slot for expansion. This can be used for additional memory (units come with 4 MB to 32 MB of RAM), and the newer units are shielded so a paging card can be inserted. However, these extra capabilities decrease the battery life to only 7 to 14 hours.

The Windows CE operating system is less efficient than the Palm and requires more memory. Thus, 4 MB on the Palm stores about the same number of programs as 16 MB on the Windows CE unit. Palm-size PCs come with the standard organizer software (address book, calendar, task list, and notepad). Pocket Streets (a street atlas program with detailed city maps) is available free online at the Microsoft site. Users who own Microsoft Streets 2000 can create custom street-level maps of any part of the country; a 20-by-20-mile square takes about 0.5 MB of memory. DeLorme Company has a similar product for the Palm computer that can link to a Global Positioning System receiver. Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT but cannot connect to desktop computers running the Macintosh operating system

Computers with keyboards

Windows CE Hand-held PC/Hand-held PC Pro

This is a heterogeneous group of hand-held computers. All run the Windows CE operating system; all have a keyboard; and they tend to have more memory and faster processors than their cousins the Palm-size PCs. The quality of the keyboard varies considerably, though. Some units (such as the Velo 500, Hewlett Packard 320, and Hewlett Packard 660) have small “chicklet” style keys that are only suitable for hunt-and-peck typing. Some of the newer units have keyboards that are between 76% (Hewlett Packard Jornada 680) and 90% (NEC MobilePro 770 or 800) of the size of a desktop keyboard and are more useful for touch-typists (Figure 3). All units now have color screens, and the screen size of hand-held PCs varies from 640 x 240 pixels in the more compact units to 640 x 480 and even 800 x 600 pixels in some of the larger units. The former typically weigh around 1 to 1.5 pounds, while the latter weigh 2 to 3 pounds and are really closer to subnotebooks in size. Most manufacturers of the hand-held PC now also have a model with a color screen.

Hand-held PCs come with an excellent selection of built-in software, including Pocket versions of Microsoft Word, Excel, Access, and PowerPoint. They all have a built-in modem and include Pocket Internet Explorer for Web browsing and an InBox program for E-mail. Pocket Streets can be downloaded at no charge, and as with the Palm-size PCs, users can create their own street-level maps if they have Microsoft Streets 2000. Manufacturers also bundle a variety of other programs, such as expense managers and Pocket Quicken with these units (Table 2).

Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT, so exchanging documents is as easy as dragging and dropping an icon on the computer’s desktop. Although the Pocket versions of the Microsoft Office applications use a file format different from the desktop versions to save space, translation occurs automatically as files are transferred from the desktop computer to hand-held computer and back. Although hand-held PCs cannot connect to desktop computers running the Macintosh operating system, they can connect to Macintoshes running an emulation of Windows as long as the user has a serial to parallel cable.

This category includes 2 interesting computers for the health care environment, the Sharp Tri-Pad and the Vadem Clio. These units open like a miniature laptop, revealing a nearly full-size keyboardand 640 x 480 color screen. However, the screen can flip around, concealing the keyboard and turning the unit into a tablet-style pen computer. The latter is particularly useful for environments like the office, where the large screen and long battery life make it a good unit to consider for electronic medical record applications.

Psion

The Psion is a very compact hand-held computer with an excellent keyboard for its size and a very long battery life (20-30 hours). It has a backlit 640-by-240 pixel screen that displays 16 shades of gray. It runs the EPOC operating system and can connect to both Windows and Macintosh desktop computers. The Psion comes with a full suite of software, including word processor, spreadsheet, database, and programming language. Although it is the most popular hand-held computer in Great Britain, the Psion has never achieved popularity in the United States, and the amount of medical software available is somewhat limited.

Choosing a hand-held computer

Which hand-held computer should a physician choose? There is no single answer. The best hand-held computer depends on individual budget and needs. If only a basic organizer is needed, the Palm IIIx is an excellent choice. If the user wants to be able to listen to music, recorded books, and other multimedia content, the Casio E-100 or 105 is a better choice. If the user will be doing a lot of touch-typing and using the hand-held PC as a partial replacement for a desktop or laptop computer, the NEC MobilePro 770 has a terrific screen and keyboard (although the larger size makes it less mobile). Finally, if the user wants the convenience of a keyboard, built-in modem, and Internet support and a highly portable device that fits in the pocket of a white coat, the Hewlett Packard Jornada 680 is an excellent value. One other caveat: For those using Apple computers, the best choice is a Palm or Psion unit since the Windows CE units do not communicate well with the Macintosh operating system (Table 3).

