Handheld Computers in Veterinary Medical Education - Journal of ...

[23.3.2005–12:18am] [121–126] L:/Inprocess/UTPress/JVME/JVME32(1)-Revises-2/JVME-018.3d

[Page No. 121] Journal of Veterinary

Student e-Learning Technology

Handheld Computers in Veterinary Medical Education: A View from Human Medical Education Debra Nestel Harry Brenton Roger Kneebone g

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ABSTRACT Handheld computers are widely used in clinical practice, and their use in both human medical education and veterinary medical education is increasing, especially, for the former, in activities involving point-of-care access. This article references the insights that can be obtained from the usage and activities that are gaining a strong foothold in human medical education. Handheld computer technology gives students access to a large and changing knowledge base for clinical practice, especially when they are geographically dispersed. Differences in use between education and practice largely relate to the importance clinicians place on patient information. Student use focuses on progress mapping and ready access to clinical reference material. Suggestions are made for future use in medical education.

INTRODUCTION Technological developments are continually being incorporated into medical education. Handheld computers offer a broad range of teaching and learning opportunities. This article reviews the educational potential of this mobile technology and considers how it relates to applications within clinical practice. Like other technology-driven areas, handheld computing is a fast-moving field. A comprehensive literature review is difficult to achieve, especially because terms such as ‘‘handheld computers’’ and ‘‘personal digital assistant’’ (PDA) are not registered as medical subject headings (MeSH). It is apparent that handheld computers are used in medical education in many ways other than those described in published reports. Using the key word ‘‘handheld computers,’’ a search of Medline and PubMed databases yielded 91 and 389 articles respectively. We make selective use of the literature to summarize contemporary developments and highlight key areas for educational development. We have consulted reports and peer-reviewed papers in other sources, as well as abstracts from dedicated national and international meetings on the use of mobile technology.1,2

WHAT ARE HANDHELD COMPUTERS? Handheld computers are also known as PDAs and were originally designed as personal organizers running simple calendar, calculator, and address book software. Handheld computers are considerably smaller and cheaper than laptop computers and will typically fit into a shirt pocket. The two most popular operating systems for handheld computers are the Palm Operating System (Palm OS) and Microsoft PocketPC. The iPaq, a PocketPC, was originally more sophisticated and expensive than the Palm OS and offered higher-quality screens and multimedia support. Recent Palm OS developments such as the Tungsten T3 have closed the technological gap. Handheld computers are operated by touch-sensitive display screens and a stylus. Text is entered using either an onscreen keyboard or ‘‘Graffiti’’ software that allows characters to be input using the stylus as a pen. Drop-down JVME 32(1) ß 2005 AAVMC

menus allow common functions to be selected quickly, which is especially useful when repeatedly entering similar information into a database. Over the last five years, handheld computers have become increasingly sophisticated. Hardware developments include high-quality color screens, global positioning systems, video cameras, and wireless (WiFi) and Bluetooth connectivity. Functions include word processors, databases, Web browsers, and a huge variety of software for professional and leisure use, including standard medical textbooks and customized reference and educational material. Data can be synchronized between the handheld and a desktop computer by means of a cradle or USB cable. For example, during synchronization any appointments entered into calendar software on the desktop computer will be transferred to the handheld, and vice versa. Contact information, databases, and word processor documents can also be synchronized, while infrared or Bluetooth connections allow data to be exchanged directly between handheld devices. In 2003, handheld computer use among doctors in Canada was estimated at 28%, with the highest use (53%) among doctors under age 35.3 Similar figures are reported for doctors in the United States, the United Kingdom, and Australia,4, 5 with the numbers increasing exponentially. No studies have reported professional undergraduate student ownership of handheld computers.

