Note: This article appeared in Intranet Professional, prior to its relaunch as Intranets (in 2004).
The medical library is an essential part of every academic hospital. Medical staff constantly evaluate clinical findings at the patient's bedside to establish the diagnosis and to provide evidence-based treatment options. Excellent care is the desired outcome. The search for medical literature is an important tool for the evaluation and precipitates a connection between the staff at the patient's bedside and the medical library. Access must be time-effective to provide the best possible care for the patient.
Different projects on medical information at the patient's bedside have been started at Mount Sinai Hospital in Toronto in cooperation with several departments and the Sidney Liswood Library. Hand-held computers, also referred to as personal digital assistants (PDAs), have achieved a key role and today are a popular tool for medical staff.
Mount Sinai Hospital is a small, community- based, city teaching hospital with approximately 465 beds. Each clinical department has its own subject specialty and its own unique information needs. It is possible and essential for the library to adapt PDAs to the specific information needs of each department. This article discusses how the Sidney Liswood Library at Mount Sinai Hospital used PDAs to facilitate bedside health information.
Medical Textbooks on a Hand-Held Device
Numerous applications providing medical information can be installed on a PDA. In 1999, the first hand-held project was started in cooperation between the Sidney Liswood Library and the Intensive Care Unit. Up to 14 critically ill patients can be treated in the Intensive Care Unit. The patients present with a variety of different and severe medical problems requiring special attention by the intensive care physicians. Medical information is needed quickly at the patients' bedside to provide excellent care in often life-threatening situations. To access essential information, an electronic version of the Critical Care Handbook of the Massachusetts General Hospital (Hurford) was provided by the publisher. Converted to a PDA-readable format by student interns in the Critical Care Unit, the file became a full textbook with multiple hyperlinks and images. The converted text was installed on several hand-held devices and provided to the medical residents during their medical training rotation. Large, heavy handbooks are replaced by stocking small accessible devices with content to answer questions at the patient's bedside.
Many different medical reference books have been converted into electronic files. Most of them are available through the publisher or on the Internet and can easily be downloaded and installed onto a hand-held computer. Core medical reference texts include titles such as the Merck Manual, Harrison's and the Washington Manual. Most of the customized software like books, tables, and guidelines, needs a reader installed on the PDA device. Of the many customized readers available over the Internet, Isilo [http://www.isilo.com] was chosen by Mount Sinai. Isilo can be downloaded to the computer desktop and allows the conversion of Microsoft Word documents into PDA documents.
To ease the search for specific topics within a text, most hand-held devices offer the option to enter search terms and automatically search through the text. The electronic PDA index provides quick access to the required information contained in a device format.
Hospital Intranet and Hand-Held Devices
Detailed information on medications is essential to every medical resident. The Mount Sinai Hospital intranet provides access for residents to drug information like dosing, side effects, and contraindications for drug referencing. Neither the physician nor the pharmacist always has access to a computer at the patient's bedside, so the Sidney Liswood Library provides a hand-held electronic version of the customized pharmacopoeia, Micromedex. The Library established a link on the PDA intranet section of the hospital's intranet to help download the pharmacopoeia onto the hand-held device. The pharmacopoeia provides easy access to pharmacy information and drug details for the residents.
The intranet provides links to multiple Web sites with information on available medical software, technology, and resources for hand-helds. A crossover link to the Mount Sinai Technical Application Unit (TAU) details information about projects on hand-held devices as well as downloadable software for the individual's needs.
