BMJ  2004;328:1162 (15 May), doi:10.1136/bmj.328.7449.1162

Paper

Doctors' experience with handheld computers in clinical practice: qualitative study

¹ Division of Health Services Management and Policy, Ohio State University, School of Public Health, 1583 Perry Street, Atwell 246, Columbus, OH 43210-1234, USA, ² Division of General Internal Medicine, Ohio State University College of Medicine and Public Health, Columbus, OH 43210, USA

Abstract

Objective To examine doctors' perspectives about their experiences with handheld computers in clinical practice.

Design Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns.

Setting Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists.

Participants 54 doctors who did or did not use handheld computers.

Results Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice about purchase and usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency and over-reliance as a substitute for clinical thinking.

Conclusions Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors' comfort with other information technology and ehealth initiatives and providing point of care support to doctors that helps improve patient care.

Introduction

A quarter of US doctors use handheld computers (personal digital assistants), with the proportion predicted to double by 2005.¹ Many uses have been found for these devices in clinical practice, but little research has examined how doctors view their experience with them, especially the effects on patient care. We studied doctors' experiences with and perceptions of handheld computers in various clinical settings.

Methods

Our findings come from doctors' focus groups as one component of a two part qualitative study designed to explore experiences with handheld computers in clinical practice from the perspectives of both organisations and doctors.² We purposely sampled organisations that were reportedly using handheld computers in clinical practice, and we contacted their affiliated doctors to participate in our study.

Focus groups and participants
We held eight focus group sessions lasting 60-90 minutes between April 2002 and September 2003. Six sessions were conducted at a medical centre, a children's hospital, an independent practice association, two community based healthcare systems, and a community hospital. Two sessions were conducted at a meeting of general internists. The sessions were audio-taped, transcribed, and then verified and corrected by one investigator.

Our eight focus groups consisted of 54 doctors. One third of the doctors were women and three quarters were generalists. Nearly half of the participants practised full time, and the remainder were residents or fellows. The groups contained doctors who did or did not use handheld computers, with users representing a variety of levels and patterns of use. One third of participants were affiliated with an academic medical centre and the remainder were affiliated with an independent practice association, community hospital, or children's hospital.

Analyses
We analysed our data using a combination of deductive and inductive methods.³ The investigators read the transcripts, identified broad themes, and discussed emergent findings. By the end of the sixth session no new major themes emerged, indicating near saturation.⁴ We identified categories from the transcripts and constructed major themes.

Results

The use of handheld computers varies widely in clinical practice (box). Clinicians use administrative functions for the development and sharing of lists and databases to keep track of drug formularies, call schedules, and contact details. Specific applications allow patients to be tracked and clinical results to be monitored. The use of administrative functions linked to clinical activities is expanding, with applications such as electronic prescribing and coding attracting attention because of their potential to increase doctors' productivity.

Participants typically used handheld computers at their own initiation, buying devices based on personal preferences or recommendations. An increasing number of organisations are promoting handheld computers as part of the strategy for clinical information technology, with many academic medical centres purchasing devices for their residents. In one institution, doctors use handheld computers to access patients' electronic records through a browser based application, similar to that in a recent study.⁵ At two organisations we studied, residents use their devices to share patient details between shifts.

Patterns of use and characteristics of handheld computer users
We identified several categories of users (table). Non-users had never used handheld computers or had abandoned them. Niche users included those doctors whose use was restricted to a single application but reported that this limited use was sufficiently valuable such that they would continue use. Routine users had integrated handheld computers into their clinical workflow, using multiple applications on a regular basis. Power users were self described "technophiles" who were eager to showcase their latest device.

View this table: [in this window] [in a new window]   Patterns and characteristics of users of handheld computers

 

Perceived benefits of handheld computers
Users seemed generally satisfied with their handheld computers and perceived many benefits. We anticipated discussion about productivity gains and convenience, but we also heard many doctors describing how they do things differently and "better" with the device. One doctor explained "I don't guess that something is not interacting with warfarin and cross my fingers and hope. That's my biggest thing, I don't guess. Or say I will look that up later and not get to it." Similarly, many participants noted how they "look things up more, medication-wise."

Across all groups, users reported that handheld computer applications often provided complementary benefits, improving both productivity and interactions with patients: "It reminds me to do things that I might forget to do. Not just be at this meeting. But I can get a glance and see that I haven't done the stool occult blood on that patient because they are in front of me." These findings are supported by other studies.^{6 7}

Barriers to use of handheld computers
The two main barriers to using handheld computers were personal issues and the device itself. Issues concerning the device included size, limited memory and battery life, and speed of data exchange. Many participants expressed frustration, especially with data entry: "You know, with the Palm you are trying to write graffiti. And, you know me, I'm going `Oh, that's wrong.' I can't remember what is a seven? It's coming out two! I think the data entry is real tough."

Examples of common uses of handheld computers Point of care assistance—drug information, clinical guidelines, decision aids, patient education Patient information—tracking, clinical results Administrative functions—electronic prescribing, coding, tracking schedules Research activities—data collection, participant education Medical education—lecture notes, presentations, photographs and diagrams

Two major personal barriers described by non-users were physical constraints, such as eyesight, and perceptual constraints, including comfort with the device and personal preferences. In contrast, users rarely reported personal barriers and instead described those device features perceived as problematic by non-users as strengths, such as raving about portability rather than complaining about a small screen. Similarly, whereas non-users reported that "these things just have to be easier," routine and power users described the operating systems as "intuitive." A major barrier for non-users expressed in all focus groups was their perception that they did not receive, or expect to receive, enough value from the devices to change their existing practice patterns.

