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Palm devices in dermatology

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The use of personal digital assistants in dermatology
Noah Scheinfeld MD
Dermatology Online Journal 12 (3): 8

St Lukes Roosevelt Hospital Center Department of Dermatology, New York NY.

Cui bono fuerit—"Who benefits" asked Lucius Cassius Longinus Ravilla Roman senator in the 2nd century BCE when trying to understand the motives that lay behind an action. The use of personal digital assistants (PDAs) in the practice of medicine and dermatology has grown in recent years as has the number of PDA applications [1, 2]. Who benefits from the use of handheld devices in medicine? Perhaps when we assess this question we must start by considering the most successful and visible success in handheld medicine—Epocrates—and then a few less successful deployments.

When Epocrates came out it transformed the way that interns, residents, fellows, and medical students acquired pharmaceutical data [3, 4]. A free program, it swept away its competitors (in particular Tarascon's Pocket Pharmacopoeia, which since its genesis less than a decade before had achieved a ubiquity in the hospital). Why did Epocrates succeed? First it was free if you had a Palm based PDA; Pocket Pharmacopoeia cost $7-8 dollars. You had to use the index in the Pocket Pharmacopoeia; with Epocrates you just typed in a name. I recall as a student squinting at the 2 or 3-point type of the Pharmacopoeia in dimly lighted hospital corridors and the shock of viewing the 10-point type of Epocrates. Epocrates was updated simply by syncing it. The real genius of the Epocrates was its use of a relational database that allowed drug interactions to be checked for any medication in seconds. Epocrates is a small footprint program that gives important, relevant, small, discrete quanta of information. It has a spare lyrical simplicity that makes information no more distant than four or five taps. Who benefits? Physicians, fellows, residents, interns, medical students, and (most importantly) patients benefit. Who loses? the competitors of Epocrates. The success of PDAs, exemplified by the Epocrates module, has not been repeated by other medical information programs. Successful textbooks, such as Dermatological Treatment by Lebwohl et al. [5] and successful on-line resouces, such as eMedicine [6], do not seem to be as useful on the PDA. Why isn't the PDA version of eMedicine as successful as the on-line version? The desktop version is free and the PDA version costs $50-100. The desktop version has a fullly standardized set of data and the PDA is more an outline than a text. The information too cursory. Because it is not free and because it is abbreviated, the penetration of the PDA version of eMedicine is fractional compared to Epocrates.

The PDA was also supposed to transform medical billing. This was attempted in the Albert Einstein Medical School Division of Dermatology at Jacobi Medical Center in the Bronx. Residents were trained and given Palms with Patient Keeper billing software [7]. It was a debacle, their use saved no time. The Palms would not sync at times. They could not acquire information from the medical record, which was paper and not digital. Everything had to be inputted manually taking 1-2 minutes per patient. In a clinic where each resident saw 15 patients, this added an extra 15-30 minutes of work. Sometimes information was lost and sometimes codes could not be found. Besides, the residents got paid whether bills were generate or not generated. When problems happened the resident did not prepare bills or wrote them out. The donation of an LCD projector to the Division of Dermatology by the Jacobi's Information technology office was gladly accepted by the residents but did not change their habits or actions. The hospital supervisor who deployed this project was round criticized and almost dismissed. The system was withdrawn. Who would have benefited? The hospital. Who did not perceive a benefit? The residents. Who could keep their jobs and get paid if the system failed? The residents. As such, the people who did the work did not benefit and the system failed.

More recently, I have been subjected to a new Palm billing program. Its name is MDeverywhere [8]. It runs on a desktop or Palm. It is not part of an EMR but rather is parallel to the medical record. Thus, MDeverywhere adds to work. Circling a diagnosis code, 2 procedure codes and writing two modifiers takes 20 seconds on paper, but on the Palm it takes 20 taps and 3 minutes. Most bills take 5-10 taps (site of visit tap "doctors office", place of visit tap "Beth Israel", insert procedure tap "a diagnosis from favorite diagnosis list," linking procedures to diagnosis tap "diagnosis", etc.). Moreover, some bills still need to be filled out on paper because the hospital does split billing (i.e., it bills medical services facility fees separately for Medicare patients). The information that was formally input by a biller paid by the hospital is now done by a physician whose salary remains unchanged (although it is possible fewer bills will be rejected). The doctor is paid the same salary as before although he or she has to work at the very least 15 minutes and at the most 30-40 minutes to enter the data.

Other departments besides dermatology seem to have greater acceptance rates for the MDeverywhere system, but they do not see as many patients per hour nor do they perform as many small procedures as dermatologists. Unlike the system at Jacobi, the pay of the dermatologists at St Lukes-Roosevelt and Beth Israel depends on input data so they must input data or forego their salaries. Thus, because the system ties payment to use, it is sustainable and at least a limited success.

The MDeverywhere PDA billing system's actual efficiency, efficacy, and effect is dubious. The dermatologists who use the system are working more for the same salary. The system has substituted the labor of a busy dermatologist for a $25 per hour biller, but then the hospital pays the biller and the doctor gets the same percentage of billing as before. The system is not popular among the attending doctors in our Department of Dermatology but it is a take it or leave it system. The dermatologists did not shape the billing interface nor will the hospital customize it to their needs; that would cost the hospital more money. The system has been a blow against morale. In sum, the system does not make money, rather it shifts labor, a specious efficiency. At least for the dermatologists, an incomplete deployment of PDA technology decreases efficiency, efficacy, and utility more than no PDA deployment at all.

It is said that electronic medical records (EMR) do not save time. The time saved by not filing charts is taken up by a systems analyst maintaining the EMR. The time to type in a note is not much less than the time to write a note. The benefits to an EMR come elsewhere from decreasing medical errors and increasing the availability and replicatability of data. It is not yet known if EMR will change outcomes. The great work of outcomes analysis and EMRs remains.

How could digital technology save dermatologists time? By having a doctor type a word once and have it appears in the several places it needs to go. Example type "doxycycline 100 mg BID" and it appears in the chart, on an automatically generated prescription and to the pharmacy and insurance company. Type acne in the chart and have 706.1 appear in the billing statement. We are still waiting for this to happen.

What are we to learn from all this? It could be that the PDA is just a bridge to something else. Already integrated PDA cell phones are the fasted growing part of the cell phone and PDA markets. Perhaps physical examination and billing data could just be spoken into the cell phone and appear where they need to appear. Perhaps tablets with perfect hand writing recognition and wireless capabilities will allow the physicians to scribble the notes as they usually do and have the data transformed into type that allows for effective recording of medical data and billing. We dermatologists may have to wait a while for dissemination of the benefits of technology, handheld or otherwise. Who will benefit from all the changes in handheld use? As Chou En Lai said when asked what he thought of the French Revolution "It is still too soon to tell."


1. Scheinfeld N, Goldblum O. Handheld Computers in Dermatology. Emedicine (accessed November 28, 2005)

2. Goldblum OM: Practical applications of hand-held computers in dermatology. Semin Cutan Med Surg 2002 Sep; 21(3): 190-201[Medline]. (accessed November 28, 2005)

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4. Fox GN, Gill KU, Music RE: Epocrates Essentials: Is the expanded product an improvement? J Fam Pract 2005 Jan; 54(1): 57-63[Medline]. (accessed November 28, 2005)

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