Abstract

When it comes to the adoption of portable information technology devices called personal digital assistants and the selection of new application software to be used on the personal digital assistant, most healthcare professionals in general, including pharmacists, are in a dilemma as to which hardware and software applications are best suited for them. Having made a personal digital assistant device selection, an even more difficult task is deciding which of the hundreds of clinical applications should be installed on their personal digital assistant for everyday practice. This article provides an overview of the personal digital assistant-based clinical software applications that are most important and relevant for use by practicing pharmacists in any community setting.

One of the biggest challenges faced by practicing pharmacists is information overload. Today's information age presents a significant burden on practicing pharmacists, forcing them to manage an enormous base of knowledge about medications and disease states. It is very hard to keep track of the ever-increasing evidence-based information applicable to pharmacy practice. From a practical perspective, pharmacists must be able to readily retrieve drug information that is timely and accurate and assists them in making treatment decisions at the point of care. Like professionals in any specialty practice, pharmacists spend much of their time identifying, solving, and preventing problems relating to their area of expertise-in this case, drugs.1,2 Information technology is perhaps the best example of how technology can enhance human performance in health care by overcoming the limitations of memory and reducing the use of conjecture in clinical decision making.

It is a well-recognized fact that the rapid advancement of information technology in health care has influenced many aspects of the practice of medicine and pharmacy. The term "pharmacy informatics" refers to the field that uses specialized applications of information technology such as computers and other related tools for improving and advancing pharmacy practice.' One of the most useful information technology tools now available is the handheld computer or personal digital assistant (PDA). The degree of adoption of PDAs has increased in the last decade to a relatively high level, and paralleling the tremendous growth in PDA use has been an extensive increase in the number of medical and other healthcare applications that have been created for PDAs.1,4

Personal digital assistants have been utilized in any number of ways by pharmacists in their practice. Certain features of the device, such as its portability, storage capacity, usability, and price, make it an excellent data management tool. The practical applications of PDAs have expanded from basic personal information management to clinical decision support. It is chiefly the availability of evidencebased clinical software applications that has made the PDA a truly valuable and influential clinical decision-support tool. Vast amounts of information about diseases, drugs, over-the-counter products, and alternative therapies can be retrieved via software applications that can be downloaded. Pharmacists can use a PDA to supplement their clinical experience and judgment, reducing uncertainties involved in clinical decision making.1,5

Today, handheld computers have become an essential part of pharmacy practice.6 More and more healthcare practitioners are utilizing their PDA as a replacement for notebook and desktop computers. Many practicing pharmacists have fully adopted PDAs for use as personal information managers and are using theirPDA primarily as a mobile clinical reference tool. Some pharmacists are using PDAs as a professional and patient education tool. Regardless of the purpose for which a PDA is used, most pharmacists will find these devices to be very resourceful and valuable in their day-to-day practice.7

Choosing a PDA

The initial concern of people interested in purchasing a PDA is determining which one to buy. One of the first decision points relates to the available operating systems. Before buying a PDA, it is very important to decide which operating system to use. Basically, Palm OS and Pocket PC (Windows CE) are the two types of operating systems for handheld applications. The Blackberry system is a third type of PDA, but it will assist in clinical decision-making only if it is used with one of the other two operating systems, because little pharmacy software is available for the Blackberry platform.

Palm OS is currently the leader and offers the most pharmacy applications to the user. Palm OS offers some basic advantages such as small size and ease of use for both new and experienced users. This is the main reason that a large number of software applications have been built for Palm OS; however, more and more are being developed for both systems. More than 800 programs for medicine and pharmacy are available for Palm OS, whereas just over 200 are available for Pocket PC. The Pocket PC platform is a scaled-down version of the desktop Windows OS, and its memory and processor requirements are fairly large. Therefore, any PDA software application that runs on Pocket PC requires a fast processor and relatively large amounts of memory. The biggest advantage of Pocket PC is that it allows multiple tasks to run simultaneously on the PDA, whereas the Palm OS has not yet developed that capability. The PDA with Palm OS is designed more as a personal management or information tool, whereas Pocket PC is often seen as more suitable for business purposes.2,5,8

Guide to PDA Clinical Software Core References

Comprehensive information about the PDA software applications that are currently available for healthcare practitioners can be found on several websites. Choosing the best information resources depends on the practitioner's information needs, knowledge and skills, and workload and workflow. Table 1 lists some of the important PDA healthcare websites.9

Most of the PDA resource websites mentioned in Table 1 contain a comprehensive list of medical applications available for use by healthcare practitioners. These include general drug information resources, drug interaction programs, diagnostic programs, herbal/ alternative medication references, and specialty references such as cardiology, infectious disease, and pediatrics. There are hundreds of clinical software applications that have been designed and developed specifically for PDAs. As of September 2004, 863 Palm OS healthcare software applications were available for download from a single site, www.healthypalmpilot.com. These included 147 diagnostic tools (identification and classification of disease), 58 health and fitness tools (lifestyle modification tools), 146 intervention programs (procedural and treatment protocols), 110 record-tracking tools (databases for tracking care), 300 references (textbook references on the medical knowledge base), and 38 research tools (critical assessment tools).10 Although comprehensive, this website does not offer an exhaustive listing of all Palm OS software applications that are available to the clinician.