Hand-held computer software

All hand-held computers come with a broad array of software. Although not specifically designed for medical use, they can be easily adapted by motivated physicians. For example, the address book can be used to keep a list of patients, colleagues, and consultants; the task/to-do list can be used as a “scut list”, and the calendar can be used for office and patient scheduling. In fact, a member of the Information Technology Department for the Michigan State University Health Team has written a program that takes the patient appointment schedules from our mainframe computer and synchronizes them with the Microsoft Outlook calendars on our desktop computers. When I synchronize my hand-held computer, it updates my calendar, and I can view my clinic schedule from anywhere. For those of us who have difficulty keeping everything in our heads, this device can help keep life and practice in order.

The notepad software in all hand-held computers can be used to track key information about inpatients, which can then be beamed using infrared to other members of the inpatient team. It can also replace the “pearls book” developed by many physicians. Some physicians keep summaries of commonly used practice guidelines, advanced cardiac life support protocols, Mini-Mental State Examination questions, minimal criteria for diagnosis of various conditions, or commonly used drugs. The advantage over a paper version is that it can be kept up-to-date more easily and can readily be shared with colleagues who also have hand-held computers.

Database software comes with some hand-held computers and can be purchased as third-party add-on software for others. Many computer-literate physicians are using database programs to develop their own customized medical applications. For example, physicians can create databases of their patients, with key information such as current medications and diagnoses

We have summarized general-purpose software in Table 4, and medical software for hand-held computers in Table 5. Table 6 includes a list of Web sites for users of handheld computers, including sites that are focused on medical applications. Below, we briefly discuss some medical applications for each platform. The purpose of this section is not to review these software items but rather to make the user aware that they exist.

Palm OS

MedData, Raphael, and PocketChart are all basic medical record systems. Although all 3 packages have some limitations over desktop systems because of size and memory limitations, they offer a remarkably complete set of features. Medical references available for the Palm include the 5-Minute Clinical Consult and the Lexidrugs Drug Information Handbook. In addition, many Palm users have created their own references and collections of pearls. A good source for these is the Palm Central site (www.palmcentral.com) or one of the other Palm sites listed in Table 6.

Windows CE Operating System

Although the number of medical software applications for the Windows CE OS is small, it is growing rapidly. PocketChart is a fully-functional electronic medical record that can either run as a stand-alone program on a single Windows CE unit or be linked using wireless modems to a central server. K2 Medical makes several medical reference applications, including an extensive drug database (Lexicomp), an internal medicine reference (Outlines in Clinical Medicine), and a medical calculator (Archimedes). InfoPOEMs has released a Windows CE version of its InfoRetriever software that contains a variety of evidence-based sources of information, basic drug information, summaries of guidelines, and clinical rules and calculators.

Another option for Windows CE users is to run a program called Citrix WinFrame. This allows users to access and run (usually through a wireless modem) programs and data that reside on a central server computer. This expands the number of electronic medical record programs that can be run on the Windows CE hand-held computer.

EPOC Operating System (Psion)

There is one medical record package available, called MedPalm. It is full-featured and can share information with a desktop computer. We were unable to identify any medical reference software for the Psion, although this may change in the future.

Conclusions

Hand-held computers are finally achieving the combination of price, power, and portability to make them a useful tool. Physicians in particular stand to benefit from their use, and according to Microsoft, half of all Windows CE devices have been purchased by health care professionals. This is a good time to take the plunge and make it possible to access vital information whenever and wherever it is needed.

Acknowledgements

Work on this article was supported by a grant from the American Academy of Family Physicians to establish the Michigan Consortium for Family Practice Research and by a Generalist Physician Faculty Award from the Robert Wood Johnson Foundation. Dr Ebell is author of the InfoRetriever software and profits from its sale.

Family physicians generate many questions as they care for their patients.^1-3 Some are urgent information needs (“What is the dose of naloxone for an infant with respiratory depression?”); some are important but less urgent (“How do I interpret a negative troponin blood test result in a patient with chest pain?”); and others represent expressions of curiosity or frustration (“Why did this patient develop asthma late in life?”).

Unfortunately, physicians who want to answer their questions in time to have an impact on patient care face several barriers. These include the unavailability of high-quality medical information at the point of care and a lack of time. Both are especially problematic for family physicians who have less time with each patient than do consultants. They also practice in a variety of environments: office, hospital bedside, emergency department, nursing home, and house call. Although Sackett and Straus⁴ have described an “evidence cart” with a computer and references that is pushed through the hospital while on rounds, this is expensive and impractical for most physicians and does not solve the problem of access to information at multiple locations.

