Pediatricians’ Use of and Attitudes About Personal Digital Assistants
Aaron E. Carroll, MD, MS*‡, and Dimitri A. Christakis, MD, MPH§储
ABSTRACT. Background. Personal digital assistants (PDAs) are being increasingly used in medical practice. Although they have been touted as having the ability to improve efficiency and safety, little is known about pe-diatricians’ use of and attitudes about PDAs.
Objective. Our goals were to 1) determine the per-centage of pediatricians using PDAs and computers, 2) determine perceived strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use.
Design/Methods. Pediatricians (2130) were selected randomly from the American Medical Association Phy-sician Masterfile of US-licensed phyPhy-sicians. All partici-pants were mailed a survey along with a prepaid return envelope and a $1 incentive. Up to 3 mailings were sent per participant.
Results. Of eligible participants, 63.2% returned a survey. There were no significant differences between respondents and nonrespondents with respect to sex, type of practice, and present employment. Thirty-five percent of respondents currently use PDAs at work, and 40% currently use PDAs for personal use. Of those using PDAs, the most commonly used applications were for drug reference (80%), personal scheduling (67%), and medical calculations (61%). Few pediatricians are cur-rently using PDAs for prescription writing (8%) or bill-ing (4%). Users of PDAs were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confidence interval [CI]: 1.64 –3.19), in an urban community (AOR: 1.81; 95% CI: 1.30 –2.55), in training (AOR: 2.64; 95% CI: 1.58 – 4.42), not in private practice (AOR: 1.47; 95% CI: 1.03–2.11), and a more recent graduate of medical school (AOR: 1.04 per year; 95% CI: 1.02–1.06). When controlling for covariates, those using PDAs were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% CI: 1.46 – 3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56 – 3.71). When compared with nonusers, users were less likely to view the small screen size (AOR: 0.53; 95% CI: 0.37– 0.77) or system speed (AOR: 0.47; 95% CI: 0.26 – 0.84) as a problem but were significantly more likely to view memory as an issue (AOR: 3.48; 95% CI: 2.30 –5.25).
Conclusions. More than one third of pediatricians are using PDAs in clinical practice. There seems to be a general consensus among users that they have the poten-tial to improve patient safety and streamline care. Future
studies should explore means to utilize their potential. Pediatrics 2004;113:238 –242;pediatrician, hand-held, PDA, computer.
ABBREVIATIONS. PDA, personal digital assistant; AMA, Amer-ican Medical Association; AOR, adjusted odds ratio; CI, confi-dence interval.
P
ortable information technology is increasingly being used in clinical practice. Personal digital assistants (PDAs) have the ability to allow cli-nicians to enter and access data both remotely and at the point of care. PDAs have been reported as a means to document patient encounters and proce-dure logs,1– 4 provide decision support,5,6and accessclinical information wirelessly and securely.7
Appli-cations have been developed to record and store patient information, calculate appropriate drug doses, provide databases of important information, and offer other forms of bedside data support.8More
significantly, recent studies have documented the potential of PDAs to affect the quality of patient care.9,10Automated wireless alerts have been used to
prevent medical errors and alert clinicians to critical lab values as soon as they are available;10
point-of-care information has improved the quality of antibi-otic prescribing.11 A PDA-based patient record and
charting system showed some benefit in improving the accuracy of documentation in resident progress notes in a neonatal intensive care unit.9 Rigorous
studies documenting benefits and harms of PDA use, however, are unfortunately not available in large numbers.
Information about PDA use in the lay press abounds; little is known, however, about the actual use and practice patterns of physicians using them. Although others have attempted to estimate use and perceptions among different groups, these prior studies have been hampered either by selective sam-pling or because they have been issued by industry and thereby are potentially biased.12 Other
investi-gations have been published as news reports or press releases but without the scrutiny of peer review.13–15
Little information exists that accurately summarizes the beliefs of pediatricians concerning PDA strengths and weaknesses, and even less is available that de-scribes the differences between users and nonusers. Such information is essential to the planning of fu-ture applications and systems, because the effective-ness of programs and systems depends on user ac-ceptance of them.16,17
We undertook this research to 1) determine the percentage of pediatricians using PDAs and comput-From the *Department of Pediatrics, Indiana University, Indianapolis,
In-diana; and ‡Robert Wood Johnson Clinical Scholars Program, §Department of Pediatrics, and储Child Health Institute, University of Washington, Seattle, Washington.
Received for publication Jan 16, 2003; accepted Jun 23, 2003.
The views expressed within this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the University of Washington.
Address correspondence to Aaron E. Carroll, MD, MS, Riley Research, Rm 330, Indiana University School of Medicine, 699 West Dr, Indianapolis, IN 46202. E-mail: acarro@u.washington.edu
ers, 2) determine their perceptions of strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use.