HANDHELD COMPUTERS IN MEDICAL EDUCATION Common to most studies is the role of the handheld computer in substituting for paper documents: 1. Clinical logbooks and portfolios6–11, 21 2. Assessments12–14 3. Reference materials15–19 4. Curriculum information13 In addition to reducing the use of paper, these studies identify additional benefits, including 121



1. immediacy of data capture, processing, and feedback. 2. high data integrity related to point-of-care data entry and software that rejects missing values. 3. the capacity to quickly transmit and receive information between handheld computers or to and from personal computers. 4. software that enables the creation of databases for comparing multiple sets of information. 5. wireless technology that transmits clinical information (such as patient records) to users at the point of care. All of these benefits support curricula that promote work-based and mobile learning. The next section outlines specific studies on handheld computers as they are used in medical education. 1. Clinical Logbooks and Portfolios Handheld computers are regularly used as clinical logbooks. In one study, medical students undertaking a 15-month primary care attachment (preceptorship) used handheld computers to record their clinical experiences, with two key aims6: first, for course organizers to monitor the number and nature of clinical problems accessible to students in this new community-based rotation; and, second, to support students in taking responsibility for planning learning. Students recorded their clinical experiences on a database spreadsheet installed on a handheld computer. Information was downloaded to a central computer for analysis every two months. No computers were lost, and data transfer was effective. Students found the handheld computers easy to use. Data entries were reported to be accurate and complete, which was attributed to the portability of handheld computers and the ability to make contemporaneous entries. Cumulative data identified deficits in students’ exposure to patients from different specialties. This enabled students to recognize and rectify this situation, ensuring a balance in clinical experiences. A second study describing handheld computers for logging activity in primary care attachments (preceptorships)9 compared students’ experiences of these clinical rotations using handheld computer-based logs with entries made on optically scanned cards. Unlike participants in other published studies, students used their own handheld computers loaded with custom-built tracking software. Students who used handheld computers reported significantly more patient encounters and had fewer missing data than students who used cards. Both groups of students found the recording devices easy and quick to use (approximately 30 seconds per entry), although some in the handheld computer group reported that identifying disease classifications took additional time. Students with handheld computers liked having pharmacology, clinical databases, and medical reference books immediately accessible. Comparisons in cost between a handheld computer and an equivalent paper-based documentation system in primary care education identified handheld computers as twice as expensive.23 A new professional role in a UK healthcare setting (Peri-operative Specialist Practitioner in surgery) has 122

explored the use of handheld computers in recording clinical activity.10–11 Participants are based at a number of clinical sites throughout England, coming together at intervals for intensive training in London. Participants use a handheld computer loaded with an activity-logging database, so that all clinical procedures observed and performed can be recorded at the time they take place, then collated centrally. This allows activity and learning opportunities to be monitored, despite the dispersed nature of the group. Pilot studies have shown considerable benefit from this approach. 2. Assessment In undergraduate medical education, clinical skills are often assessed using objective structured clinical examinations (OSCEs).22 Students move through a series of timed stations that focus on different skills. Rating forms are used by observers to assess students’ performance at each station. One study evaluated the use of handheld computers by assessors.13 Paper rating forms were translated to handheld computers and databases created to provide students with immediate structured feedback on their performance in OSCEs. Raters received brief training in using the handheld computers, many features of which were described as intuitive. Advantages of handheld computers for use in OSCEs include the lack of manual data entry, the fact that they are less intrusive than paper checklists, and the efficiencies of processing large amounts of information quickly to enable immediate feedback to students and faculty.13 A second study also converted paper rating forms to handheld computers.14 Although the study was conducted with nurses, the same research team has used this approach with medical students. Students conducting scenario-based assessments receive feedback from technical and communications skills experts and simulated patients, then review a videotape of their performance for self-assessment. The study highlighted challenges with the small visual field of the handheld computer in contrast to viewing an A4 page, and there were limitations with free-text data entry, an important feature for recording specific feedback for students.14 Another study has described the use of handheld computers in wireless environments for formative and summative assessments.12 Multiple-choice questions were completed during lectures, providing immediate results and thus identifying areas for timely remediation. In summative assessments, students were authenticated prior to accessing the exam materials. Once they logged on, their handheld computer was locked out of other applications. Additional security measures enabled invigilators to simultaneously view and record activity on individual handheld computers through a console located at the front of the lecture hall. If a student tried to receive e-mail or access the Internet, their connection to the server was terminated. The console also provided information on the battery life of individual handheld computers so that additional support could be provided if necessary. Fifty-three percent of students in the study thought that preparation for the computer-based US Medical Licensure was the greatest advantage of using the handheld computer for assessment; generating immediate results was their second most favored use (37%). JVME 32(1) ß 2005 AAVMC