One solution is to put medical references on a hand-held computer (Table 1). These devices have become very popular among a wide variety of professionals and are characterized by:

• light weight (5 to 17 oz)
• immediate start-up and shutdown
• relatively low cost ($300 to $1000)
• high durability with few or no moving parts
• long battery life (7 to 30 hours)
• a natural pen-based interface that is similar to a clipboard or chart

These characteristics make hand-held computers a good fit for the demanding medical environment. There are drawbacks, however, such as:

• slower microprocessors
• less memory for storage
• a small screen that may be hard to read in bright sunlight, low-light conditions, or both
• no keyboard or a small keyboard that may make typing difficult

A previous article⁵ examined the advantages and drawbacks of hand-held computers for physicians. Recent advances in technology have begun to address some of the drawbacks and have made these units even more useful for physicians. The newest models have 16 to 32 megabytes for storage, color screens, and a full suite of programs. They also have faster processors than the earliergeneration of hand-held computers, and although not as fast as desktop computers, they now provide quicker performance for most programs. Also, some units now have keyboards that allow touch-typing, although this comes at the price of increased size and decreased portability.

In this article we describe the latest generation of hand-held computer hardware. We also describe the medical software available, including both record and reference software.

Computers without keyboards

Palm Computers

Palm computers (Figure 1) are highly compact and measure 3.2 inches wide by 4.7 inches in height and weigh 6 ounces. The screen displays 4 shades of gray and measures 160 by 160 pixels. All Palm computers provide an excellent battery life of 20 to 30 hours’ continuous use. Most users enter text with a built-in handwriting-recognition software program called Graffiti. The letters and numerals are very close to standard script; most people need 20 to 30 minutes to learn the anomalies. An on-screen keyboard can also be used for inputting data.

The Palm III is the basic model and has 2 MB of memory. It has a built-in flip-top, and an infrared port allows it to communicate with other Palm computers. The screen can be backlit for low-light applications. The Palm IIIx features an improved screen that is easier to view in low-light situations. It also has an expansion slot for accessories such as pager and memory cards, supports synchronization with networks and Microsoft Outlook, and comes with 4 MB of memory built in.

The Palm V is even thinner (only 0.4 inches) and sleeker than previous Palm units. It has 2 MB of random-access memory (RAM), a rechargeable lithium ion battery, and the same improved screen as the Palm IIIx. The Palm VII was recently released. In addition to all of the functionality of the Palm III, it offers 2-way wireless access to the Internet through Palm.Net (www.palm.net). This network is designed around the BellSouth Wireless Data network to provide extensive coverage and customer support. Although it will not allow full Web browsing, it will enable users to download “Web clips,” such as stock quotes, directions to the nearest automated teller machine, weather reports, travel directions, and E-mail. The Palm VII costs approximately $600, and the Palm.Net service is $10 per month for the most basic level of service. It is only available in selected metropolitan areas.

All models use the Palm operating system and come loaded with these applications: date book, address book, to do list, memo pad, and calculator. The most current versions also support E-mail and basic Internet capabilities, although the optional modem costs an additional $120 and clips onto the bottom of the unit, increasing its size and weight and decreasing the battery life. Infrared transmission of data between devices (beaming) is also possible and is a built-in feature. In addition to the built-in applications, the user can add third-party software to the Palm. These software applications allow it to exchange information with many popular programs, including Lotus Notes, Meeting Maker, Act!, and Microsoft Outlook.

The ability to load information on a Palm computer is partially determined by the model. For example, the Palm III has 2 megabytes (MB) of RAM and a capacity for 6000 addresses, 3000 appointments, 1500 to-do items, 1500 memos, and 200 E-mail messages. Average users can add more than 25 third-party applications. With 4 MB of RAM, the Palm IIIx has approximately double the capacity of the Palm III. The less data stored, the more applications or programs can be installed. The size of the third-party applications used on the Palm will also influence the total number that can be installed. Application sizes can range from less than 1 to more than 100 kilobytes. If a user runs out of memory, the Palm III, IIIx, and V are all upgradable to 8 MB.

The Palm computer comes equipped with a docking cradle that attaches to a Windows-based personal computer (PC) or a Macintosh for data transfers using a HotSync session. The cradle allows easy synchronization of information between the PC and the Palm computer. Software that mirrors the Palm’s capabilities on the desktop computer is included with the product. This software allows users to edit or create data on the desktop computer and then transfer them to the Palm.

