I have come to believe that medical progress can be ascertained by closely examining the contents of a medical resident’s white coat pocket. Tradi- tionally, in addition to various paraphernalia and reprinted articles, a resi- dent’s white coat has contained as much reference material and books as that particular resident was able to carry. Although maximum intracranial knowledge was encouraged, occasional perusal of reference material was tolerated at the training level. Conversely, by tradition, attending physicians could be spotted by the relative paucity of any type of onboard books or reference material. Clinical questions, whether in the hospital or the out- patient setting, are usually answered by “cranial resources,” good guesses, or perhaps not at all. Clinical information is usually separated from the patient’s encounter in both time and space, which presents an almost insur- mountable barrier to obtaining accurate, timely, and useful critical information.
As Bob Dylan once wrote, “The times they are a-changin,” and with the advent of pocket-sized PDAs and the ever-increasing capacity of memory chips it has become possible to carry multiple books and resources in a shirt or coat pocket. The purpose of this chapter is to introduce and review these resources. I will place emphasis on the World Wide Web as the ideal place to peruse, evaluate, and, in most cases, download trial and fully functional versions of reference and book software.
Also, please note that we show you alternative ways to get references on your handheld in Chapter 10 by using programs such as iSilo and AvantGo (these amazing programs allow you to put almost any Web content directly on your handheld). We also describe other references in our chapter on Evi- dence-Based Medicine (Chapter 14), and database references are described in Chapter 11. Finally, don’t forget to mine our chapter on Web sites for your handheld (Chapter 4), where numerous treasure troves of medical ref- erences are shown.
7
Medical References: Information at Your Fingertips
Louis Spikol
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Evaluating PDA Medical Books and Reference Material
It should come as no surprise to anyone that there is a significant differ- ence between reading a book in paper form and reading a book formatted for a PDA. In fact, the first thing that should be considered is whether you, the reader, actually actively read medical books or use them as references.
Although some PDA users are able to read lengthy sections of books on their devices without difficulties, some otherwise enthusiastic users consider this task an exercise in patience and eyestrain. My advice for those wishing to read long sections of medical textbooks is to consider either regular books or electronic books for full-size computers/laptops. The PDA plat- form really shines for medical books used as references and evidence-based sources.
The functionality of medical references for PDAs is dependent on both hardware and software factors. Hardware considerations with both the Pocket PC and Palm platform relating to the viewing of books and other references include the following:
• Screen size does vary somewhat across and within both platforms. A larger screen size provides for easier reading, with a trade-off being a larger device size.
• Two devices having the same screen size can differ in their resolution and total number of pixels produced, with the higher-resolution device being easier to read.
• Color versus black and white: color screens are generally easier to read at the expense of shorter battery life, and devices using black and white can vary in shades of gray produced.
• Various software tricks and processes can be used to make print on a small screen appear sharper and easier to read, such as the Microsoft process called ClearType.
• The hardware and the operating system should be able to accommodate different font sizes and appearances that can be adjusted by the user.
• Finally, and perhaps most important, the hardware and operating system should allow expansion cards to hold the large amount of data contained in books and other references. The Palm platform has lagged in this area until recently, with newer models having adequate expansion capability.
The software itself should be able to be installed and run from the expan- sion card.
Software considerations for individual medical books and references are also critically important. Considering the small size of the screen, medical books and other resources ported to the PDA platform must have increased functionality to be useful. Some attributes to look for in PDA books and other medical references include the following:
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• The ability to search for topics in multiple ways, such as the table of contents, the index, and ability to search for specific words and other topics.
• The ability to fit words on the screen in a fashion that is convenient and readable. Many but not all programs have the ability to resize fonts.
• The ability to scroll both vertically and horizontally if needed. The text should be constructed so that scrolling horizontally is minimized. It is also useful to be able to rapidly go between pages as well as go to a specific page.
• The program ideally should allow the user to set multiple bookmarks and return to those bookmarks at a later time as needed.