Categories of Clinical Applications

We believe that every pharmacist should have certain core resources loaded onto a PDA; these include a drug reference; an interaction analysis tool; a disease reference; a laboratory reference; a pharmacy calculator; a record tracker; an intervention documenter; patient education resources; and a source for clinical pearls, algorithms, and guidelines. PDA efficiency utilities are optional but recommended. Additional resources can be added to meet individual needs.8 Some of these applications are free, and some are available by subscription. The important clinical categories are outlined in Table 2.

PDA Clinical Tool Evaluation Criteria

With hundreds of clinical software applications available for PDAs, determining which specific applications to use is very difficult for the pharmacist. A choice of software packages is available for most clinical needs, each developed and/or marketed by a different software development and publishing company. It is essential that the pharmacist decide which software package(s) offer the best value for the dollar investment. Clinical software applications are not equal with regard to content, frequency of updates, and memory requirements. It is very important that pharmacists critically evaluate the resources using criteria that enable comparison of different software packages, thus ensuring purchase of programs that are up-to-date, relevant, and accurate. The following criteria are useful to a practicing pharmacist for thorough evaluation of clinical software packages for the PDA:5,11

* Accuracy - Is drug information correct and free of any errors?

* Comprehensive - Does the software provide all information needed? The program should not leave out critical information.

* Cost - How much does the subscription cost? Does this include updates? Are the benefits derived from using the software worth the price you pay?

* Memory requirements - How much memory space is required to install the software package? Can the software reside on a memory card?

* Time interval of updates - How often is the software updated with new information?

* User friendly - Is the software easy to use and understand? The user should require minimal training for practice applications, and installation and updates should be easy to manage. Navigation of the program should seem intuitive.

Clinical Software Evaluation Study

A clinical software evaluation research project funded by Avenus Pharmaceuticals was conducted in the summer of 2002 by Auburn University's Harrison School of Pharmacy Department of Pharmacy Care Systems. A 19-member expert panel consisting of 6 physicians and 13 pharmacists from across the US participated in the study and responded to questions concerning software applications and their respective benefits as applicable to their practice. The panel was divided into a pharmacist group and a physician group. Members of both groups were given a Handera 330 PDA with 50 different software applications and were asked to use the device in their practice environment for a period of 9 weeks. The 50 software applications were grouped into 12 different categories based on the software purpose. After using the software applications in practice, the expert panel members completed an online evaluation form indicating their level of satisfaction with the software based on several criteria, such as quality of content, ease of use, benefit in practice, appeal of layout, and utility design. Table 3 summarizes the results of these evaluations. Of the nine drug databases compared, Lexi Interact and Lexi Drugs were ranked highest by pharmacists in all categories. Physicians ranked ePocrates qRx the highest. Both pharmacist and physician expert panel members reported 5-Minute Clinical Consult as the software that contained the richest content while being most reliable, error free, and easier to learn than the other medical databases. Moreover, members of both panels reported that 5-Minute Clinical Consult was useful, beneficial, and made their practice more efficient. Finally, members of both panels felt that 5-Minute Clinical Consult had a more appealing layout and was easier to understand, navigate, and find information than the other diagnostic software applications.12

Lowry et al subjectively analyzed and evaluated 10 drug information databases on the basis of their experience in using the software application as well as the information available from the product's website and the vendor's website. The study demonstrated that the 10 drug information databases were not equivalent in their content, author credentials, frequency of updates, or memory requirements.13 In several other studies that evaluated and conducted head-to-head comparisons on the scope, breadth of coverage, clinical dependability, and ease of use of different drug information databases for PDAs, Lexi-Drugs Platinum was preferred and regarded as the best drug reference software application according to the criteria described by the audiors.14-16

PDA Resource Libraries for Specialty Pharmacy Practice

In a recent paper on PDA pharmacy applications, Fox and Felkey identified and created lists of software applicable to five specific pharmacy practice types: pharmacy administrators, nutrition pharmacists, oncology pharmacists, pediatric pharmacists, and pharmacists focusing on pharmacotherapy.17 Even though the lists are not exhaustive, they serve as a good starting point for each of the practice settings.