3. Reference Materials: Note Taking, Clinical Resources, Clinical Decision Making Handheld computers can be used to enter notes during lectures and other learning settings as well as to store medical references, presentations, photographs, diagrams, and low-resolution ‘‘micro videos.’’ Web pages can be downloaded to handheld computers. Ready access to medical reference material offers obvious potential benefits, as large amounts of textual material can be presented in an easily portable format. A range of standard textbooks is now available, while medical journals and evidence-based reports can be accessed in PDF format and viewed using a portable version of Adobe Acrobat software. In a study published in 2004, third-year students on clinical rotations were given handheld computers loaded with clinical reference material.15 Survey responses from students highly rated the usefulness of the software (5-Minute Clinical Consulta and ePocratesb). Student usage indicated a steady increase in the number of launches of clinical applications during the period of study, while the number of minutes spent using the handheld computer decreased, suggesting improved efficiency. Interviews revealed that students thought handheld computers made them more efficient and that they appreciated not having to carry books with them. Pre-clinical software:12

students

have

identified

their

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Taber’s Cyclopaedic Medical Dictionary.

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Anatomy Recall PDA.

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Pathology Recall PDA.

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US-MLE Step 1 Recall PDA.

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Buzzwords for the Boards.

preferred

Electronic versions of Microsoft PowerPointc handouts can be distributed by infrared beaming between handheld computers.16 In one study, lecturers in a continuing medical education program were supported in creating virtual handouts that were incorporated into the notes section of a handheld computer address card. Evaluation included feedback from lecturers as well as recipients of the handouts. Nine of 13 lecturers reported that the virtual handout was easy to create, and 12 thought the development was worth pursuing. Of the attendees, 35 of 170 had a handheld computer, and all 35 elected to receive the virtual handout. The author describes benefits of reducing paper handouts of complete lectures and suggests that citations and Web addresses can be accurately beamed, avoiding transcription errors and saving time. Using the principle of ‘‘just in time’’ learning, ‘‘micro videos’’ of clinical procedures accessible on handheld computers and viewable at the point of care have been developed.17 These videos allow a procedure to be reviewed immediately prior to performance. The videos use compression techniques to minimize file sizes and avoid consuming too much computer memory. Preliminary evaluations report learners’ appreciation of the accessibility of procedures. Not all reports are positive, however. In a recent study, fourth-year medical students (N ¼ 169) were given JVME 32(1) ß 2005 AAVMC

handheld computers loaded with clinical decision support software (CDSS) to facilitate the adoption of evidence-based medicine at the point of care.19 Overall, students found the CDSS useful. However, they were less satisfied with functional features of the CDSS and the handheld computer. Usage patterns were relatively low (< 1 weekly), even though students reported needing information at least once daily. The median value for successful information retrieval was 20%, and search time was 30 seconds. The students who reported highest satisfaction were those with higher use in clinical settings and successful retrieval rates. Greater perceived usefulness was associated with more supportive faculty attitudes, greater knowledge of evidencebased medicine, better computer literacy, and increased use in a clinical setting. 4. Curriculum Information Diary and schedule management functions are popular uses of handheld computers. One medical school reports the use of handheld computers to manage pre-clinical curriculum information such as schedules.12 Students reported using their handheld computers for up to one hour daily; the faculty calendar and schedule were the most popular non-wireless features. Handheld computers offer an efficient approach to curriculum evaluation where student activities are monitored (logbooks, portfolios). Course evaluation documents have been loaded on handheld computers.12, 20 Cumulative data generated from assessments and evaluations can quickly generate tabular summaries. The importance of faculty (clinicians, administrators, academics, and librarians) working with students to develop materials for handheld computers that include the above examples has been highlighted.23