• Determine if the reference is updated often and, if so, does it cost extra?
Many references provide free updates for a year.
A Survey of PDA Medical Book Resources
Skyscape: www.skyscape.com
Products
Skyscape is the “800-pound gorilla” of the PDA medical book field. They have been releasing and perfecting medical references for the PDA plat- form since the Apple Newton. They carry well over 100 reference books and drug guides (see their website for a listing of all titles) for both the Palm and Pocket PC platform. They have a sophisticated interface that is carried throughout their titles.
Cost
Cost of Skyscape resources depends on the reference; it is comparable to hard copy, with some specials.
Highlights
The typical well laid out format is shown by their Primary Care Medical References (Figure 7.1). The software can show figures, graphs, and charts, as in The Harriet Lane Handbook (Figure 7.2). Search by index (Figure 7.3) or table of contents (Figure 7.4), and choose different text sizes (Figure 7.5).
A unique feature of Skyscape references is the ability to link to other Skyscape titles installed on your PDA (Figure 7.6). Demo versions of books are provided. Updates are free for 1 year. The company discounts certain multiple book packages and runs various specials throughout the year.
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Figure 7.1. A typical Skyscape medical book.
Used with permission from Skyscape, Inc.
Figure 7.2. Harriet Lane table. Used with permission from Skyscape, Inc.
Figure 7.3. Index search. Used with permission from Skyscape, Inc.
Figure 7.4. Table of contents search. Used with permission from Skyscape, Inc.
Handheld Med: www.handheldmed.com
Products
About 30 different medical books including the Merck manual (see their Web site for full listing).
Cost
Cost depends on the book; comparable to hard copy.
Highlights
About 30 different books including the Merck manual. Palm and Pocket PC platform. EZReader software (Figure 7.7) provides one reading plat- form. Multiple ways to search including chapters (Figure 7.8) and index (Figure 7.9).
Figure 7.5. Different text size. Used with permission from Skyscape, Inc.
Figure 7.6. Links to other titles. Used with permission from Skyscape, Inc.
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Figure 7.7. EZReader software. (Reprinted with permission from Handheldmed, Inc.)
Figure 7.8. Chapter search. (Reprinted with permission from Handheldmed, Inc.)
Figure 7.9. Index search. (Reprinted with permission from Handheldmed, Inc.)
Unbound Medicine: www.unboundmedicine.com
Products
Unbound Medicine offers a number of electronic books and CogniQ, “a knowledge management platform integrating handheld devices and the web.” They also have Harrison’s and Ovid online with PDA components, for both Palm and Pocket PC.
Cost
British Medical Journal content is offered through CogniQ as a free trial.
It is uncertain what the future price will be. Harrison’s is $250/year, and Ovid online is sold through resellers.
Highlights
Medical books and journal reference. Routine updates available. CogniQ represents a unique approach to books and journals. The CogniQ main interface (Figure 7.10) shows active subscriptions that are updated via the Internet when the PDA is synched to the computer. Tapping on subscrip- tions expands into the appropriate submenus (Figures 7.11, 7.12) and appro- priate further information (Figures 7.13–7.15). Also notice that the program gives the user the opportunity to either ask more clinical questions or request the full topic. During the next Hotsync, the user is taken to his or her personal information retrieval desktop on the Web (Figure 7.16). Infor- mation can then be managed with the online interface as well as the hand- held computer.
Figure 7.10. CogniQ main menu.
(Reprinted with permission from Unbound Medicine.)
Figure 7.11. CogniQ clinical evidence.
(Reprinted with permission from Unbound Medicine.)
Electronic Drug References
By far the most popular use of PDA’s among healthcare professionals has been electronic drug references. In my opinion, all of them are easy to use and provide a wealth of features. Special features to be noted include drug interaction checking, updates via the Web, and state-specific formulary checking.
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Figure 7.12. CogniQ journals. (Reprinted with permission from Unbound Medicine.)
Figure 7.13. CogniQ citation. (Reprinted with permission from Unbound Medicine.)
