Buying a handheld? Consider these five key factors

Size is still an important consideration, but issues like screen quality can be just as critical

Copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

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Eric G. Tangalos, FACP, doesn't know everything there is to know about handheld computers. And frankly, he doesn't want to.

Ask him why he chose the model he did—a Palm m500—and he gives a simple reply: He's "not one of those aficionados" who can tell you every gizmo on every model. "I went with what was mainstream stuff out there," said Dr. Tangalos.

In fact, the 52-year-old internist and geriatrician at the Mayo Clinic in Rochester, Minn., got his first handheld computer, also known as a personal digital assistant (PDA), only about a year and half ago. "I'm not fascinated by the technology," he said. "I just want it to work for me."

You don't have to be a techie to see the benefits of using a PDA, a mini-computer that sits in the palm of your hand. Physicians are increasingly using these tiny computers to track schedules or patient contacts, check drug dosages and interactions at the bedside, download journal abstracts to read on the fly, take notes at lectures and even show images or movies to patients who want to better understand conditions and procedures.

Manufacturers abound—Palm, Compaq and Sony, to name just a few-and models change all the time. Prices range from about $150 on the low end to more than $500. With so many choices, the first difficult step when looking for a PDA is determining what features you'll need.

"The key issue is what you see yourself using, and what do you see as possible to use," said Michael H. Zaroukian, FACP, a general internist, program director for Michigan State University's internal medicine residency in East Lansing and the university's medical director of information systems. "Part of that is imagining what you might use it for."

Here are some of the major issues to consider.

1. Size. This is what techies call "form factor": the way a PDA feels when you're holding it in your hand, and how easily it will slip into your pocket.

A "slim profile," for example, was a top priority for Dr. Tangalos, who is a member of the College's Medical Informatics Subcommittee. He keeps his Palm in the right inside pocket of his sportscoat, while his stethoscope sits in his left pocket.

"Some physicians won't carry a handheld at all unless it is literally as small as their palm," Dr. Zaroukian said.

Keep in mind, though, that in exchange for a smaller device, you give up screen size. That means you'll have to do more scrolling when reading text, which could prove frustrating if you plan to do a lot of reading-or if you're looking for a specific piece of information in a hurry.

2. Memory. Machines come with a certain amount of memory, which allows you to use several programs at the same time. Newer machines also include an expansion slot that lets you add memory as you introduce new software to your machine. Memory comes in a number of formats (such as Memory Sticks, CompactFlash, SD), depending on the PDA manufacturer.

The good news is that memory comes relatively cheap. A recent Internet search, for example, found a 128 megabyte Memory Stick for only $68.

Whether you'll need a memory boost depends on the type of applications you'll use—and how many.

Sarah T. Corley, FACP, bought an additional 8 megabytes of memory when she first purchased her Handspring Visor a few years ago, doubling the memory that came standard with the device. Dr. Corley, an internist at University Medical Associates and associate professor at the University of Virginia in Charlottesville, uses several medical calculators, a program that contains CPT codes, a medical Spanish dictionary and ePocrates, a clinical drug database. "I don't recall using the additional memory," Dr. Corley said. "I have it, but I have not needed it."

If you hold off on purchasing additional memory for your machine, buy a model with an expansion slot so you can bulk up on memory later.

If you're a new user and unsure exactly which programs you'll be using, you can hold off on purchasing additional memory. But your best bet is to buy a newer machine with an expansion slot so you can add more memory later.

Gary J. Kerkvliet, ACP-ASIM Member, a general internist at Sinai Hospital's faculty practice in Baltimore and associate program director at the Johns Hopkins/Sinai Hospital program in internal medicine, recently upgraded from an older Palm PDA with 8 megabytes of memory and no expansion capability. He replaced it with a Sony CLIÉ, which has double the standard memory of his old machine and an expansion slot.

His boss had given him a new electronic medical reference manual that uses 4 megabytes of memory. Because he was already storing so much patient information on his PDA, he found that he needed more memory.

3. Input. Handhelds typically offer some form of handwriting recognition. Palm devices, for example, use Graffiti, a program that requires users to write using a slightly different alphabet.

Some users swear by it. "I can take notes quickly using the Graffiti writing system," said Charles F. Shaefer, FACP, an internist with University Medical Associates, a multispecialty group in Augusta, Ga. "I can sit at a lecture and take notes as fast as the speaker is giving information."

Others, however, said they have found the software troublesome. "It's not an easy device for data entry for people who are not aficionados," said R. Hal Baker, ACP-ASIM Member, who uses a Palm.

"Try 'the brown dog jumped over the lazy fox,' " said Dr. Baker, a general internist with Apple Hill Internal Medicine, associate residency program director at York Hospital in York, Pa., and a member of the College's Medical Informatics Subcommittee. "It will take five times longer than writing it out by hand."

