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Emergency medicine group finds doctors eager to use handhelds

www.iHealthbeat.org, March 28, 2002

Conventional wisdom has long held that physicians are Luddites, reluctant to incorporate computers and related technologies into clinical practice. So when emergency medicine Drs. Martin Ogle and Mark Thomas led a project to reduce adverse drug events (ADEs) by encouraging members of their medical group to use handheld computers, they expected fewer than 200 of the group’s 700 members to participate. To their surprise, more than 600 clinicians took advantage of the initiative, under which California Emergency Physicians Medical Group (CEP) offered its members a Palm Vx handheld, complete with clinical reference tools to research drugs at the bedside, for the nominal price of $60.

The software tools included with the Palms allow CEP physicians to quickly determine appropriate medications, check for drug interactions, calculate doses and consult other clinical references, all at the bedside. Particularly in the fast-paced emergency medicine setting, the handheld offers clear advantages over paper reference materials and manual dose calculation, according to Ogle. “It’s changed how I practice,” says Ogle. “I rely on it for checking virtually every medication I’m going to administer to a patient.” Thomas adds, “I feel naked without mine in my pocket.”

CEP’s Palm initiative has only been in place for a few months, but Thomas and Ogle say they already see its impact at the hospitals where they practice. Ogle, who is the medical director at Garden Grove Hospital and Medical Center in Garden Grove, Calif., and also practices at Saddleback Memorial Medical Center in Laguna Hills, Calif., says he sees many CEP physicians now using Palms for every shift they work. Thomas, who practices at Riverside County Regional Medical Center in Riverside, Calif., reports that all but one of his 10 fellow CEP physicians at Riverside now use the Palms in clinical practice. “I was overwhelmed” by the response to the Palm program, he says. “The physicians who don’t even know how to turn on their PCs are using these things.”

Patient safety as risk management
Thomas and Ogle first developed the idea of putting PDAs into the hands of their colleagues in response to the 1999 Institute of Medicine report To Err is Human, which estimated that medical errors were responsible for as many as 98,000 deaths in the United States in 1998. In the spring of 2001, they created a simple plan to help combat medication errors: Select a PDA suitable for emergency medical practice, load it with the most effective clinical tools for use at the bedside, and make it available to CEP physicians at a discounted price.

Although improving patient safety was their primary goal, Thomas and Ogle recognized that preventing adverse drug events was also a solid risk management practice that could easily generate a positive return on investment. According to CEP President Dr. Wes Curry, the average settlement in the United States for an emergency medicine malpractice suit that goes to trial exceeds $130,000—more than the initial budget of CEP’s entire Palm program. In an era when some physicians complain they are being driven out of practice by rising malpractice insurance costs, taking steps to avoid ADEs can reduce outlays for malpractice settlements and, ultimately, help control insurance premiums.

Thomas and Ogle approached MedAmerica Mutual Risk Retention Group (MAM), a physician-owned liability insurance company that CEP helped form in 1992 and that insures several hundred CEP physicians, as well as a number of other emergency medicine groups. MAM agreed to support the project and to help subsidize the cost of the PDAs for MAM-insured physicians.

Using in-house expertise
Project implementation began in April 2001, with an initial budget of approximately $125,000. Thomas and Ogle chose the Palm Vx handheld in large part because of the wide array of software available for the Palm operating system. Thomas asked other CEP physicians with technical savvy to suggest software applications for use in clinical practice. He then evaluated the applications, searching for those that were most effective in the ED setting and that were available at no cost or on a free trial basis, in order to minimize expenses for CEP and for physician users.

With the permission of the software developers, Thomas created a self-installing CD-ROM containing the chosen clinical software, including the Epocrates prescription drug database, an infectious disease reference called qID, dose calculators, and other clinical reference materials. To ensure ease of use, the software was tested not only by MAM staff who already owned PDAs, but also by inexperienced PDA users. Thomas and Ogle also created a handbook to accompany the software, in order to ensure that users could quickly become comfortable with using the Palm at the bedside.

MAM negotiated a price of $160 each for the Palms and provided a $100 subsidy for MAM-insured physicians, bringing the total cost to the physician to $60. The first Palms were delivered to physicians in August, and CEP and MAM have distributed a total of about 650 handhelds to date. In recognition of its successful concept and execution, the initiative recently received an honorable mention for the Excellence in Health Care Risk Management Award, which is sponsored by Modern Healthcare and St. Paul Liability.

Next step: Find new ways to use the technology
Building on the initial success of the Palm program, CEP is now exploring additional uses for the handhelds, according to Curry. “I’d like to think that this isn’t the end of the program; it’s the beginning. The real issue is getting technology into the hands of our physicians and then finding ways to use it,” he says.

With its physicians scattered among 61 locations across California, communication can be a challenge for CEP. The group plans to place information developed in-house, such as best clinical practices and current policies, on its Web site in a format that physicians can download to their handhelds and view at their convenience. CEP is also working on a trial program with eMedicine, an online provider of emergency medicine literature that can be downloaded to a handheld, and considering an electronic prescription-writing application such as iScribe.

Once the Palm program has been in place long enough, CEP officials hope to conduct both qualitative and quantitative studies of the program’s impact, assessing not only physicians’ use of the Palms but data such as malpractice claims as well. Regardless of those findings, though, Curry says he and other CEP leaders are already convinced of the program’s worth. “[This program] helps us be better physicians and provide better services for our patients,” he says. “That’s our first goal.”