Personal digital assistants (PDAs)

improving patients safety

Personal digital assistants could help revolutionise the
way medicine is being practised. They can be used in
a multitude of settings and for the most varied functions.
Stephen Bolsin, Andrew Patrick and Rita Pal explain
M
edicine is moving into the 21st century,
helped by advances of the computer industry.
Stephen Ryder, consultant gastroenterologist
at Queens Medical Centre in Nottingham, said: NHS
information technology is still in the dark ages, although
it should catch up in the next few years as more money
goes into it. Its first bold step into the technology age
was the 500m contract with Microsoft. An exciting
application for current NHS technology is the personal
digital assistant (PDA), a handheld device that combines
computing, telephone and fax, internet, and networking
features. Unlike portable computers, most PDAs began
as pen based devices, using a stylus rather than a
keyboard for input. This means they also incorporate
handwriting recognition features. Some PDAs can
also react to voice input, using voice recognition
technologies.
Role in assessment and revalidation
The recommendations of the Bristol, Shipman, and
Neale inquiries make assessing performance a vital part
of day to day medicine.
13
Increasing public scrutiny
demands greater accuracy and higher standards in
medicine. PDAs can have a role in assessment and
revalidation. Geelong Hospital in Australia has pro-
grammed the PDA to become the new doctors assistant.
The results are promising and can be applied to a broad
range of hospital specialties as well as general practice.
Many doctors in the United Kingdom admit to being
technophobes, but the Department of Health has devel-
oped the NHS University (NHSU, www.nhsu.nhs.uk) and
the European Computer Driving Licence (ECDL, www.
ecdl.nhs.uk) to help doctors with their computer skills.
The older generation of doctors may view this technol-
ogy with some scepticism, but the exciting advantages
are something that cannot be missed. PDA technology as
the doctors assistant is a positive step into the future
of medicine. With revalidation looming, the PDA could
provide an effective record of performance and free
appraisal procedures from anxiety.
Security issues
Preliminary views from two eminent NHS specialists are
promising. Professor Peter Hindmarsh, consultant pae-
diatrician at Great Ormond Street Hospital in London,
told us Certainly, PDAs are used but more from a
personal perspective to store things such as protocols
and guidelines. That said, they have immense use for
communicating lab information, etc without the need for
pageswhich seem not to be very efficient way of
communication. The main issues I see or rather that we
would come up against are info transfer when it relates
to patients so that would need some hefty firewall and
encryption. Not impossible, however. Stephen Ryder
welcomed the idea of PDAs: I think we would all
welcome better IT use in the NHS, and I certainly think
that PDA approach is a good one and there are already
good examples of benefit from it. Our results are
outlined below and given these positive initial responses
there is no reason why royal colleges, trusts, hospitals,
and healthcare organisations should not welcome this
application of technology. Its value in the post-Shipman
era is unlimited and timely.
Background
Anaesthetic registrars in Geelong, Australia, have been
using PDAs to collect data for several years. The
registrars electronically log their caseload, their specialty
exposure, and their success (or failure) at practical
procedures and report critical incidents.
4
The functions
are easy to incorporate in a PDA and achieved by using
a website to allow trainees to view their performance and
logbook data.
Performance monitoring
Performance monitoring in medicine is a desired goal of
healthcare educators and managers. The recent Bristol
inquiry
1
stimulated efforts to improve performance
monitoring in the NHS and abroad.
5
Anaesthetic regis-
trars in the Geelong hospital are provided with pro-
grammed PDAs on arrival and are then encouraged to
collect their performance at practical procedures hon-
estly and accurately (see box 1). The success or failure
at the procedures, when logged, is converted automati-
cally to a performance chart (Cusum graph) by the
central database.
6
The graphs provide statistically sensi-
tive information about the performance of the trainee
and are used to improve skills acquisition, through
retraining, and optimise trainee exposure to procedures.
These methods can certainly be used for revalidation
and appraisal and exceed current proposals from
the General Medical Council on the assessment of
competence.
Critical incident reporting
This has been the most surprising component of the
programme. We attached the critical incident reporting
module to see if trainees reported incidents; our expe-
rience has been incredibly positive. Registrars will report
critical incidents in about 3% of the cases they under-
take.
4
Fifty per cent of the incidents they report are near
miss incidents, where no patient harm occurred.
4 7
The
most interesting data came from examining case notes
where no critical incident was reported. This confirmed
that registrars had reported 98% of all critical incidents
Box 1: Practical procedures
currently monitored
x Epidural insertion
x Spinal insertion
x Arterial line insertion
x Insertion of a central venous
catheter
x One other procedure designated
by trainee
Box 2: Functions achieved with
PDA technology
x Documentation of and exposure to
caseload
x Procedural monitoring
x Performance charts
x Incident reporting
Box 3: Generations
Ages
Veterans 1935-1950
Baby boomers 1950-1965
Generation X 1966-1980
Generation Y 1981-1995
Features
Veterans: technophobe; unethical;
command-control structures
Baby boomers: technophobe; less
unethical; command-control
structures
Generation X: technophile; ethical;
require inspirational leadership
Generation Y: more technophile and
ethical and required more
inspirational leadership than
Generation X
Box 4: Improvements achieved
with the program
x Improved documentation of
exposure
x Improved procedural performance
x Standardised performance rates
(first year, second year, etc)
x 98% incident reporting
x 50% near miss incident reporting
P
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career focus
BMJcareers 6 AUGUST 2005 57

occurring in their practice.