METHODS
The American Medical Association (AMA) Physician Masterfile is recognized as the most complete and accurate list of licensed physicians in the United States. We sampled 2130 pediatricians from this masterfile through Direct Medical Data (Skokie, IL), which manages and distributes data from the masterfile through a licensing agreement with the AMA. The sample was completely random, with no oversampling or adjusting. We estimated that, if we had a response rate of 50% yielding 1000 responses, we could estimate the prevalence of PDA use with 95% confidence with an interval of⫾3%. Resident physicians were included in the sample. All participants were mailed the survey along with a cover letter, prepaid return envelope, and a $1 incentive. The cover letter assured all recipients that participation was voluntary and re-sponses would remain anonymous. Recipients were instructed to return the survey unanswered if they chose not to participate. Those not responding were contacted and resent the survey up to 2 additional times at 1-month intervals between July and Septem-ber 2002.
This study was approved by the University of Washington Institutional Review Board.
Survey
The survey took⬃5 minutes to complete. The initial questions asked recipients to indicate whether they use a PDA at home or work and whether they use a computer at home or work. If they used a PDA, they were asked to provide its make and model and what applications they used at work. We also asked them to indicate potential strengths of PDAs to improve health care and impediments to their use through a 5-point Likert scale ranging from 5 (“strongly agree”) to 1 (“strongly disagree”).
The rest of the survey consisted of 6 questions asking partici-pants to supply their percent of time in general versus specialty practice, year of medical school graduation, training status, gen-der, primary practice description, and primary practice commu-nity.
Statistical Analysis
We used multivariate logistic regression to assess relationships between demographic and professional characteristics and atti-tudes about PDAs. Multivariable models were adjusted for covari-ates chosen a priori, including sex, year of graduation, training status, specialty distinction, practice setting, and practice location. When comparing users to nonusers, we grouped Likert responses into 2 groups: “agree” (5 and 4) and “disagree” (3, 2, and 1). We did this because we wished to compare those that “agreed” with the statements to all others. We performed calculations using the STATA 7.0 statistical package (STATA Corporation, College Sta-tion, TX).
RESULTS Sample
Of the 2130 mailed surveys, 164 were returned by the post office with no forwarding address, and 91 were returned by nonpracticing physicians. These were excluded from subsequent analyses. From the 1875 remaining eligible participants, we received 1185 surveys, yielding a response rate of 63.2%. Be-cause of missing data, not all totals equaled 1185. There were no significant differences between re-spondents and nonrere-spondents with respect to gen-der and type of practice as defined in the AMA Physician Masterfile. Respondents, on average, had graduated from medical school 1 year later than nonrespondents (P⬍.02). Demographic data on sur-vey respondents are presented in Table 1.
Use of PDAs
Of those responding to the survey, 35% currently use a PDA at work, and 40% currently use a PDA for personal use (Table 2). Of note, an additional 9.6% indicated that they had used a PDA in the past but no longer considered themselves users. The majority of those using PDAs chose one running the Palm operating system (Palm Pilot, Handspring Visor, or Sony Clie´) system (89.7%), with most of those re-maining (8.9%) choosing to use a PDA running the PocketPC operating system (Casio Cassiopeia, Com-paq ICom-paq, or HP Jordana).
Of those using PDAs, the most commonly used applications in the work setting were for drug refer-ence (80%), personal scheduling (67%), medical cal-culations (61%), and computerized texts (38%). Few pediatricians are currently using PDAs for prescrip-tion writing (8%) or billing (4%) (Fig 1).
In analyses adjusting for potential differences in other major personal and practice characteristics, a number of predictors of PDA use remained indepen-dently significant. PDA users were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confi-dence interval [CI]: 1.64 –3.19), practice in an urban community (AOR: 1.81; 95% CI: 1.30 –2.55), be in training (AOR: 2.64; 95% CI: 1.58 – 4.42), and not be in private practice (AOR: 1.47; 95% CI: 1.03–2.11). For every year later that a respondent graduated from medical school (ie, 1986 vs 1985), their use of a PDA increased significantly (AOR: 1.04 for each year later; 95% CI: 1.02–1.06).
Those graduating medical school in the last 5 years were much more likely to use PDAs in practice than those who graduated⬎5 years ago (62% vs 29%;P⬍
.001).
Pediatricians’ Perceptions of PDAs
In general, users were somewhat more likely to feel that PDAs have greater potential to improve health care than nonusers (Fig 2). On a 5-point Likert scale, both users and nonusers felt that the greatest potential lay in their ability to increase access to information (means: 4.5 for users and 4.0 for nonus-TABLE 1. Demographic Data on Survey Respondents
Demographic Data Percent of Respondents
Male 52
Medical school graduation after 1985 53 In training (resident or fellow) 17 In a private-practice setting 55
Urban community 51
Average time spent in generalist practice 88
TABLE 2. Pediatricians’ Use of PDAs and Computers
Computer/PDA Use No. of
Respondents (%)
Ever used a PDA 580 (50.9)
ers). Respondents also felt that PDAs had the poten-tial to decrease medical errors (means: 4.2 for users and 3.8 for nonusers) and improve efficiency (means: 4.2 for users and 3.6 for nonusers). With respect to barriers to the use of PDAs, nonusers felt that each of the potential weaknesses was more of an impedi-ment than users (Fig 2). The greatest impediimpedi-ments were felt to be the difficulty of data entry into a PDA (means: 3.4 for users and 3.7 for nonusers) and the small screen size (means: 3.1 for users and 3.6 for nonusers).