Pharmacy Administrators

The needs of pharmacy administrators are different than those of their clinical counterparts. For pharmacy administrators, office applications such as word processing, spreadsheet, and presentation files are most important. Accordingly, pharmacy administrators should equip their PDAs with such applications. These programs are categorized either as document managers that enable creation and editing of files directly on the PDA or document readers that allow the user to read (but not edit) the existing office-type documents (Table 4).

Nutrition Support Pharmacists

Pharmacists who specialize in nutrition support services usually provide parenteral or enterai nutrition formulations, and therefore rely heavily on patient-specific information to tailor nutrition requirements according to the individual's need. A basic reference on clinical nutrition support is almost always required. While numerous paper-based references are available for nutrition support pharmacists, PDA-based references in this area are lacking. References targeted to other clinicians are available, however, including Nutrition and Diagnosis-Related Care for PDA (5th ed.). Nutrition support pharmacists also perform many calculations as part of their routine patient care activities. Table 5 lists some of the important PDA-based software calculators that are deemed necessary for nutrition pharmacists.

Oncology Pharmacists

Pharmacists who specialize in oncology focus on accurate disease recognition and effective treatment, while simultaneously addressing quality-of-life issues. They should equip their PDAs with references and drug databases that provide specialized chemotherapeutic information. Table 6 lists some of the useful PDA-based applications that assist oncology pharmacists in addressing their specialized routine activities.

Pediatric Pharmacists

Pharmacists who specialize in pediatric pharmacy practice should have access to unique resources and tools specifically about infants and children. These include specialized drug databases that provide information specific to the use of medications in children and numerous programs that provide dosing calculations for oral and intravenous mediations. Software applications that can track development of children, such as STATGrowth or Riley Kidometer, are also important and useful for pharmacists who practice pediatric pharmacy. Table 7 lists some of relevant software applications for this group of practitioners.

Pharmacotherapy Focus

Pharmacists practicing with an emphasis on pharmacotherapy often work with other healthcare professionals to optimize patient outcomes. They should be well-equipped with the most current, complete, and accurate drug database applications. Moreover, they are responsible for checking for any possible drug interactions, performing appropriate pharmacokinetic calculations, and compiling patient information profiles to gain a complete understanding of a patient's condition. Table 2 summarizes the various PDA resources that are helpful for pharmacists having a pharmacotherapy focus.17

Needs of Compounding Pharmacists

The dispensing activities performed by compounding pharmacists constitute an entirely unique specialty. Some of the PDA-related applications that would be relevant and most useful for compounding pharmacists are outlined here.

Compounding is generally considered the art of tailoring medications to suit the individual needs of patients. It allows pharmacists to prepare specific medications and medication strengths or dosage forms that otherwise may not be available commercially. Most compounding pharmacists work together with the prescriber and the patient: the prescriber first prescribes the medication; the pharmacist then takes the necessary ingredients, compounds them, and dispenses the prepared medicine to the patient and provides consultation or patient education. Connectivity between prescribers and pharmacists and pharmacists and their patients can be facilitated through the use of PDA applications. The technology supports the pharmacist's ability to provide patients the personalized care they deserve.

Although there is evidence that the PDA has been used extensively by pharmacists who practice in more traditional pharmacy settings, PDA use among compounding pharmacists is not well documented. One of the reasons for their potentially lower rate of use could be the small number of software applications designed specifically for compounding pharmacists. Generally, however, compounding pharmacists can utilize existing PDA-based drug references to reduce uncertainty in decision making or to spot potential problems such as drug interactions within a regimen. They also can use PDAs to reduce the amount of paper they use every day in their practice (e.g., for documenting interventions or to log compounding activities). PDAs can be used for patient education purposes by generating printed leaflets on demand or for displaying multimedia still-in-motion images to explain to patients the use of medications in their treatment. PDA utilities may improve pharmacists' work efficiency by facilitating connectivity with both prescribers and patients.

We believe that pharmacists can quickly customize documentation software and data forms themselves or modify off-the-shelf products such as RxRounds, HealthProLink, or Pharmacy Information Documentation Solution (PIDS) to maintain information on their patients, including history, medication profile, and other important clinical data. Eliminating the need to maintain and store paper-based files will improve operations in most practices. By moving to a more digital environment, compounding pharmacists can easily access patient information anytime they desire. Furthermore, they can make use of PDA document management applications such as Microsoft Excel spreadsheets or other database management software for keeping inventory of their supplies and equipment. Other software applications could be useful for maintaining current contact information for all suppliers, vendors, manufacturers, and wholesalers that supply them their compounding needs.