Strategies proposed by doctors to overcome barriers
Participants suggested several ways in which organisations could help to overcome barriers. Doctors who had never used handheld computers noted that advice about which device to use might be sufficient to tip them into a user category: "For people who aren't used to using computers, it's just not worth the time to figure all that stuff out." Niche users wanted specific advice about the appropriateness of applications, and our impression was that this might shift them towards routine use.

Organisations could provide training and retraining to overcome many barriers. Both niche users and routine users were aware that there was more they could do with the device, if only they knew what and how.

Concerns about handheld computers
Concerns raised in early focus groups were purposely explored further in subsequent groups. We categorised concerns into four areas: the device itself, information security, over-reliance, and potential changes to practice.

Doctors' concerns about the device included loss, breakage, and reliability. Less common were concerns about security. Although doctors expressed concern about secure patient data, they seemed unconvinced that handheld computers represented a greater threat than paper records.

A major concern that emerged in every focus group was dependency, particularly among routine users and power users: "The Palm runs my life—if I lost it! Ugh." Many users also raised the theoretical concern about becoming over-reliant on the device as a "peripheral brain."

Some doctors were concerned about handheld computers changing clinical practice for the worse. Several doctors were concerned that avid users might continuously collect data without furthering patient care. Others were troubled that patients might look negatively upon them for using the devices. A few respondents in each group remarked that they purposely did not use the devices in front of patients, but others were comfortable doing so: "Initially I was afraid that if I had to use a device, they would think I was stupid. But they don't. It doesn't seem that they feel that way. I think I get credit for having a device, which is trendy. So they think I'm smarter." Another group of doctors voiced concern that these devices may become a tool of administration to further constrain their practice, for example, by enforcing guidelines.

Expectations about future use of handheld computers
Most doctors thought that the trend towards incorporating new electronic technologies into medicine would continue. Participants remarked that new doctors were more comfortable with electronic technologies, and this may help promote handheld computer use. Participants in each group said that handheld computers were destined to become critical because of their potential to improve patient safety and the quality of care.

Discussion

Doctors seem to expect handheld computers to become increasingly useful, if not ubiquitous. Organisations can help doctors leverage the use of devices in several ways. Firstly, they can develop applications to facilitate the downloading of material otherwise available on paper. Secondly, they can provide advice, training, and user support and create opportunities for doctors to learn from each other. Finally, they can develop options for mobile access to essential point of care information that can be used on handheld computers.

What is already known on this topic Little research has examined doctors' perspectives about experience with handheld computers It is not understood how doctors across practice settings view or value the devices, nor if they have concerns What this study adds Doctors who use handheld computers seem satisfied with them and perceive that they enhance patient care; they expect devices to be more useful in the future when input becomes easier and when organisations offer options for wireless connectivity Concerns about the devices include reliability and dependency Organisations could promote devices by providing training, user support, and advice to build confidence in the technology and its capabilities; organisations can also leverage use by developing handheld formatted databases and options for mobile access to essential point of care information

Our sample was limited to the United States. Although we sought representation from users and non-users of handheld computers, participants were self selecting, and participation was voluntary. It is likely that doctors interested in handheld computers would be more inclined to participate, although our groups did include sceptics and non-users.

As the use of handheld computers in clinical practice is relatively new, and because organisational use of handheld computers varies widely,⁸ we included doctors at various stages in both their own and their organisation's learning about the devices. Our findings are therefore in part influenced by each doctor's place on the learning curve.

Developing strategies to accommodate handheld computers in clinical practice may be advantageous for both institutions and doctors, especially when the devices are used to access clinical information systems, promoting both enhanced safety and improved time efficiency for doctors. When the expected benefits of electronic health records and other electronic applications largely depend on doctors' use of technology, strategies to promote use of such technologies are critical. For many doctors, handheld computers are emerging as a key means to develop familiarity with and to access electronic clinical information. These devices thus may serve as a technology stepping stone for doctors as they face new ehealth initiatives.

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This is an abridged version; the full version is on bmj.com

Contributors: See bmj.com

Funding: Center for Health Management Research.

Competing interests: None declared.

Ethical approval: Behavioral and Social Sciences Institutional Review Board, Ohio State University (IRB protocol number 01B012).

References

1. Harris Interactive. Doctors' use of handheld personal computing devices increases from 15% in 1999 to 26% in 2001. www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=345 (accessed 1 October 2003).
2. Maxwell J. Qualitative research design. Thousand Oaks, CA: Sage, 1996.
3. Miles M, Huberman A. Qualitative data analysis. Thousand Oaks, CA: Sage, 1994.
4. Glaser B, Strauss A. The discovery of grounded theory: strategies for qualitative research. New York: Aldine de Gruyter, 1967.
5. Chen E, Medonca E, McKnight L, Stetson P, Lei J, Cimino J. PalmCIS: a wireless handheld application for satisfying clinical information needs. J Am Med Inform Assoc 2004;11: 19-28.[Abstract/Free Full Text]
6. Doolan D, Bates D, James B. The use of computers for clinical care: a case series of advanced US sites. J Am Med Inform Assoc 2003;10: 94-107.[Free Full Text]
7. Rothschild J, Lee T, Bae T, Bates D. Clinician use of a palmtop drug reference guide. J Am Med Inform Assoc 2002;9: 223-9.[Abstract/Free Full Text]
8. Al-Ubaydli M. Handheld computers for doctors. West Sussex, England: John Wiley, 2003.

(Accepted 13 April 2004)

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Handheld Computer in Clinical Practice

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