Windows CE Palm-Size PCs

Palm-size PCs (Figure 2) run the Windows CE operating system from Microsoft. Made by several different manufacturers, they are all slightly larger and heavier than the Palm III computer and use a variety of microprocessors. However, they all easily fit into a pocket. Palm-size PCs have a larger screen than the Palm units (320 by 240 pixels), and most units have color screens. Some of the newer models also have stereo headphone jacks for replaying MP3 audio files (including the Casio E-100 and E-105), and all have a compact flash slot for expansion. This can be used for additional memory (units come with 4 MB to 32 MB of RAM), and the newer units are shielded so a paging card can be inserted. However, these extra capabilities decrease the battery life to only 7 to 14 hours.

The Windows CE operating system is less efficient than the Palm and requires more memory. Thus, 4 MB on the Palm stores about the same number of programs as 16 MB on the Windows CE unit. Palm-size PCs come with the standard organizer software (address book, calendar, task list, and notepad). Pocket Streets (a street atlas program with detailed city maps) is available free online at the Microsoft site. Users who own Microsoft Streets 2000 can create custom street-level maps of any part of the country; a 20-by-20-mile square takes about 0.5 MB of memory. DeLorme Company has a similar product for the Palm computer that can link to a Global Positioning System receiver. Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT but cannot connect to desktop computers running the Macintosh operating system

Computers with keyboards

Windows CE Hand-held PC/Hand-held PC Pro

This is a heterogeneous group of hand-held computers. All run the Windows CE operating system; all have a keyboard; and they tend to have more memory and faster processors than their cousins the Palm-size PCs. The quality of the keyboard varies considerably, though. Some units (such as the Velo 500, Hewlett Packard 320, and Hewlett Packard 660) have small “chicklet” style keys that are only suitable for hunt-and-peck typing. Some of the newer units have keyboards that are between 76% (Hewlett Packard Jornada 680) and 90% (NEC MobilePro 770 or 800) of the size of a desktop keyboard and are more useful for touch-typists (Figure 3). All units now have color screens, and the screen size of hand-held PCs varies from 640 x 240 pixels in the more compact units to 640 x 480 and even 800 x 600 pixels in some of the larger units. The former typically weigh around 1 to 1.5 pounds, while the latter weigh 2 to 3 pounds and are really closer to subnotebooks in size. Most manufacturers of the hand-held PC now also have a model with a color screen.

Hand-held PCs come with an excellent selection of built-in software, including Pocket versions of Microsoft Word, Excel, Access, and PowerPoint. They all have a built-in modem and include Pocket Internet Explorer for Web browsing and an InBox program for E-mail. Pocket Streets can be downloaded at no charge, and as with the Palm-size PCs, users can create their own street-level maps if they have Microsoft Streets 2000. Manufacturers also bundle a variety of other programs, such as expense managers and Pocket Quicken with these units (Table 2).

Like the Palm-size PCs, these computers can connect to desktop computers running Windows 95, Windows 98, or Windows NT, so exchanging documents is as easy as dragging and dropping an icon on the computer’s desktop. Although the Pocket versions of the Microsoft Office applications use a file format different from the desktop versions to save space, translation occurs automatically as files are transferred from the desktop computer to hand-held computer and back. Although hand-held PCs cannot connect to desktop computers running the Macintosh operating system, they can connect to Macintoshes running an emulation of Windows as long as the user has a serial to parallel cable.

This category includes 2 interesting computers for the health care environment, the Sharp Tri-Pad and the Vadem Clio. These units open like a miniature laptop, revealing a nearly full-size keyboardand 640 x 480 color screen. However, the screen can flip around, concealing the keyboard and turning the unit into a tablet-style pen computer. The latter is particularly useful for environments like the office, where the large screen and long battery life make it a good unit to consider for electronic medical record applications.

Psion

The Psion is a very compact hand-held computer with an excellent keyboard for its size and a very long battery life (20-30 hours). It has a backlit 640-by-240 pixel screen that displays 16 shades of gray. It runs the EPOC operating system and can connect to both Windows and Macintosh desktop computers. The Psion comes with a full suite of software, including word processor, spreadsheet, database, and programming language. Although it is the most popular hand-held computer in Great Britain, the Psion has never achieved popularity in the United States, and the amount of medical software available is somewhat limited.