HANDHELD COMPUTER USE IN CLINICAL PRACTICE Descriptive and research papers outline functions of handheld computers in clinical practice.4, 5, 24–28 Such functions overlap with the teaching and learning activities outlined above, but there is much greater emphasis on patient information in all categories. In a US hospital survey, 46% of respondents reported using handheld computers.25 Differences in use and settings were reported, with younger doctors using the handheld computers more frequently in hospital- and clinic-based work while older doctors used them more frequently for administrative functions. Handheld computer users have reported the perceived benefits for clinical practice as including enhanced productivity and quality of patient care and service.4 The following key areas will be considered here: 1. Point-of-care support 2. Administrative functions 3. Research activities Handheld computers with integrated WiFi technology allow remote access to clinical data repositories, laboratory tests, and patient records at the point of care, although secure encryption of confidential patient information is an issue that needs to be tackled before such sharing becomes a reality.28 123



1. Point-of-Care Support: Drug Information, Clinical Guidelines, Protocols, Clinical Decision Aids, Patient Information, Medical References A significant proportion of drug errors result from prescribing mistakes. Most national pharmacopoeias are now available in handheld computer formats.d, e Some institutions have provided clinicians with a preloaded pharmacopoeia and medical calculators with the goal of reducing prescribing errors.5 A survey of ePocrates Rx use reports that the handheld pharmacopoeia saved time during information retrieval, was easily incorporated into doctors’ existing working patterns, and improved their drug-related decision making.29 Doctors also reported that it reduced preventable adverse drug events. Protocols and other relevant documents can be created on PCs and converted to Microsoft Wordf format for download to handheld computers. An extensive list of Web sites related to medical use of handheld computers has been classified according to application.18 The applications include the following (see source for details): 1. Medical handheld software collections 2. Handheld medical publishers 3. University medical handheld resources 4. Document readers 5. Access to medical literature 6. Pharmacopoeias 7. Patient tracking 8. Specialty specific

information. Paper and handheld computer patient records have been compared.31 Expert ratings of document qualities suggest that patient records made on handheld computers are of higher quality than those made in the traditional paper format in terms of mapping patient progress. 3. Research: Databases, Clinical Audit, Logbooks, Patients The use of handheld computers for research activities in clinical practice is well documented. As a tool for point-ofcare database entry, they have been successfully used in emergency medicine,32 clinical audits,33 clinical trials,34 and clinical encounter and procedure logbooks.6–8, 30, 35 In a study published in 2002, trainee anesthetists used handheld computers to log all anesthetic procedures undertaken.8 Data were collected on a range of variables including the type of anesthetic, surgery, supervision, critical incident, and outcome. Information appeared in drop-down menus and so was quick and easy to enter. Logbook data were periodically uploaded to a central database and the results were then fed back to individual trainees to identify their level of practice. Using this approach, trainees practicing at unacceptable levels can be identified and remediation provided. The literature offers few studies that explore patients’ views on the use of handheld computers by doctors. Ten percent of patients in one study did not like the idea of the doctor using the handheld computer in the examination room.36 It is important to assess patients’ perceptions and experiences of any intervention that may influence their interactions with clinicians. Patients have also been provided with handheld computers to document their symptoms at the time they occur.37, 38

