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Palm-sized computers put medical evidence into doctors' hands

If your doctor plucks an electronic device out of a pocket and starts pressing buttons, he or she certainly isn't playing a video game and probably isn't making a cell-phone call. In Dartmouth's Department of Medicine, such a doctor is likely part of a concerted effort to incorporate handheld computers into daily practice. Blair Brooks, M.D., an associate professor of medicine, is leading the charge.

Palm-sized electronic organizers —also called personal digital assistants—are a popular way to store schedules, addresses, and phone numbers and to run simple programs. But Brooks hopes to harness their power to improve the decisions that doctors and patients make together. He also sees them as a tool to help residents learn how to apply evidence- based medicine.

Currently, all of the residents in DHMC's primary-care program have been given Palm IIIx organizers, and Brooks estimates that half of the general medicine faculty have taken them up too. They use the devices for all the things everyone else does—in place of pocket calendars and address books. In addition, Brooks is building a database of what he calls "second-order distilled information" that can be accessed on the Palms.

Blair Brooks shows a patient how he can pull up a variety of relevant information digested from medical journals onto his palm-sized organizer.

Photo: Jon Gilbert Fox

Key: The devices are key to getting information to providers at the right time. As Brooks sees it, the first challenge of improving medical decisions is "trying to figure out what the evidence is for particular treatments and particular diagnostic testing strategies." If there is no data on the outcomes of a particular treatment, that is one obvious hindrance. But even when data does exist, it can be time consuming, sometimes prohibitively so, for a doctor to retreat to an office or library to look up an applicable study, then bring that information back to the patient. Some medical centers have placed desktop computers that can access such information at strategic locations through the institution. But the Palm organizer fits into doctors' pockets and goes everywhere with them.

Brooks's database is designed to be useful in the specific DHMC practice setting. It is organized by general categories— such as cardiology—then by subcategories that represent conditions a doctor would be looking to treat—high cholesterol, for instance. A doctor can select one of these subcategories and see actual data from a study or group of studies.

Each entry lists the type of study and the types of patients included in the study. The doctor can assess the reliability of the study and decide if it is appropriate for a given patient. The entry also describes the positive outcomes of the study and the number of interventions needed to attain those outcomes, as well as the negative outcomes and their frequency. The entries are also dated, so doctors can be sure they're working with timely information.

Risk: "One of the risks of this is if you put the wrong information in," Brooks adds. To avoid that pitfall, every entry is reviewed in a multilayered process. First, residents select studies that they think are important and relevant to DHMC's patient population. The residents review the study, summarize it, and put it into the correct format for the database. They then present the topic at a department meeting, giving faculty a chance to go over each entry. This is why Brooks calls it second-order distilled information: it is taken out of journals that have often already summarized and collated data, then it is distilled again. Brooks plans to add six entries a week to the database by this method.

Value: This makes for a lot of work for Brooks and the others involved with the project, but, he says, "there's a value to it being homegrown." First, the department gets to apply consistent standards to the information that they will later use. "It's also asking the questions and putting in the information that's relevant to our patient population," he adds. This creates a role for the instincts and knowledge that the doctors have developed in their years of practice. The project is not aiming to create unfiltered data or to allow machines to make medical judgements. Brooks's hope is that the devices will help physicians to better understand the medical basis for their decisions.

For the residents, simply participating in the data-development process serves an educational purpose. "They've learned a lot, we've learned a lot, and then it's in [the database] and everybody can use it," Brooks says. He also hopes that using the Palm organizer will teach the residents to seek out appropriate evidence and apply it to their patients rather than equivocating or acting solely on instinct. The computer will function like a mentor, reminding the young doctors to base their decisions on hard evidence and pointing them toward the best studies.

"I had been thinking a lot about how to get the information to the bedside, where doctors make their decisions," he says. The hand-held devices were just the way to do that, he decided.

The Palm's strong points are its portability and its readable display. It also has the advantage of a technology called HotSync, which allows each user to download data from a central computer at regular intervals; this enables everyone in the department to easily obtain the most up-to-date version of the database. Its downside is limited memory, so it can't carry a whole library of data or sophisticated applications.

Flexible: Brooks points out, though, that the hand-held computer is in some ways not a huge leap over "handing out a little sheet of paper and putting it in a notebook." But the Palm is easier to handle and more attractive. And the data is better organized, as well as easier to update and cross-reference, than it would be in a notebook. The Palm also has potential for future expandability and flexibility. Brooks hopes to develop ways of reporting which entries are used most often and of helping with physician evaluations.

Brooks began the program as a way to encourage patients and physicians to make more informed medical decisions. Now, to accomplish that very patientfocused goal, he's promoting electronic devices. "I'm sort of chuckling at the fact that I'm the gizmo-pusher," he admits.

Jonathan Weisberg

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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