Figure 7.14. CogniQ journal. (Reprinted with permission from Unbound Medicine.)
Figure 7.15. CogniQ more information.
(Reprinted with permission from Unbound Medicine.)
Epocrates: www.epocrates.com
Products
Epocrates Rx (Palm Platform only) and Rx Pro (Palm and Pocket PC).
Cost
Epocrates Rx, free; Epocrates Rx Pro, $50/year.
Highlights
Both versions have interaction checking, formularies, and auto-updates. The Pro version has infectious disease information, alternative medicine, clini- cal tables, and med math. The Pocket PC version doesn’t offer infectious disease information, Doc Alert Messages, or MedMath at the time of this printing. They are scheduled to be added.
Highlights
Epocrates is the most popular medication PDA reference. It has a very nice clean interface (Figures 7.17, 7.18), with sections for pediatric dosing (Figure 7.19) and pregnancy and lactation (Figure 7.20). A particularly useful aspect of the program provides specific insurance formulary infor- mation with drug alternatives (Figure 7.21). Other parts of the professional edition include doctor alerts (sent to your handheld each time you syn- chronize over the Internet), infectious disease information, and tables (Figures 7.22–7.25).
Figure 7.16. CogniQ Web interface. (Reprinted with permission from Unbound Medicine.)
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Figure 7.17. Epocrates lookup. (Reprinted with permission from Epocrates.)
Figure 7.18. Epocrates drug information.
(Reprinted with permission from Epocrates.)
Figure 7.19. Epocrates pediatric dosing.
(Reprinted with permission from Epocrates.)
Figure 7.20. Epocrates pregnancy information. (Reprinted with permission from Epocrates.)
Figure 7.21. Epocrates formulary information. (Reprinted with permission from Epocrates.)
Figure 7.22. Epocrates extras. (Reprinted with permission from Epocrates.)
Figure 7.23. Epocrates infectious disease.
(Reprinted with permission from Epocrates.)
Figure 7.24. Epocrates tables. (Reprinted with permission from Epocrates.)
Figure 7.25. Epocrates doctor alerts.
(Reprinted with permission from Epocrates.)
Tarascon Pharmacopoeia: www.tarascon.com
Products
Tarascon Pharmacopoeia is the electronic version of the well-known pocket drug reference (Palm and Pocket PC platform).
Cost
Approximately $30 annually.
Highlights
Drug search by index or class (Figure 7.26). The program has drug interac- tion checking (Figure 7.27).
Mobile PDR: www.mobilepdr.com
Products
Mobile PDR (Palm and Pocket PC platforms).
Cost
Free.
Highlights
Drug search by index (Figure 7.28). Well laid out information (including
“black box” warnings) with the ability to add notes (Figure 7.29). The program provides interaction checking (Figure 7.30) and medication alerts that are updated when you synchronize (Figure 7.31).
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Figure 7.26. Tarascon main. (Reprinted with permission from Tarascon publishing and USBMIS, Inc.)
Figure 7.27. Tarascon interactions. (Reprinted with permission from Tarascon publishing and USBMIS, Inc.)
Figure 7.28. Mobile PDR index.
(Reprinted with permission from The Thomson Corporation.)
Figure 7.29. Mobile PDR drug information. (Reprinted with permission from The Thomson Corporation.)
Figure 7.30. Mobile PDR interactions.
(Reprinted with permission from The
Thomson Corporation.) Figure 7.31. Mobile PDR alerts.
(Reprinted with permission from The Thomson Corporation.)
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Medication Program (Platform)
Cost Web
Updates Interactions Formulary
Information Extras
Epocrates (Palm)
Rx-free Rx Pro- 50$\Yr
Yes Yes Yes
Rx-Doctor alerts
Rx Pro:Infectious disease,clinical
tables, medmath, alternative medications Mobile PDR
(Palm and Pocket PC)
Free Yes Yes No Doctor Alerts
Tarascon Pharmacopeia
(Palm and Pocket PC)
Free (During beta test)
Yes Yes No
Medical calculator Drugs by class
Tables Figure 7.32. Drug reference comparison table.