That's why other physicians purchase a portable keyboard. Annabelle Rodriguez, MD, an endocrinologist with the diabetes and lipid program at Sinai Hospital in Baltimore, initially bought hers to type up a lecture for residents directly onto her IBM WorkPad.

While she was giving the lecture, Dr. Rodriguez gave her PDA to residents in the audience. Using the device's infrared feature, housestaff were able to "beam" her notes about how to diagnose and treat diabetic ketoacidosis directly to their own handhelds.

Dr. Rodriguez also uses her keyboard, which she bought in June 2001, to take notes at lectures and to write letters to referring primary care physicians. Though she handwrites her charts, she types letters to physicians directly rather than dictate them. She said typing letters herself saves her money, ensures that the letter doesn't get lost and helps with patient care.

"It gives me a chance to review the chart more carefully," Dr. Rodriguez said. "I pick things up I might have overlooked in the haste of trying to dictate it and get it done."

4. Screen quality. Not all PDA screens provide the same quality. The readability of a screen hinges on its resolution, its color and whether it has backlighting.

Resolution—the sharpness of an image-is measured in pixels, or the pieces that form letters and pictures. The more pixels, the sharper the image.

A higher number of pixels also permits your machine to show more on the screen at any one time, which may be important if you're trying to read quickly at the bedside. A backlit screen will make it easier to read in any light condition-even outside, where sunlight can wash out text.

Physicians who plan to frequently download images might consider a color screen. Dr. Zaroukian from Michigan State downloads photographs of gram stains for teaching residents. He also has used his PDA to show patients a movie that demonstrates a lumbar puncture.

As a result, "there are far fewer questions, or their questions are more to the point," he said of his patients. "It's a much richer way to provide information that reduces patients' anxiety and helps them make good decisions."

Color has nonclinical uses as well. Patricia L. Hale, ACP-ASIM Member, color codes her appointments. When she looks at appointment blocks on her weekly calendar, for example, she knows without viewing the details which are telephone conferences (green), which are work appointments (blue), which are family-related (mauve) and which involve travel (beige).

"Is it critical? No," said Dr. Hale, a general internist at Fort Edward Internal Medicine in Saratoga Springs, N.Y., and Chair of the College's Medical Informatics Subcommittee. "But it makes things easy."

The downside: Color screens are more expensive and reduce battery life, requiring more frequent recharging.

And no matter what screen you choose, you're never going to have as much viewing screen as a desktop or even a laptop. Some physicians find the small screen no problem, but others get frustrated, particularly when pressed for time.

Daniel R. Masys, FACP, for example, has used his PDA to search Medline for citations, but he said it is "extremely burdensome. Maybe it's my impatience of not wishing to scroll after having read 200 characters," said Dr. Masys, a hematologist/oncologist who is associate professor of medicine at the University of California, San Diego, School of Medicine and its director of biomedical informatics.

Dr. Masys said that while "zealots" say you can do anything on a PDA, he has found that "PDAs lend themselves to information that can be chunked into small chunks or lists. It's not very good for things that require a lot of prose," he added. "Would I read Harrison's on a PDA? I don't think so."

5. Connectivity. Want to read e-mail or surf the Web from the palm of your hand? If your hospital or clinic has set up a local area network, you can buy a radio frequency card (you might hear it referred to as "802.11b," which is the most popular standard at the moment) that allows you to access the Internet more quickly through a PDA.

Physicians at the University of Michigan, for example, can get online from their PDA by tapping into wireless base stations in the hospital, some clinics and other areas, said J. Michael Kramer, MD, an internist and pediatrician who is a project manager and physician lead for the University of Michigan Hospital and Health System's clinical health records system.

Some PDAs let you go online even if you don't have access to some type of wireless network. Some have built-in equipment to connect you to the Web, while others let you connect through a cell phone. Accessing the Internet through your PDA, however, will mean more monthly fees, and your connection could be much slower than you're accustomed to with your desktop.

If you're planning to surf the Web from your PDA, make sure your existing equipment is compatible before buying a machine. Dr. Rodriguez bought an IBM WorkPad with the goal of going online wirelessly. She hoped she could track down a speaker's citations in PubMed while attending medical conferences or even change her airline tickets if she felt like leaving the conference early.

To go online, she had to connect her PDA to her cell phone. Only after buying it, however, did she realize her Motorola phone would not work with that particular PDA.

"At that point, I figured I'd already spent enough," Dr. Rodriguez said. "I was not going to get another cell phone just for wireless communication with the PDA because I didn't think I'd use it all that much."

Even without wireless access, you can download medical abstracts or even the front page of today's New York Times from the Web. Services such as AvantGo will "clip" the items you want from the Web and download them to your handheld each time you link (or "hot sync") your PDA to your desktop computer.

Finally, if true Web surfing is what you're looking for, you might be better off with a traditional laptop or desktop. "I use the Web all the time for clinical practice," Dr. Kramer said. But "I usually sit down and use my notebook. I find it very hard to browse the Web on a very small device."

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