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R.M. Balen PharmD 1
Optimizing Personal Digital Assistant Use in Your Pharmacy Practice: A Look at What’s New, What’s Useful and Future Implications.
Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]
RM Balen PharmD - PPC 2005 2
Download Handout &/or View Slides
www.vhpharmsci.com/PresentationIndex.htm
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Greetings from Steveston BC
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Outline
Practice ChallengesDocumentationPoint of need resource materialData confidentiality / security
Questions
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Conflict of Interest Declaration
No financial conflicts of interests to declare
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Nicholson Cove,Ladysmith, BC
R.M. Balen PharmD 2
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Conclusion
Competent PDA use skills are a valuable component of an optimal professional practice information management strategy.
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Pharmacy Practice
Research
Patient Care
Teaching
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Practice Challenge: Documentation
ContextPatient care interventions
Departmental requirementsMedical record
Research Q/ADUEStudies
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Pharmacist Intervention Documentation:US Survey
N = 433 Pharmacy Directors62% Mandatory intervention documentation31% Optional but highly encouraged61% Report dissatisfaction“PDA could improve documentation efficiency”
Youngmee K, Schepers G. Pharmacist Intervention Documentationin US Health Care Systems. Hosp Pharm 2003; 38 (12): 1141-1147
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Pharmacist Intervention Documentation: VGH
Collective evolution:Internal patient monitoring recordsHealth record progress note copiesSome summary data reflecting processes
ProblemsComplianceNo outcomesData not readily analyzableNo characterization of Drug Related Problems
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Documentation: PDAs
What’s new?Non technical database development software
Pendragon Forms www.pendragonsoftware.com
Increasing 3rd party servicesHealthProLink www.healthprolink.com
PIDS www.pidsware.com
CliniTrends Mobile www.ashp.com
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PDA-Based Documentation
Database: Build it or buy it? Options:
Internally developed projectCommercially available product
ConsderationsSupportNeeds / expertiseIntegration with organization IT
Fox,BI, Felkey BG. Considerations for PDA-Based Intervention Documentation. Hosp Pharm 2003; 38(12):1180-82URL: http://www.factsandcomparisons.com/assets/hospitalpharm/dec2003_pda.pdf
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Documentation: Some Site Built PDA-based Systems in the Literature
Bosinski TJ et al. Using a personal digital assistant to document pharamcotherapeutic interventions. Am J Health-Syst Pharm 2004; 61:931-4.
Collins MF. Measuring performance indicators in clinical pharmacy services with a personal digital assistant. Am J Health-Syst Pharm 2004; 61:498-501.
Reilly JC et al. Tracking pharmacists interventions with a hand-held computer. Am J Health-Syst Pharm 2001;58:158-61
Lynx DH et al. Use of a PDA-based pharmacist intervention system. Am J Health-Syst Pharm 2003;60:2341-44.
Ong SW et al. Application of a Palm OS patient monitoring tool in an infectious diseases consult service. Can J Hosp Pharm 2003;56:218-25.
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PDA-based Data Management
VGH we built our own infrastructureReasons
Unique needsSpecific information needs
Short term vs. long term data collection
Infrastructure & process scalable to upcoming needsDUE / Medication Use Management InitiativesInformation “push” – e.g. DUE / Cost update reports
User friendly “non technical” development software available Standard office software for analysisIn house experience & expertise
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Data Collection: The Challenge
Seamless with workflowUnobtrusive processMeaningful
Data → information → knowledge → actionImpetus for service improvementService justificationQuality assurance
Paper vs Electronic Forms
Lau A, Balen RM, Lam R, Malyuk DL. Using a personal digital assistant to document clinicalpharmacy services in an intensive care unit. Am J Health-Syst Pharm. 2001; 58:1229-32
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PDA-based Data Management: VGH Evolution
Service characterization & consult managementIVRN ServiceOutpatient Antibiotic Therapy ProgramPeripherally Inserted Central Line ProgramClinical Pharmacists Interventions
DRP tracker database
ResearchDrug Related Hospitalizations StudyDUE data collection
Simple
IncreasingComplexity
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PDA-based Data Management
Levels of complexity1 user: 1 PDA
Local database > 1 user: 1 shared PDA
Local databaseMultiple user: Multiple PDA
One shared databaseLocalNetworked Merging data
