Student Use of Handheld Computers in Ambulatory Clerkships

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Student Use of Handheld Computers in Ambulatory
Clerkships

• Jason Chao, M.D., Pete Spanos,
• Patricia Moore, M.D., Judy Parsons
• Dept. of Family Medicine, Case Western Reserve
  University School of Medicine

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Outline

• Medical Informatics
• PDAs in Medical Education
• Our Experience experiment in progress
• Findings to Date successes and difficulties
• Where to go next?

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Medical Informatics

• There is a tremendous amount of medical
  information available, and it is increasing at an
  exponential rate
• The physician must learn methods to master the
  information overload and be able access
  appropriate information when it is needed
• Making information available at the point of
  service streamlines the process for both patient
  and physician

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Medical Informatics (cont.)

• Increasing numbers of physicians are using
  handheld computers in clinical practice
• Students and residents need to be introduced to
  new technologies that will improve efficiency
• Two-thirds of all Family Practice residency
  programs now use handheld devices and more are
  moving in that direction

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Medical Informatics (cont.)

• Many residents now use log programs on handheld
  devices to track information, especially
  procedures performed
• Medical education is moving out of the hospital
  as the exclusive location for clinical training
  and increasingly use the ambulatory (out-patient)
  setting for clinical training

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Medical Student Education

• Decentralized ambulatory clerkships need
  information about patient care experiences for
  monitoring and improving clerkships
• Handheld computers offer an alternative way to
  collect information about patient care experiences

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Medical Students (cont.)

• Information sources including textbooks and large
  databases are a major source of clinical
  education for medical students
• Web based materials are becoming more frequent
• Handheld devices are an ideal way to deliver
  these information sources to the student before,
  during and after patient visits

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Study Questions

• Will medical students use handheld computers to
  record patient care experiences and access
  medical information?
• What types of programs are most used by medical
  students?
• Is implementation of handheld computers in a
  clerkship beneficial?

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Methods

• A 16 Meg Visor Pro PDA (Palm OS) is loaned to
  CWRU students during their 8 week combined Family
  Medicine and ambulatory Internal Medicine
  Clerkship
• A program on the PDA records all programs used
  on the PDA (App Usage)
• Students are required to use the PDA to record
  information on all patients seen during the
  Clerkships using a log program

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Methods, cont.

• Data is collected by hot-synching during weekly
  didactic clerkship sessions
• Students receive an orientation session to the
  PDA at the beginning of the Clerkship
• Students are informed of the study at the
  orientation
• IRB approval was obtained for this study

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Pharmacology Databases

• ePocrates (2.2 Meg)
• now has commercial version that adds herbs,
  tables, and ID database
• Tarascon (3.1 Meg)
• popular commercial hard copy reference
• Herbal Zone (0.1 Meg)
• common medicinal herbs, with indications and side
  effects

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Medical Textbooks

• 5 Minute Clinical Consult (3.3 Meg)
• Easy to use reference for over 1000 specific
  medical diagnoses
• Outline
• Merck Manual (4.4 Meg)
• More complete reference covering a wide spectrum
  of medical, pediatric and surgical topics

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Patient Log program

• Students enter data on individual patient
  encounters via check-offs and pop-up menus
• Demographic data collected includes patient age,
  gender, and whether the patient was seen before
  by the student
• Free text entry is possible for diagnoses not
  listed

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Patient Log program (cont.)

• Students record the extent of their involvement
  with the visit and type of teaching received
• A summary view mode is available at any time,
  showing number of encounters for each diagnosis
• Students review this view with their preceptor to
  identify significant gaps in their clinical
  encounters

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Free Medical Programs Provided

• Breast CA ATP3 (lipids)
• Shots 2002 Med Calc
• MMSE Baby Calc (OB wheel)
• Med Rules ABG Pro
• Child Growth Charts Med Math
• Obesity ABG

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(No Transcript)
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Results

• Data from the first six months of PDA use are
  presented here
• Outcome data (exam scores) are not yet available
  for analysis

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Student Demographics

• 72 students received PDAs (first 6 months)
• 65 male
• Mean student age 26.7 years
• Prior experience with PDAs
• None 12
• Non-clinical applications 17
• Medical applications 37
• Other applications 3
• PDA programming 2
• 1 student did not use the PDA

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Program Usage 28,944 uses
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Program Time 37,282 minutes used

• Programs were used for 37,282 minutes
• Log Program 8,383 min. 22
• Pharm Databases 7,734 min. 21
• Text books 6,940 min. 19
• ID references 482 min. 1
• Medical Apps 1,466 min. 4
• Utilities 5,931 min. 16
• Games 5,120 min. 14
• Other 1,226 min. 3