9. Other handheld medical sites Patient tracking systems can be developed with links to drug information, differential diagnoses, and medical procedures and protocols. Patient information can be synchronized with team members and beamed in an electronic handover. Several patient management applications are available. Decision making in the intensive care unit (ICU) requires access to strategic clinical data as well as to medical reference information.30 ICU patients often generate large volumes of data that are challenging for clinicians to integrate and process. In a 2001 study by Lapinski et al., clinicians reported that a handheld computer database increased their knowledge of patients and that continuous access to patient information enabled more effective decision making. Clinicians also reported improved handovers for patients with long and complex histories. Fewer advantages were noted for short-term patients. Senior clinicians appreciated the value of PDAs more than junior clinicians, which may have been a reflection of the longer period that senior clinicians used the handheld computers and the fact that juniors were required to enter more data than their senior colleagues. Clinicians recommended that databases integrate more completely with hospital systems, that specific ICU software be developed, and that data entry methods be improved.30 2. Administrative Functions Software is widely available for patient data storage, appointments, scheduling, billing, and site-specific 124

EVALUATION METHODOLOGIES Studies of handheld computers use diverse evaluation methods, and the level of rigor varies greatly. Understandably, perhaps, many studies present the benefits of innovative approaches to handheld technology, while drawbacks may be under-reported. The rapidly changing nature of the technology means that long-term studies are extremely hard to design, since any hardware or software is likely to become obsolete long before the study results become available. Qualitative methods include self-report studies,6, 8, 12 observational studies,10, 11, 14 and group interviews,4, 14, 19 while quantitative methods include monitoring handheld computer usage (AppUsage)15, 19 and surveys.12, 15, 17, 25, 29 Sample sizes reflect the context of studies. Evaluations largely rely on self-report usage or experiences, and so participant integrity is critical to validity. Most studies are level one39 evaluations focusing on satisfaction with using handheld computers and perceived impact on learning and clinical practice rather than on obtaining objective measures of the technology’s actual impact on learning/practice. Some evaluations had clearly stated research questions.6, 14, 15, 19 A randomized controlled study design was used in a comparative study of paper and handheld computer patient records.31 Future evaluations should continue to consider these diverse approaches, as they offer different perspectives. A critical approach to reported studies is essential, however, JVME 32(1) ß 2005 AAVMC



and caution may be needed in interpreting findings and applying them to wider settings.

FUTURE DEVELOPMENTS It is clear that handheld technology will continue to develop rapidly and that much innovation will be driven by device manufacturers who shape and respond to market forces beyond health care. Handheld hardware and software have enormous potential for development within clinical care and medical education. It seems likely that the next few years will see a move from individually driven projects by isolated enthusiasts to an understanding by institutions of the educational and clinical potential of handheld computing.

CONCLUSIONS Handheld computers are already widely used in medical education and clinical practice. This article has identified examples from both settings, since they are likely to influence each other. The benefits of handheld computers as teaching and learning devices include the following:

ePocrates .

c

Microsoft Corp., Redmond, WA .

d

British National Formulary 48 .

e

Australian Medicines Handbook, PDA version (pAMH 2004) .

f

Microsoft Corp., Redmond, WA .

REFERENCES 1 Second IEEE International Workshop on Wireless and Mobile Technologies in Education (WMTE). Accepted Papers . Accessed 01/28/05. IEEE, 2003.

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Portability, convenient pocket size

2 PDAs @ Work: Integrating Mobile Technology in Health, Law & Education . Accessed 01/31/05. Medical Information Systems for PDAs, 2004.

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Relatively low cost compared to desktop and laptop computers

3 Martin S. More than half of MDs under age 35 now using PDAs. Can Med Assoc J 169:952, 2003.

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Ready availability of large databases in compact form

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Ability to turn on and off much more quickly than desktop or laptop computers

4 McAlearney AS, Schweikhart SB, Medow MA. Doctors’ experience with handheld computers in clinical practice: Qualitative study. Brit Med J 328:1162–1167, 2004.

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Quick exchange of information by infrared beaming; uploading using cradle and Bluetooth technology

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Offline and online capacity (with the possibility of integrating wirelessly with existing hospital systems)

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Relative ease of use

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Potential for reduction in paper use

Challenges to successful uptake of handheld computers in education and clinical practice include the following: .