When adjusting for covariates, a number of these potential benefits and perceived barriers were found to be significantly associated with use of a PDA. Users were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% CI: 1.46 – 3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56 –3.71). When compared with nonusers, users were less likely to view as a problem the small screen size (AOR: 0.53; 95% CI: 0.37– 0.77) or system speed (AOR: 0.47; 95% CI: 0.26 – 0.84) but were significantly more likely to view memory as an issue (AOR: 3.48; 95% CI: 2.30 –5.25).
DISCUSSION
Our study indicates that more than one-third of pediatricians are currently using PDAs in their clin-ical practices. In analyses adjusting for differences in personal and practice characteristics, we found that users were more likely to be male, in training, prac-ticing in a nonprivate setting, in an urban commu-nity, and later graduates of medical school. Both
users and nonusers agreed that PDAs have the po-tential to improve access to information, although users were more likely than nonusers to believe in the PDA’s potential to decrease medical errors and improve efficiency. Users were also more likely to view the limited memory of a PDA as an issue and less likely to view small screen size or system insta-bility as an impediment to use.
This study is subject to the typical limitations of self-report surveys, such as response bias and an inability to establish a causal relationship between differences in personal and professional characteris-tics and pediatrician attitudes. However, we had a response rate of 63.2%, which is considerably higher than the mean for published survey studies of phy-sicians.18Furthermore, respondents were not
signif-icantly different from nonrespondents with respect to gender and type of practice as defined in the AMA Physician Masterfile. It is also possible that responses to surveys do not reflect actual practice. However, our questions were simple and straightforward, and the potential for social desirability in responses seems low. Finally, some of our differences were quite small, although they reached statistical signif-icance. How clinically relevant these differences are is unknown.
or rejected after completion.19 Without
well-de-signed trials we cannot tell if the use of any informa-tion technology carries actual benefits or even harms.20 Although there is a growing body of
liter-ature about PDAs and their uses, little of it is evi-dence based.21 We hope that this study helps to
provide some answers and a foundation for future investigations.
The effectiveness and usefulness of future applica-tions and systems certainly depends on user accep-tance of them.16,17 Our results suggest that concerns
about screen size and system speed are 2 factors that significantly separate users from nonusers. Such in-formation may be useful to those designing PDAs that may be more widely accepted by pediatricians. According to our results, there seems to be a general consensus that PDAs can improve access to informa-tion. There also seems to be a belief, especially among users, that PDAs can contribute to a reduc-tion in medical errors. Addireduc-tionally, a majority of users are using applications for drug reference and medical calculations. Medication errors have been found to be the most common type of medical error in the pediatric inpatient setting.22Therefore, it may
be wise for future studies to examine the ability of PDAs to reduce medication errors through the use of existing or new drug-prescribing or error-checking applications. Because such programs already have widespread acceptance among PDA users, they may have a higher probability of showing a significant improvement in care.
Although a minority of pediatricians overall are using PDAs, a majority of recent medical school graduates are using them. According to the adopter
categories described by Rogers,23pediatricians have
likely passed the “early adopters” stage and gone into the “early majority” stage. This could have ad-ditional implications on how quickly pediatricians as a whole continue to adopt this technology.24 It is
likely that the overall percentage of pediatricians using PDAs will rise significantly in the next few years as more-recent graduates adopt their use and less-recent graduates retire. If current trends con-tinue, in the near future the PDA may be a com-monly used tool in the practice of pediatrics. Studies to evaluate the potential benefits and harms of PDA use are warranted.
ACKNOWLEDGMENTS
Support for Dr Carroll was provided by the Robert Wood Johnson Foundation.
We thank Frederick P. Rivara, MD, MPH, for helpful sugges-tions in the preparation of this manuscript.
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CHANCE BLINDNESS
“Consider this scenario: if you were watching a circle of people passing a basketball, and someone dressed in a gorilla costume walked through the circle, stopped to beat his chest, and exited, of course you would notice him imme-diately—wouldn’t you? Simons and the psychologist Chris Chabris filmed such a scene and showed it to people who were asked to track the movement of the ball by counting the number of passes made by one of the team. Approximately half of the participants failed to notice the gorilla. . . . Focused on tracking the ball’s movement, people are blind to what happens to unattended objects and thus do not encode the sudden change.”
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DOI: 10.1542/peds.113.2.238
2004;113;238
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