Punch in the data, read out the answer, no pen and paper, no heavy textbook or bulky manual, just a computer the size of a pack of playing cards. Keisha loves her new PDA (Personal Digital Assistant). In pediatrics, where drug doses and fluid needs vary with weight, and the margin of error is minuscule, she depends on her PDA to help keep her patients safe. She’s even given the slender black box a name, and often tells her colleagues she needs to check with Paddy before she starts a procedure.

Today Keisha enters a newly ordered infusion rate for a newborn with meningitis into the preprogrammed application on her PDA, and the screen confirms that the rate is within safe parameters for the weight and age of her patient. She also confirms the baby’s antibiotic dose. With the timer set to alert her to reassess in 15 minutes, she slips Paddy back into the pocket of her scrubs.

Another patient is about to be discharged home on a new medication, and Keisha uses her PDA to call up teaching points for the family on the drug’s therapeutic effects, compatibilities, and adverse effects that should trigger a call to the physician. Before she left for work that morning, she downloaded two nursing articles she plans to use to prepare for an inservice she’ll present the following week. If time permits, she’ll start looking them over later in the day.

PDA technology

Early electronic organizers that served as efficient address and appointment books have rapidly evolved from personal information managers into today’s more sophisticated handheld PDAs with the ability to share data with a desktop or laptop (host) computer. Through shared software applications and a process of synchronization (referred to as a “hot synch”), programs, files, and other information from the PDA and the host computer are transferred, analyzed, updated, and finally stored on both units. Specialized cables or cradles that might also serve to recharge the batteries of the handheld units work this magic. If the host computer can be connected to the Internet, the synchronization process can include called-up and downloaded data.

Most modern PDAs now use a handwriting recognition application called Graffiti, or the newer Graffiti-2, which allows the user to input information by writing on a portion of the screen. The user can even navigate around the screen and application with the touch of a stylus, which functions like a mouse.

Choosing your PDA

The choice of a PDA depends on its use. Consider the following criteria —

• The type of operating system (OS), often based on the availability of software applications appropriate to the intended use
• Memory, both internal and external
• The need for and availability of communication capabilities, often determined by the need to interact with other users within a facility
• Built-in and add-on features
• Cost

In some facilities, nursing informatics specialists may be available to help staff select the best product for the setting.

Operating Systems (OS): The OS is at the heart of the PDA. It allows the PDA to function and use a wide variety of applications. PDAs with the Palm OS come with Palm Desktop® software that allows the calendar, address book, to-do lists, and notes to appear on the computer with which the PDA is synchronized. Up until recently, this software was not compatible with other desktop applications, but not so today. The vast majority of current PDAs using the Palm OS are models in the Tungsten and Zire series made and sold by Palm One. As the popularity of PDAs increased, Microsoft developed its own OS that would be compatible, even if on a limited basis, with its widely used Windows® and Microsoft Office® software. This limited or “compact edition” of the Windows OS (previously known as Windows CE® and currently called Windows Mobile®) is used by a variety of PDA manufacturers, including Dell, Hewlett-Packard, and Toshiba.

In the past, the choice of an OS had a significant impact on what software applications may be available, with Palm OS devices outnumbering the “Pocket PCs” that use the Windows operating systems. This impact is lessening as the market continues to change. Recent reports present a variety of potentially confusing information concerning the PDA market. For conventional PDAs, it appears that Palm OS devices may still outsell Microsoft OS devices in terms of units sold, but in terms of $$ of market share, Microsoft OS devices gained the lead in 2004. Both market sectors have seen declining sales recently, particularly with the increasing popularity of “Blackberry” devices and “Smart Phones.”^1-4 Devices using the Palm operating system will probably continue to be extremely popular due to the wide variety of medical software available, much of which is free or reasonably priced. Because of the relative simplicity of the Palm OS, many people have developed small programs and applications available at little or no cost to the user. The large number of these free or shared programs accounts for much of the medical software, and nearly 75% of medical software currently available is designed for the Palm OS.⁵ Increasing in number and variety every day, commercially produced medical software generally has versions for both Palm OS and Microsoft OS devices. As old applications are revised and new applications developed, differences in the availability of major software applications for the two operating systems will continue to lessen.

Memory: The amount of usable internal memory and the ability to add external memory to the PDA are other critical factors in the search for the right product. Sufficient memory to run and store required software and references and accommodate future needs is a must.

The amount of internal memory depends a great deal on the OS. Current PDAs with Palm OS have at least 32 mb, while Pocket PC devices generally contain at least 64 mb of internal memory. The Palm Tungsten LifeDrive boasts an amazing 4 gigabytes of internal memory. While Pocket PCs often have more internal memory, their systems use a great deal more memory to operate. In addition, Pocket PC applications generally require much more memory to run, often 50% to 100% or more. Wise buyers know to evaluate the memory requirements of the specific software they will use on the PDA.