Security of information, especially if devices are lost or stolen

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Creative ways to use the small display screen

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Battery life

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Development of customized software

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Convenient data backup

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Integration with other computer systems, including patient records and networked learning environments

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Unified databases with a search capability

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The necessity for and hidden costs of training and support

The potential benefits of handheld computing seem enormous. The challenges now are to harness them to the needs of medical education and clinical practice and to form a bridge that unites the two.

NOTES a

b

5-minute Clinical Consult .

JVME 32(1) ß 2005 AAVMC

5 Wilcox RA, La Tella RR. The personal digital assistant: A new medical instrument for the exchange of clinical information at the point of care. Med J Australia 175:659–662, 2001. 6 Alderson T, Oswald N. Clinical experience of medical students in primary care: Use of an electronic log in monitoring experience and in guiding education in the Cambridge Community Based Clinical Course. Med Educ 33:429–433, 1999. 7 Hammond E, Sweeney B. Electronic data collection by trainee anesthetists using palmtop computers. Eur J Anaesth 17:91–98, 2000. 8 Bent P, Bolsin S, Creati B, Patrick A, Colson M. Professional monitoring and critical incident reporting using personal digital assistants. Med J Australia 177:496–499, 2002. 9 Kurth RJ, Silenzio V, Irigoyen MM. Use of personal digital assistants to enhance educational evaluation in a primary care clerkship. Med Teach 24:488–490, 2002. 10 Kneebone R, Fry H, Sorensen C, Wiredu G, Younger J. Using handheld computers for mobile learning. In Proceedings of the Association of Medical Education in Europe Conference, Bern 2003. Dundee, UK: AMEE, 2003:4.121. 11 Brenton H, Kneebone R. Handheld computers and a new professional role. In Proceedings of the Association for Medical Education in Europe Conference, Edinburgh 2004. Dundee, UK: AMEE, 2004:4.103. 12 Ganger AC, Jackson M. Wireless handheld computers in the pre-clinical undergraduate curriculum . Accessed 01/18/05. Med Educ Online 8, 2003. 125



13 Schmidts MB. OSCE logistics: Handheld computers replace checklists and provide automated feedback. Med Educ 34:957–958, 2000. 14 Kneebone R, Nestel D, Ratnasothy J, Kidd J, Darzi A. The use of handheld computers in scenario-based procedural assessments. Med Teach 25:1–11, 2003. 15 Greenberg R. Use of personal digital assistant (PDA) in medical education. Med Educ 38:570–571, 2004. 16 Topps D. Virtual handouts for handheld computers. Med Educ 36:1101, 2004. 17 Topps D, Crutcher R, Lockyer J. ‘‘Pocketsnips’’: Micro videos on medical procedures. Med Educ 38:572–573, 2004.

31 Stengel D, Bauwens K, Walter M, Kopfer T, Ekkernkamp A. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records: A randomized controlled trial. J Bone Joint Surg 86A:553–560, 2004. 32 Lal S, Smith F, Davis J, Castro H, Smith D, Chinkes P, Barrow R. Palm computer demonstrates a fast and accurate means of burn data collection. J Burn Care Rehabil 21:559–561, 2000. 33 Curl M, Robinson D. Handheld computers in clinical audit: A comparison with established paper and pencil methods. Int J Health Care Quality Assurance 7:16–20, 1994.

18 Fischer S, Stewart TE, Mehta S, Wax R, Lapinsky SE. Handheld computer in medicine. J Am Med Inform Assn 10:139–149, 2003.

34 Breitfeld P, Weisburd M, Overhage J, Sledge G, Tierney W. Pilot study of a point-of-use decision support tool for cancer clinical trials eligibility. J Am Med Inform Assn 6:466–477, 1999.

19 Johnston J, Leung GM, Tin KYK, Ho LM, Lam W, Fielding R. Evaluation of a handheld clinical decision support tool for evidence-based learning and practice in medical undergraduates. Med Teach 38:628–637, 2004.

