1. Handheld Hardware and Operating Systems

PRACTICE AT THE B EDSIDE “Palm reading”: 1. Handheld hardware and operating systems Feisal A. Adatia, Philippe L. Bedard Case 1 Joanna is a third-year medical student getting ready to start her clinical clerkship. She has seen other clerks and residents using their handheld computers to look up drug dosages and medical reference information on the wards. She feels that a handheld computer would be a useful aide for her clinical training. She envisions using a handheld primarily as an information resource, but she worries that she is limited by a narrow budget. Which handhelds would best meet Joanna’s needs? Case 2 Dr. Edwards is a family physician with a busy practice in Northern Ontario. Although he uses a personal computer in his office for word processing and email messaging, he does not regard himself as technologically savvy and is skeptical about using a new electronic gadget in his practice. After hearing from colleagues at a conference about how they use their handheld computers to log their billing claims, he is interested in finding out if a handheld could improve his billing efficiency. What benefits could a handheld computer bring to him? What models would best suit his needs through being functional, yet small and elegant? lthough handheld computers have yet to take their uate level, a recent survey of family practice residency pro- place alongside the stethoscope and the reflex ham- grams in the United States indicated that handhelds were mer as essential tools in the practising doctor’s ar- used by 67% of residency programs that responded to the A 10 mamentarium, they are becoming increasingly popular in survey. Medical training programs are integrating hand- medical practice. According to a recent survey of 834 US held computers in their curricula to meet the changing in- physicians, about 26% of physicians now use handhelds and formation needs of their trainees.11 Given the growing vol- an estimated 50% will use the devices by 2005.1 Physicians ume of medical information, and the increasing expectation are using handheld computers in their practices today for a for practitioners to adhere to standards of evidence-based variety of routine tasks: from accessing medical textbooks care, physicians and trainees increasingly require ready ac- and making medical calculations using laboratory test re- cess to medical information at the bedside. The appeal of sults to tracking patient data and billing for patient encoun- the handheld computer is that it can function as a compact, ters. Recent data suggest that handheld computers may not portable medical information resource that can be accessed only enable clinicians to practise more efficiently,2 they at the point of care. Moreover, it can be easily updated to may even reduce medical errors and improve patient out- incorporate emerging research and evolving clinical prac- comes. For instance, in a recent Canadian study, the intro- tice guidelines. duction of handheld computers in an intensive care unit Although the handheld computer offers the promise of (ICU) in a teaching hospital led to improved communica- bringing evidence-based medicine to the bedside in every- tion of patient information among ICU staff.3 Research day practice, most physicians today either do not own a presented at a meeting of the American Society of Anesthe- handheld computer or use their handheld computers siologists suggests that handhelds can facilitate screening solely as a day planner for keeping track of important ap- for drug interactions and can be used to improve postsurgi- pointments and contact information. There are a number cal pain control through recording each patient’s pain rat- of reasons why many practitioners are reticent about using ings and response to analgesics.4 handheld computers: data entry through the “Graffiti” Recognizing that familiarity with information technol- character recognition pad on a handheld, although fairly ogy will be as important to the future physician as knowl- easy to learn, can be tedious for entering large quantities edge of the pathophysiology and treatment of common dis- of data; handhelds have small screens that are less than eases, many medical schools in the United States, including ideal for reading long volumes of text and for displaying Wake Forest University, NC, and Stanford University, graphics; when compared with personal computers (PCs), Calif., are providing their undergraduate students with handhelds have limited memory and slower processing handheld computers.5,6 Medical students are using hand- speeds and, finally, many physicians have raised questions held computers to keep track of clinical encounters and fa- about the security of storing confidential patient informa- cilitate evidence-based decision-making.7–9 At the postgrad- tion on handhelds.12 CMAJ • OCT. 1, 2002; 167 (7) 775 © 2002 Canadian Medical Association or its licensors AT THE B EDSIDE In spite of these concerns, many practitioners are inter- titles sold in the United States last year were for the Palm ested in purchasing their first handheld computer or upgrad- OS.16 Because most medical personnel currently use Palm ing their current handheld model. For non-computer-savvy OS devices, this article focuses on hardware models that physicians, the handheld industry’s excess of technical jargon support the Palm OS. and its rapidly expanding array of available gadgets can be dizzying. The aim of this article is to introduce novice hand- Memory and expansion support held users to the range of hardware options that are available and the important features that should be considered when The capacity to store information is fundamental to purchasing a handheld for medical use. A second article will the operation of any computing device. A handheld’s in- describe software applications relevant to medical practice. ternal random access memory (RAM) is akin to the hard drive of a PC. Most currently available handheld models Considerations when buying feature either 8 or 16 MB of internal RAM. Generally, this amount of memory is sufficient to support all of the Before determining which handheld is personal information management programs on Palm OS best for you, it is important to first decide devices, along with one or two more space-intensive med- upon which features would best suit your ical reference tools, such as pharmacopoeias and elec- needs. There are a number of important tronic textbooks. considerations to keep in mind: the type of Many of the newer models allow users to increase the operating system, the availability of soft- storage capacity of their handhelds through expansion ware, memory, expansion support, memory cards. These handhelds have either a Compact processor speed, size and weight, Flash, Secure Digital, Memory Stick or a Springboard screen resolution, availability of pe- expansion slot that allows users to add an additional ripheral devices, text entry options, 8–128 MB of expansion memory to their devices. convergence features, and price and support (Table 1). (An expanded Processor speeds version of Table 1 may be found on the CMAJ Web site.) Processor speeds determine how quickly a handheld is able to retrieve information. Point- Operating system of-care access to information is only helpful if it is efficient enough to allow you to find the rele- Just as PCs have different oper- vant information rapidly. For instance, all cur- ating systems, so do handhelds. In rently available handhelds are fast enough to the handheld arena, the major op- look up a drug in a fraction of the time it erating systems are the Palm, Mi- would take to turn the pages of the Com- crosoft Pocket PC and pendium of Pharmaceuticals (CPS). Most cur- Psion/EPOC. Although devices rently available handhelds use the same 33- that run the Psion/EPOC and MHz Dragonball processor. Newer nney Microsoft Pocket PC (formerly e handhelds from Sony, the T665 and the Windows CE) operating systems NR70, are the first devices to employ the Su- hristine K are certainly in wide use, the C perDragonball 66-MHz processor. With the Palm Operating System (OS) is release of the new Palm OS 5 operating sys- the industry leader, with 85% of tem, it is anticipated that new handhelds will sales in Canada and 87.2% of be able to support processors that are 5-10 sales in the United States.13,14 times faster than currently available models. Although Palm originally Expansion memory can be used to store designed the Palm OS, there Size and weight large databases and medical texts that can are a number of other manu- be retrieved quickly at the bedside. facturers — including Hand- The general trend in the handheld spring, Sony and HandEra — arena has been toward smaller devices. with licences to produce devices that run the Palm OS. Some of the smallest devices, such as Palm’s m500 series, This is akin to PCs made by different manufacturers like Sony’s T series, Handspring’s Visor Edge or the new Dell, IBM and Compaq all running the Windows OS. Handspring Treo 90, can fit comfortably into a shirt With regard to software availability, the Palm OS cur- pocket. Larger devices can fit comfortably into a lab-coat rently has about 14 thousand different program titles and pocket. Ultimately, handheld size is a matter of personal the largest selection of medical applications available for preference. There are 2 main factors to take into considera- any handheld OS.15 More than 97% of handheld software tion when contemplating the size of a handheld: price and 776 JAMC • 1er OCT. 2002; 167 (7) AT

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