Shown in Figure 7.32 is a table comparing the salient features of the drug database programs. Please check the Web sites for the individual products because features and cost tend to change over time.
HANDS-ON EXERCISE 7.1. DOWNLOADING AND INSTALLING A MEDICAL REFERENCE
In this tutorial, we download and install the trial version of 5 Minute Clin- ical Consult from Skyscape to our Palm and Pocket PC, respectively. First, go to the Skyscape Web site (www.skyscape.com), click on “Products,” and navigate to your desired book.
1. Click on “Download the trial version” (Figure 7.33) and then choose your platform (PC or Macintosh, Palm or Pocket PC; Figure 7.34).
2. When the download dialog box appears, click on “Save” (Figure 7.35).
Remember to note where on your computer the book file is being saved and what it is called (Figure 7.36). The download will then proceed (Figure 7.37).
Figure 7.33. Skyscape download. Used with permission from Skyscape, Inc.
Figure 7.34. Skyscape choose product. Used with permission from Skyscape, Inc.
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Figure 7.35. Skyscape save. Used with permission from Skyscape, Inc.
Figure 7.36. Skyscape location. Used with permission from Skyscape, Inc.
3. For the Palm: after the file has transferred to your computer, find it and click on it. Click on the type of installation you prefer (Figure 7.38) and which device you prefer (with one device, it will just say “Next sync oper- ation”; Figure 7.39).
4. The next dialog box (Figure 7.40) gives you a choice between putting the book in main memory or a storage card. Most of the time, you will choose a storage card. The program will then be installed on the next Hotsync.
For the Pocket PC, go through a similar routine of downloading the appro- priate file. Make sure your Pocket PC is connected and ActiveSync is running.
1. Clicking on the program will produce similar screens as the Palm version, with a different screen detecting the Pocket PC and offering to proceed with the installation (Figure 7.41).
Figure 7.37. Skyscape downloading. Used with permission from Skyscape, Inc.
Figure 7.38. Skyscape trial. Used with permission from Skyscape, Inc.
Figure 7.39. Skyscape user. Used with permission from Skyscape, Inc.
Figure 7.40. Skyscape Palm install. Used with permission from Skyscape, Inc.
Figure 7.41. Install Pocket PC. Used with permission from Skyscape, Inc. and Microsoft Corporation.
2. Choosing not to install in the default installation directory will bring up a screen where you can specify the location for installation (Figure 7.42), which will then proceed (Figure 7.43).
Final Words and Hot Tips
There is an old adage in medicine that clinical questions remain the same but the answers change every 5 years. I strongly believe that medical ref- erences in electronic format should take advantage of the strengths of this format. These main strengths include the ability to be easily updated and easily searched and the potential to provide personalized information.
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Figure 7.42. Install card. Used with permission from Skyscape, Inc. and Microsoft Corporation.
Figure 7.43. Install Pocket PC finish. Used with permission from Skyscape, Inc.
and Microsoft Corporation.
Certainly some of these references (drug references and CogniQ from Unbound Medicine, in particular) have taken advantages of the strengths of the electronic format. Most of the other references can be easily updated, but continue to be connected to the printed version, in my opinion. So, I leave you with a few quick tips regarding electronic references on PDAs:
• Many companies offer trial downloadable versions from the Web. Take advantage of this to try out the products and see how often you need to use them. Also, pay attention to the book’s functionality and ease of use.
• Carefully match the particular drug database to your needs.
• Strongly consider products that have frequent updates.
• Backup your electronic medical books in case of a computer crash.
• Make sure the books or drug database are compatible with your partic- ular PDA and can be run from expansion cards if you desire.
• Finally, carry your PDA with you during rounds and in the office. Patients will certainly be impressed that you are consulting up-to-date informa- tion to better care for them with such information at your fingertips!
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