35 Garvin R, Otto F, McRae D. Using handheld computers to document family practice resident procedure experience. Fam Med 32:115–118, 2000.

20 Bridge PD, Ginsburg KA. An integrated approach for evaluating students’ achievement of clinical objectives . Accessed 01/18/05. Med Educ Online 6, 2001.

36 Houston TK, Ray MN, Crawford MA, Giddens T, Berner ES. Patient perceptions of physician use of handheld computers. In Proceedings of the American Medical Informatics Association Annual Symposium. Washington, DC: AMIA, 2003:299–303.

21 Pipas CF, Carney PA, Eliassen MS, Mengshol SC, Fall LH, Olson AL, Schifferdecker KE, Russell MT, Peltier DA, Nierenberg DW. Development of a handheld computer system to enhance an integrated primary care clerkship. Acad Med 77:600–609, 2002.

37 Peters M, Sorbi M, Kruise D, Kerssen J, Verhaak M, Bensing J. Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain. Pain 84:181–192, 2000.

22

Harden R. What is an OSCE? Med Teach 10:19–22, 1988.

23 Smith R. Adapting a new technology to the academic medical library: Personal digital assistants. J Med Librarian Assoc 90:93–94, 2002.

38 Jamison R, Raymond S, Levine J, Slawsby E, Nedeljkovic S, Katz N. Electronic diaries for monitoring chronic pain. Pain 91:277–285, 2001. 39 Kirkpatrick DL. Evaluating Training Programmes: The Four Levels. San Francisco: Berrett-Koehler, 1994.

24 Al-Ubaydli M. Handheld computers. Brit Med J 328:1181–1184, 2004. 25 McLeod TG, Ebbert JO, Lymp JF. Survey assessment of Personal Digital Assistant use among trainees and attending physicians. J Am Med Inform Assn 10:605–607, 2003. 26 Barrett JR, Strayer SM, Schubart JR. Assessing medical residents’ usage and perceived needs for personal digital assistants. Int J Med Inform 73:25–34, 2004. 27 Carroll AE, Christakis DA. Pediatricians’ use of and attitudes about personal digital assistants. Pediatrics 113:238–242, 2004. 28 Duncan RG, Shabot MM. Secure remote access to a clinical data repository using a wireless personal digital assistant (PDA) . Accessed 01/31/05. In Proceedings of American Medical Informatics Association Symposium. Washington, DC: AMIA, 2000:210–214. 29 Rothschild JM, Lee TH, Bae T, Bates DW. Clinician use of a palmtop drug reference guide. J Am Med Inform Assn 9:223–229, 2002. 30 Lapinsky SE, Weshler J, Mehta S, Varkul M, Hallett D, Stewart TE. Handheld computers in critical care. Crit Care 5:227–231, 2001.

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AUTHOR INFORMATION Debra Nestel, BA, PhD, is a Senior Lecturer in the Division of Neuroscience and Psychological Medicine, Imperial College of Science, Technology and Medicine, Paterson Centre, 20 South Wharf Road, Room 407, London W2 1PD UK. E-mail: [email protected]. Her principal areas of research are clinical communication and innovative educational methodologies. Harry Brenton, BA, MA, is a Learning Technologist in the Department of Surgical Oncology and Technology, Imperial College London, Chancellor’s Teaching Centre, 2nd Floor QEQM Wing, St Mary’s Hospital, Praed Street, London W2 1NY UK. His principal interests are in Web-based anatomy teaching using 3D technologies, mobile learning, and psychological reactions to virtual humans (avatars). Roger Kneebone, PhD, FRCS, MRCGP, is a Senior Lecturer in Surgical Education, Department of Surgical Oncology and Technology, Imperial College London, Chancellor’s Teaching Centre, 2nd Floor QEQM Wing, St Mary’s Hospital, Praed Street, London W2 1NY UK. His primary research interests are in simulation in clinical education, contexualization of learning, innovative technologies, and handheld computing.

JVME 32(1) ß 2005 AAVMC