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Pharmacology Databases

• ePocrates
• Accessed 6,332 times for 7,094 min.
• Average 1.1 minutes per use
• Tarascon (only avail. first 3 months)
• Accessed 385 times for 367 min.
• Average 1.0 minutes per use
• Herbal Zone
• Accessed 266 times for 273 min.
• Average 1.0 minutes per use

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Textbooks

• 5 Minute Clinical Consult
• Accessed 3,454 times for 4,953 min.
• Average 1.4 minutes per use
• Merck Manual
• Accessed 1,071 times for 1,987 min.
• Average 1.9 minutes per use

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ID References

• Hopkins Antibiotic Guide
• Accessed 127 times for 163 min.
• Average 1.3 minutes per use
• qID (only avail. first 3 months)
• Accessed 385 times for 319 min.
• Average 0.8 minutes per use

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Log Program Use

• 5358 patient encounters recorded
• 8478 total diagnoses were recorded
• 58.2 female patients
• Avg. patient age 45 yrs. old
• 4.1 of visits were returning patients seen by
  the student before

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Log Program Use (cont.)

• Encounter types
• Health Maintenance 27
• Chronic Illness f/u 24
• Acute exacerbation 11
• Acute Illness 38
• Type of Physical Exam performed
• Focused exam 73
• Complete exam 27

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Log Program Use (cont.)

• Top 7 Diagnoses
• Well person visit (general exam)
• Hypertension
• Back / joint pain
• depression / anxiety
• Diabetes
• Hyperlipidemia
• asthma

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Log Program Use (cont.)

• Preceptor teaching
• Management of the patient 44
• Diagnosis of the patient 25
• Disease process 17
• none 14
• Physical exam teaching
• student performed unobserved 37
• preceptor observed student 32
• student observed preceptor 26

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Student Survey

• Use of PDA during the Clerkship was helpful
• Strongly agree 35
• Agree 35
• Neutral 10
• Disagree 11
• Strongly disagree 10

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Discussion

• PDA use was not uniform use varied from none to
  over 1 hour / day
• In general, students accepted the PDAs well
• We have started to incorporate use of the PDAs
  into didactic sessions, e.g. genetic risks for
  breast cancer, or lipid level goals with ATP3

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Future Directions

• Continue to use the patient log program
• Allow students to load programs onto their own
  personal PDA if they own one
• Examine for any correlation between use of PDAs
  and exam scores
• Provide feedback to preceptors on their
  individual teaching, in comparison with other
  preceptors

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Future Directions (cont.)

• Bring over materials now available on the Web
  through Blackboard
• We recommend that CWRU decide upon a uniform PDA
  platform for all clerkships to build upon
• Explore Bluetooth or other Wireless and/or
  Internet technology to bring additional resources
  to medical students

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Acknowledgement

• Funding was provided by a Predoctoral Training
  grant from HRSA

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Free Medical Programs Provided

• ABG provides a quick analysis of arterial blood
  gas results ltwww.palmgear.comgt
• ABG Pro provides a quick analysis of arterial
  blood gas results ltwww.stacworks.comgt
• ABXGuide infectious disease database from Johns
  Hopkins. No pediatrics. ltwww.hopkins-abxguide.orggt
  
• ATP 3 Adult Treatment Panel III Cholesterol
  Management Guidelines. lthttp//hin.nhlbi.nih.gov/a
  tpiii/atp3palm.htmgt
• Baby Calc calculates EDC and weeks of gestation
  from LMP ltwww.palm4you.com/show.cgi?softid15gt
• Breast CA provides two models for predicting
  risk of breast cancer lthttp//www.stanford.edu/pm
  cheng/breastca/gt
• dT-MMSE Mini-Mental State Exam
  ltwww.freewarepalm.com/medical/dtree-mmse.shtmlgt
• Herbal Zone database of medicinal herbs, with
  indications and side effects ltwww.palmgear.comgt

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Free Medical Programs Provided

• MedCalc medical calculator ltmedcalc.med-ia.netgt
  
• MedMath medical calculator ltwww.stanford.edu/pm
  cheng/medmathgt
• MedRules clinical prediction rules from the
  literature on a wide variety of conditions
  ltwww.palmgear.comgt
• OEI Obesity NHLBI Obesity Education Initiative.
  Calculates BMI and recommended management
  strategies. lthttp//hin.nhlbi.nih.gov/obgdpalm.htm
  gt
• Shots 2002 current childhood vaccine
  recommendations. Details on each vaccine are
  available by clicking on the vaccine names and
  info buttons. ltwww.immunizationed.orggt
• Tarascon prescription drug database includes
  some non-FDA approved indications more pediatric
  dosing and extensive notes ltwww.medicalogic.com/pr
  oducts/Tarascongt

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Jason Chao ltjxc19_at_cwru.edugt