Another factor, the ability to add external memory to the PDA, has become an important and increasingly available option. These external memory units, called cards or sticks, are quite small, often no bigger than a postage stamp or a stick of chewing gum. As the technology has progressed, it is not uncommon to find cards with 512 mb or even 1 or 2 gigabytes of data storage capability, sufficient space to keep entire books, hundreds of photos, numerous songs, and a wide variety of PDA applications. Not all PDA applications run from or with the external memory, however, and many larger programs require space on both internal and external memory. Thus, the amount of internal memory is always extremely important.

Communication Capability: Most, if not all, modern PDAs come with an infrared (IR) transceiver port that allows for data transmission between the PDA and another device, usually another PDA or a printer, without wires or cables. Distance and direction limit IR beam use to line-of-sight placement of the two devices. IR ports can also be used to synchronize the PDA with the host computer or with a wireless keyboard attachment for the PDA.

For other types of communication, some devices combine a PDA with a cellular telephone. These units can access the Internet through a dial-up connection, just like a telephone line and modem would connect a home computer to the Internet. “Smart Phones” even combine a PDA with a cellular telephone and high-speed wireless Internet access utilizing an EVDO connection. WiFi technology, using a specialized radio wave transceiver is also available, as a built-in or add-on feature. A WiFi-enabled PDA makes it possible to access the Internet through wireless local area networks (LAN). These networks are becoming more and more popular in homes and businesses, and an ever-increasing number of public areas, such as coffee houses, hotels, airports, and libraries, have networks available for free or by subscription.

Another type of wireless communication, Bluetooth™ technology, allows interactive network communication between PDAs, printers, or a computer equipped with the same technology and is not limited by line-of-sight. In the future, wireless communication could advance the use of the PDA even more as people share information, communicate problems, and update others within an established network in real time.⁶

Wireless PDAs offer three fundamental capabilities to nurses by simplifying workflow, optimizing productivity, and enabling real-time access to health care data anytime and anywhere.⁷

Features: Several other features of PDAs figure into the mix. In the past, both monochrome and color screens were available. The monochrome screens utilized a lower density or resolution screen and while considerably less expensive than color screen models, they tend to be harder to read. With their higher resolution and backlit color screens, newer models appear brighter, clearer, crisper, and easier to read, even with single color applications such as pure text. Most, if not all, new PDAs have color screens.

Most PDAs now come with rechargeable batteries, and improved battery life. The length of use between recharges varies based on the type and speed of the unit’s processor and the specific type of application in use. Graphics-intensive applications tend to deplete the batteries faster than text applications. Some PDAs with rechargeable batteries may need to be recharged daily for optimum use.

Among other hardware considerations is availability of built-in or attachable features, such as a keyboard, digital camera, voice recorder, music player, wireless communication devices, or GPS navigation units. While some of these types of features were all add-ons in the past, more and more PDAs offer these as built-in features. For example, nurses may find keyboards useful for narrative charting, and many different types and sizes of keyboards and keypads are available. Some PDAs have a built-in keypad. Digital cameras can also be added to some PDAs, while built-in cameras, useful for documenting injuries or wound healing, are available in others.

Cost: PDAs range in price from less than $100 to more than $600, with cost increasing with the number of features and capabilities. Pocket PC models usually cost more than others, but prices and availability change frequently. Some hospitals have made PDAs available to the physicians on staff, but not to nurses at this point.

PDAs at the Point of Care

The use of specialized software applications, often downloaded from the Internet, transforms the PDA into a powerful clinical resource. With a touch of the stylus, nurses can perform complex drug dosing calculations and check for adverse effects and drug compatibilities. References on a PDA can be used to evaluate lab results or review specific disease-related treatments and interventions. Many up-to-date medical and nursing references and even some health care journal articles are available for the PDA. In some cases, facility-specific clinical pathways and policy and procedure manuals may be added to a PDA. There are also applications that allow for patient information and documentation to be transferred to and from the PDA.⁸

Specific medical software fits into several categories, based on content and use. There are drug references, general nursing or medical references, specialty references, procedure guides and references, lab and diagnostic references, patient information or tracking applications, medical dictionaries, every sort of calculator, educational programs, and other databases. Specialized reader applications allow the nurse to peruse articles, notes, and journals downloaded from a variety of Internet sources. In addition, programs are available that allow the user to set up customized notes and databases and organize information.