7
This is in stark contrast to
the attitude of UK NHS trainees. When surveyed by a UK
website, junior doctors indicated 85% of incidents went
unreported.
8
Ethical behaviour
Medical educators have identified deterioration of ethical
standards by medical students and trainees during
undergraduate and postgraduate medical education.
9
The decline is attributed to the hidden curriculum of
medicine.
9
Despite the hidden curriculum, the use of
our PDA programme overcomes the problems immedi-
ately.
5 8 9
This informal observation was so positive we
are planning studies to document the change in attitudes
and ethical behaviour. Our conclusion is that using
current technology in a supportive environment makes it
possible to reverse the negative changes attributable to
the hidden curriculum.
Problems with implementation
Human resource managers now identify four genera-
tions of personnel, and each has different characteristics
(Avril Henry of AH Revelations, personal communica-
tion, 2004)85% of each generation conform to the
characteristics and 15% do not. The age characteristics
and the features attributable to each generation (or 85%
of them) are summarised in box 3. Unfortunately this
implies that senior managers and clinicians in healthcare
organisations in the NHS may not have the right char-
acteristics to identify the problems, let alone to embrace
the solutions. Funding for the initiatives we have under-
taken has come from health insurers and enlightened
(15% dont conform) senior healthcare managers. Until
the baby boomer generation leaves the positions of
power that allow it to halt (or considerably slow) the
implementation of technologically and ethically
appropriate solutions to the problems of healthcare
performance and safety, progress will be slow.
The future
The project is moving forward in interesting and exciting
ways. The introduction of combination PDA smart
phones allows wireless communication between users
and the server database, without any phone lines or a
computer. This enables seamless uploading of patients
information (lab, x ray results, etc) and instant reporting
of critical events.
One development is focusing on the introduction
of electronic versions of paper based clinical path-
ways. Each member of the team who is using a
PDA registers the defined steps of care for patients. By
using the instantaneous wireless interface each of
these steps is relayed back to a central database
for collation, monitoring, and uploading to all team
members. Time prompts are incorporated into the
program, along with decision support information. Box
4 shows improvements achieved with the help of the
program.
One goal of the development team is a large number of
practitioners collecting data in a number of different
institutions and countries, all relaying information back to
a single source. In this way, collective and de-identified
peer related performance and incident data could be fed
back to the individual user. The two way communication
process allows this feedback to the PDA in real time. This
strongly reinforces the age old quality assurance principle
of closing the loop by using relevant data, analysed and
returned in a timely fashion (see diagram). j
Stephen Bolsin associate professor and director, division of
perioperative medicine, anaesthesia and pain medicine,
Geelong Hospital, Geelong, VIC 3220, Australia
steveb@BarwonHealth.org.au
Andrew Patrick specialist anaesthetist and supervisor of
training
Department of Perioperative Medicine, Anaesthesia and Pain
Management, Geelong Hospital, Victoria, Australia
Rita Pal psychiatrist and medical freelance writer
London
tips on . . .
Starting a new
junior hospital job
Starting a new job is daunting
here are 20 tips I wish Id been
given.
x When working very long hours,
go outdoors from time to time to
remind yourself its still there
x Encourage nurses to bleep you if
they are worried. Paradoxically
and wonderfully, you will find
yourself bleeped less often if they
are confident you will come when
they really need you
x Book your annual leave early
x Ask your patients and their
families if they have any questions
x Be wary of people who need
comedy ties to express their
personality
x You need to take breaks to stay
safe. Try not to feel guilty about
keeping patients waiting while you
carry out this essential activity
x Help colleagues out when they are
having a bad day, and dont keep a
tally of who owes you what
x Aim to avoid making mistakes but
dont expect to achieve this. No
one does
x Some doctors are prickly with
colleagues in order to look
important or make their own lives
easier. It doesnt work, and people
dont forget. Dont be tempted
x Go to the loo when you need to
x If the workload is genuinely
unmanageable, find someone
senior as early as possible and tell
them you cant guarantee safety.
If nothing happens (something
usually does), put it in writing
x Drink something every hour, or
you will become dehydrated and
feel awful
x Dont forget to eat, and continue
eating proper meals at night if
youre working
x Enjoy elderly patients
x The moment you start resenting
being bleeped you are guaranteed
to have a bad day
x If someone helps you out, get in
touch promptly to say thanks
x Dont moan alone. Having a good
group moan with your mates is
uplifting
x Learn from the mistakes of others
x Know your chocolate wrappers
x Consider general practice. j
Adam Sandell general practitioner
Adelaide Medical Centre, Newcastle
upon Tyne
Diagram of the system
Go to web extra at bmjcareers.com/careerfocus for
references
career focus
58 6 AUGUST 2005 BMJcareers