Pharmacopoeias
The need for authoritative, evidence-based, current drug information is imperative. Many different customized Pharmacopoeias for PDA format are available. In 2002, hand-held devices were integrated into the Department of Pharmacy at the Mount Sinai Hospital. A hand-held computer support system was developed for the pharmacist on-call. The pharmacist on-call is one single pharmacist providing essential information to staff outside regular pharmacy hours. To access a large variety of information from home, the on-call pharmacist needed to carry many textbooks with drug information. To address this problem, a number of commercially available electronic pharmacopoeias were installed on a variety of PDAs. In addition, a hard copy of the formulary handbook of the Mount Sinai Hospital was converted into an electronic file and installed on each hand-held device. Other drug information is available in a spreadsheet format using J-File [http://www.land-j.com]. J-File is a customized reader that allows easy conversion of documents from Microsoft Excel onto a hand-held computer and adds to the variety of medication information. Hospital contact addresses were entered into the address book of the PDA and provided quick access to contact information for the pharmacist. Medical calculators were installed to help adjust dosages for patients with kidney or liver problems. In the event of data loss from the PDA all databases can be reinstalled from the memory card in the PDA using a backup program that keeps a copy of the installed information on the card. Updating these information resources is manageable by synchronizing with the desktop computer. Mount Sinai's project concluded that hand-held drug references have the potential to meet point-of-need requirements for physicians as well as pharmacists in critical care.
Evidence-Based Medicine
Evidence-based medicine is important for every physician. In order to search for evidence-based medicine, the Cochrane collection, MEDLINE, journals and the Internet are helpful tools. Hand-held devices provide the ability to access evidence-based literature at the patient's bedside.
A TAU was established at Mount Sinai Hospital by one of the critical-care physicians. The intent of TAU is to improve teaching, research, and patient care through development, implementation, and evaluation of technology in medicine. Many interhospital projects, national as well as international, were started and are managed from here. One of the main projects of TAU is to bring up-to-date medical information from Mount Sinai Hospital, a university-affiliated hospital, to nonteaching hospitals. Nonteaching hospitals often do not have access to the same expanse of medical information as a university-affiliated hospital or do not have an experienced medical or clinician librarian to conduct time sensitive literature searches. The TAU provides four nonteaching hospitals outside of Toronto with medical information and literature updates formatted for hand-held devices, targeted specifically for their Critical Care Units. Through synchronization, physicians in the nonteaching hospitals update their hand-held devices daily with physician reviewed, evidence-based literature. The Web site [http://www.medtau.org] provides detailed information on the technical applications as well as helpful links to a variety of software providers.
There are three software programs that provide PDA access to external sources of medical information.
Avantgo [http://www.avantgo.com] is a free software program that can be installed on the hand-held device and allows the user to download Web site information on a daily basis. Different journals can be connected to the device and be updated with every synchronization. Abstracts as well as full articles of relevant medical journals can be accessed on the handheld.
Ovid@hand [http://www.ovid.com] is a customized software program. The product has both a hand-held component and a Web-based "personal library." It allows the user to manage the request at the point of care and provides the mechanism to link back to the Web-based content under OVID. Ovid@hand allows users to select journals of interest and receive the latest table-of-contents and abstracts whenever the PDA is synchronized. Users can mark the items they would like to see in full text. On synchronization, full text items are delivered to the user's Web-based personal library. The program collects reference questions and research strategies (i.e., searches) on the PDA. During synchronization, the searches are transferred to the personal library and the most up-to-date articles are delivered to the user.
CogniQ is a software product from The British Medical Journal (BMJ). The program establishes a personal library on the desktop as well as a search engine on the PDA. Journal abstracts can be accessed on the PDA after the journals are chosen on the desktop and synchronized with the handheld. The user indicates which journal abstracts are of interest and a copy of the full text will be transferred into the personal library with the next synchronization. After synchronization, the desktop automatically links the user to the user's personal library to access the full text literature.
Summary
The Sidney Liswood Library proactively approached the need for quality PDA-formatted medical content. The intent is to make it easy, quick, and convenient for medical staff to find what they are looking for while meeting the quality standards required by healthcare professionals. The customer service focus emphasizes the unique information needs of each partner in the Mount Sinai Hospital healthcare team. The Sidney Liswood Library intends to address the specific information needs of doctors, pharmacists, nurses, residents, occupational therapists, social workers, and researchers, as well as other specific audiences that use their services. Physicians work with the library to better anticipate the challenges of providing quality information when and where it is needed. Future projects could include the integration of handheld devices into one-on-one training with physicians when receiving information about Internet and MEDLINE training.
References
Hurford W.C. Critical Care Hand- book of the Massachusetts General Hospital, 3rd edition.
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