Choosing a hand-held computer

Which hand-held computer should a physician choose? There is no single answer. The best hand-held computer depends on individual budget and needs. If only a basic organizer is needed, the Palm IIIx is an excellent choice. If the user wants to be able to listen to music, recorded books, and other multimedia content, the Casio E-100 or 105 is a better choice. If the user will be doing a lot of touch-typing and using the hand-held PC as a partial replacement for a desktop or laptop computer, the NEC MobilePro 770 has a terrific screen and keyboard (although the larger size makes it less mobile). Finally, if the user wants the convenience of a keyboard, built-in modem, and Internet support and a highly portable device that fits in the pocket of a white coat, the Hewlett Packard Jornada 680 is an excellent value. One other caveat: For those using Apple computers, the best choice is a Palm or Psion unit since the Windows CE units do not communicate well with the Macintosh operating system (Table 3).

Hand-held computer software

All hand-held computers come with a broad array of software. Although not specifically designed for medical use, they can be easily adapted by motivated physicians. For example, the address book can be used to keep a list of patients, colleagues, and consultants; the task/to-do list can be used as a “scut list”, and the calendar can be used for office and patient scheduling. In fact, a member of the Information Technology Department for the Michigan State University Health Team has written a program that takes the patient appointment schedules from our mainframe computer and synchronizes them with the Microsoft Outlook calendars on our desktop computers. When I synchronize my hand-held computer, it updates my calendar, and I can view my clinic schedule from anywhere. For those of us who have difficulty keeping everything in our heads, this device can help keep life and practice in order.

The notepad software in all hand-held computers can be used to track key information about inpatients, which can then be beamed using infrared to other members of the inpatient team. It can also replace the “pearls book” developed by many physicians. Some physicians keep summaries of commonly used practice guidelines, advanced cardiac life support protocols, Mini-Mental State Examination questions, minimal criteria for diagnosis of various conditions, or commonly used drugs. The advantage over a paper version is that it can be kept up-to-date more easily and can readily be shared with colleagues who also have hand-held computers.

Database software comes with some hand-held computers and can be purchased as third-party add-on software for others. Many computer-literate physicians are using database programs to develop their own customized medical applications. For example, physicians can create databases of their patients, with key information such as current medications and diagnoses

We have summarized general-purpose software in Table 4, and medical software for hand-held computers in Table 5. Table 6 includes a list of Web sites for users of handheld computers, including sites that are focused on medical applications. Below, we briefly discuss some medical applications for each platform. The purpose of this section is not to review these software items but rather to make the user aware that they exist.

Palm OS

MedData, Raphael, and PocketChart are all basic medical record systems. Although all 3 packages have some limitations over desktop systems because of size and memory limitations, they offer a remarkably complete set of features. Medical references available for the Palm include the 5-Minute Clinical Consult and the Lexidrugs Drug Information Handbook. In addition, many Palm users have created their own references and collections of pearls. A good source for these is the Palm Central site (www.palmcentral.com) or one of the other Palm sites listed in Table 6.

Windows CE Operating System

Although the number of medical software applications for the Windows CE OS is small, it is growing rapidly. PocketChart is a fully-functional electronic medical record that can either run as a stand-alone program on a single Windows CE unit or be linked using wireless modems to a central server. K2 Medical makes several medical reference applications, including an extensive drug database (Lexicomp), an internal medicine reference (Outlines in Clinical Medicine), and a medical calculator (Archimedes). InfoPOEMs has released a Windows CE version of its InfoRetriever software that contains a variety of evidence-based sources of information, basic drug information, summaries of guidelines, and clinical rules and calculators.

Another option for Windows CE users is to run a program called Citrix WinFrame. This allows users to access and run (usually through a wireless modem) programs and data that reside on a central server computer. This expands the number of electronic medical record programs that can be run on the Windows CE hand-held computer.

EPOC Operating System (Psion)

There is one medical record package available, called MedPalm. It is full-featured and can share information with a desktop computer. We were unable to identify any medical reference software for the Psion, although this may change in the future.

Conclusions

Hand-held computers are finally achieving the combination of price, power, and portability to make them a useful tool. Physicians in particular stand to benefit from their use, and according to Microsoft, half of all Windows CE devices have been purchased by health care professionals. This is a good time to take the plunge and make it possible to access vital information whenever and wherever it is needed.

Acknowledgements

Work on this article was supported by a grant from the American Academy of Family Physicians to establish the Michigan Consortium for Family Practice Research and by a Generalist Physician Faculty Award from the Robert Wood Johnson Foundation. Dr Ebell is author of the InfoRetriever software and profits from its sale.