Compounding pharmacists may someday have more PDA software available to help them compound and meet the specialized needs of prescribers and their patients. Until that time, available applications could increase their efficiency and help them meet their clinical and business goals.

Recommendations for Specific PDA-Clinical Application Software

Table 8 outlines some of our recommendations on specific clinical PDA application software for practicing pharmacists. The recommendations provided are based on information such as cost per year, memory and operating system requirements, frequency of updates, specific strengths and weaknesses, and features provided on all the clinical software applications reported in various review articles and comparative studies conducted on the different software applications.

References

1. Felkey BG, Fox Bl. PDA interface: The case for the personal digital assistant (PDA). Hosp Pharm 2002; 37(4): 418-422.

2. Stolworthy Y, Suszka-Hildebrandt. Mobile Information Technology at the Point-of-Care. [Medscape Website.] Available at: www.medscape.com/ viewarticle/408421. Accessed April 23, 2005.

3. Felkey BG, Villaume MA. The integration of technology into pharmacy education and practice. Int J Pharm Ed [serial online]. 2004; 2(1). Available at: www.samford.edu.schools/pharmacy/ijpe/104/104.htm. Accessed April 23, 2005.

4. Tudiver F. The usefulness of personal digital assistants for health care providers today and in the future. South Med J 2003; 96(10): 947-948.

5. Keplar KE, Urbanski CJ. Personal digital assistant applications for the healthcare provider. Ann Pharmacother2003; 37(2): 287-296.

6. Bertling CJ, Simpson DE, Hayes AM et al. Personal digital assistants herald new approaches to teaching and evaluation in medical education. WMJ 2003; 102(2): 46-50.

7. Fox Bl, Felkey BG. PDA data integrity and security. Hosp Pharm 2004; 39(7): 693-694, 696.

8. Felkey BG, Fox Bl. Beyond the basics: Using your PDA as a powerful clinical tool. Presented at: American Society of Health-System Pharmacists Annual Midyear Meeting; December 8, 2002; Atlanta, GA. [American Society of Health-System Pharmacists Website.] Available at: www.ashp.org/ce-self study/highlights02.pdf. Accessed September 9,2004.

9. [No author listed.] Auburn University's PDA Resource Center. [Auburn University Website.] Available at: frontpage.auburn.edu/pharmacy/pcs/pda/ resources.htm. Accessed April 23,2005.

10.[No author listed.] Healthy PaimPilot: Health care resource index. [Healthy PalmPilot Website.] Available at: www.healthypalmpilot.com. Accessed April 23, 2005.

11. Felkey BG, Fox Bl. PDA interface: Evaluating clinical software for your PDA. Hasp Pharm 2002; 37(9): 990, 992,1000.

12.[No author listed.] PDA Software Evaluation Research. Conducted by Auburn University and Aventis Pharmaceuticals. [Auburn University Website.] Available at: frontpage.auburn.edu/pharmacy/pcs/pda/results/resultse_ mcoder.htm. Accessed April 23,2005.

13. Lowry CM, Kostka-Rokosz MD, McCloskey WW. Evaluation of personal digital assistant drug information databases for the managed care pharmacist. J Manag Care Pharm 2003; 9(5): 441 -448.

14.Enders SJ, Enders JM, Holstad SG. Drug-information software for Palm operating system personal digital assistants: Breadth, clinical dependability, and ease of use. Pharmacotherapy2002; 22(8): 1036-1040.

15. Clauson KA, Seamon MJ, Clauson AS et al. Evaluation of drug information databases for personal digital assistants. Am JHealth Syst Pharm2004; 61(10):1015-1024.

16. Barrons R. Evaluation of personal digital assistant software for drug interactions. Am J Health Syst Pharm 2004; 61 (4): 380-385.

17.Fox Bl, Felkey BG. PDA interface: Building specialty practice resource libraries. Hosp Pharm 2003; 38(10): 985-989.

18. Keplar KE, Urbanski CJ, Kania DS. Update on personal digital assistant applications for the healthcare provider. Ann Pharmacother2005; 39(5): 892-907.

Nikhil G. Khandelwal, MS

Bill G. Felkey, MS

Pharmacy Care Systems

Auburn University

Harrison School of Pharmacy

Auburn, Alabama

Address correspondence to Nikhil G. Khandelwal, MS, Research Associate, Pharmacy Care Systems, Auburn University, Harrison School of Pharmacy, Auburn, AL 36849. E-mail: khandni@auburn.edu

Copyright International Journal of Pharmaceutical Compounding Sep/Oct 2005
Provided by ProQuest Information and Learning Company. All rights Reserved