Nurses in particular use PDAs primarily for reference materials on medications and procedures, thus promoting patient safety.⁹ In a recent survey, nurses were asked about the relative importance of their PDA software applications. Over 93% of those who responded indicated that drug references were “very important.” Almost 75% reported that “specialty references” were “very important,” and 71% reported the same for general references. Patient education and personal education also ranked high as “very important” applications.¹⁰

Many reference applications are available for PDAs from a variety of sources. Websites, such as www.pdacortex.com, www.palmsource.com, www.pdamd.com, www.healthypalmpilot.com, and others offer software applications, some free, some at nominal costs, and others at $50 and up. Other sources, such as www.SkyScape.com and www.UnboundMedicine.com, offer a more limited selection of comprehensive software titles for purchase, and many titles are electronically converted and enhanced versions of hard copy reference books and texts. Still other companies, such as PEPID at www.pepid.com and Epocrates at www.epocrates.com, have extensive proprietary applications available at their website.

Medical applications for PDAs come in all sizes and shapes. Some are called “freeware” because they are not developed for commercial distribution and offered at no cost. Other applications, often called “shareware,” can be obtained for a very minimal cost, often $15 or less. Still other applications are available for purchase for a one-time fee, and many offer a free limited time or limited content trial version. Subscription software applications, with an annual or semiannual fee for the use of the material, are also on the market and offer regular updates.

Protecting privacy

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) placed certain safeguards and restrictions on the availability of patient health information. In a nutshell, this act requires that patient information be kept confidential, whether it is recorded on a hospital computer system, a personal handheld computer, or a scrap of paper in a nurse’s pocket. PDAs may contain confidential information, and users are responsible for keeping the information secure. Typically, systems address this issue by providing encryption and user passwords. PDA users should be aware of the guidelines and restrictions developed by their specific institution.^11,12

Potential for better care

Tools that increase nursing efficiency and enhance personal effectiveness, such as the PDA, have the potential to improve care and promote patient safety. For example, the ability to check doses, complete complex drug calculations, and evaluate drug compatibilities at the point of care could potentially prevent lethal medication errors. One report shows that 50% of physicians using a PDA and a popular drug database avoided at least one, if not more, serious adverse drug events.¹³ What’s more, access to accurate references with easy-to-use calculators in highly stressful, critical situations offers an invaluable advantage. Nursing data is not yet available, but could result in the same if not higher error prevention statistics. In another aspect of care, immediate access to vital signs and lab results could also improve safety and outcomes, alerting the nurse to potentially dangerous changes in a patient’s condition.

Nurses who use PDAs might also find themselves no longer frustrated by time-consuming searches for information in a book or chart. Moreover, they will find that nursing references available on PDAs are often more current than print resources. In addition, nurses may find they have more time to spend with patients, often a key factor in improving job satisfaction.¹² This increased time with the patient translates into more opportunities to assess and evaluate needs, such as optimal pain management and education.^14,15

PDAs, in ambulatory care settings, can help nurses monitor preventive, maintenance, and long-term care. For example, in a report to the Immunization Registry Conference of the Centers for Disease Control and Prevention, a physician group in Oklahoma, collaborating with nursing staff, described its success in using a PDA program for nurses that provided reminders about immunizations and other primary and secondary preventive measures for individual patients. The program also allowed physicians and nurses to track risk factors (such as age and smoking history) and prior services.¹⁶

In many instances, PDAs help improve the efficiency of patient charting and documentation, along with coordinating and communicating patient needs with other members of the health care team.⁶ In California, at the Visiting Nurse Association Home Health Systems (VNAHHS), nurses using PDAs reported a significant reduction in the time spent on paperwork — up to 50% — while improving patient care. What’s more, the VNAHHS’s CEO reported an 80% reduction in paper costs.¹⁷

A clear crystal ball

As the PDA and software applications continue to develop, the challenge for the future will be to educate more health care administrators, educators, and nurses about this handheld technology. A 2004 Forrester’s Technographic Survey revealed that while 47% of physicians used PDAs, only 18% of nurses used them.¹³ Although several schools of nursing in the U.S. and abroad have incorporated PDAs into their curricula, for the most part nurses and nursing schools are slow to adopt this technology. Workplaces in the very near future will soon demand that graduates be ready to use the PDA technology in the practice environment.

Cost may be a contributing factor in the low percentage of nurses using PDAs. While many medical school programs require PDAs, and some hospitals provide them for physicians, nurses generally must make the purchase themselves. In addition, the average age of nurses may contribute to the lag factor in adopting this technology. Nonetheless, more and more nurses recognize that PDA technology provides significant resources to improve patient care and safety, and help make their job more efficient and less stressful.

PDA technology has developed rapidly, and health care facilities, and the nurses that staff them may soon find themselves left behind, unless they get in synch with the times soon.