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VGH IVRN Consult Management Database
Existing patientWorkload fields
Consult type Pop-up choices
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PDA Database: VGH IVRN Consult Management Data Analysis
Bosma L, Balen RM, Davidson E, Jewesson P. Point of Care Use of a Personal Digital Assistant for Patient Consult Management: Experience of an Intravenous Resource Nurse team in a Major Canadian Teaching Hospital. CIN 2003; 21 (4): 179-185
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IPE request
Initial
FollowUp
VGH OPAT Program Consult Management
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Selected OPAT Outcomes
completed home IV therapy17%
ongoing therapy6%
pt deteriorated-readmitted1%
therapy extended 4%
regional program follow-up31%
non OPAT Candidates39%
ADR - pt admitted1%
catheter pulled out-chg to po1%
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Implementation of a Personal Digital Assistant (PDA)-Based
Drug Related Problem (DRP) Documentation Tool for Pharmacy Practice
S. Raybardhan BSc (Pharm), R.M. Balen Pharm D., N. Partovi Pharm D. FCSHP, P. Loewen Pharm D. FCSHP,
G. Liu Pharm D., P.J. Jewesson PhD. FCSHP
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Objective
Implement and evaluate a multi-site PDA-based documentation tool to collate targeted pharmacist clinical intervention data
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Data -> Information -> Action
What are the DRPsWhere are they occurringWhat can we change or implement to:
Better Prevent DRPBetter resolve DRPMost effectively use clinical resources
Scaleable database for expanded use
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Results: PDA Database User Interface
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PDA-Based Data Collection Infrastructure
Site 1Multiple PDAs (approx 28)Personal & corporateMultiple sync stations
Site 2Multiple PDAs (4)Corporate onlyOne sync station
Central Data Repository LAN-Based Data transmission
Site 3One PDA Corporate One sync station
One database
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Results
Twenty-eight PDAs deployed (39 Pharmacists)Successful cross-network data transmissionData Analysis
MSAccess / MSExcel
User feedback:Easy to useEasy to learn
Documentation time ≤ 30 min/day (85%)
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Report Example: DRP TotalsCount of DRPType SiteQuarter Period VGH UBCH GFS Grand TotalQ1-2005 2005-01 1511 145 27 1683
2005-02 1559 116 64 17392005-03 1706 153 82 19412005-04 2290 179 70 2539
Q2-2005 2005-05 1591 191 34 18162005-06 1814 140 87 20412005-07 1956 166 60 2182
Q3-2005 2005-08 2224 197 63 24842005-09 2032 137 55 22242005-10 1580 40 16 1636
Grand Total 18263 1464 558 20285
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Report Example: DRP TypesCount of DRPType SiteDRPType VGH UBCH GFS Grand Totalneed to add drug 6184 305 65 6554unnecessary drug 2867 182 197 3246high dose 2234 165 85 2484wrong/suboptimal drug 2234 149 64 2447low dose 2195 123 30 2348compliance 963 355 45 1363ADR 920 66 21 1007non-formulary drug 279 56 11 346Drug interaction 237 33 23 293Pt counselling 150 30 17 197Grand Total 18263 1464 558 20285
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Report Example: DRP Details DRPType DRPDetails Totalneed to add drug continue current dosing 45
continue for chronic condition 304IV/po stepdown candidate alt. drug(s) 1low serum levels 1new medical condition 781other 74synergistic effect 14to optimize therapy 314
need to add drug Total 1534unnecessary drug excessive treatment duration 199
no valid indication 356nondrug therapy preferred 21not most cost effective 1other 39substance abuse 3treating avoidable ADR 3unecessary multi drug regimen 165
unnecessary drug Total 787
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PDA DRP Database: Conclusions
Successful infrastructure / implementationSuccessful cross-network transmission
Documentation tool easy to learn and useEfficient data analysis
PDA DRP Database Demo
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PDA-Based Data Collection:Facilitating Research
Drug Related Hospitalizations StudyDrug Use Evaluation
Carbapenem initiativeQuinolone evaluationSurgical antibiotics
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Drug-Related Hospitalization to Internal Medicine: Prospective, Observational Study
Principal InvestigatorPeter J. Zed, B.Sc., B.Sc.(Pharm), Pharm.D.
Pharmacy ResidentLeslie Samoy, B.Sc.(Pharm)
Co-InvestigatorsKerry Wilbur, B.Sc.(Pharm), Pharm.D.Robert M. Balen, B.Sc.(Pharm), Pharm.D.Mark Roberts, M.D.Riyad B. Abu-Laban, M.D., M.H.Sc., FRCPC
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DRH Study: ObjectiveTo determine:
IncidenceClassificationSeverityPreventabilityEconomic impactRisk factors
Of drug-related hospitalization to internal med
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DRH Study Data Algorithm
Not Drug Related
Severity Preventability
Discharge
Resolution of DRP
DRP Details
Drug Related-Hospitalization
Patient Work-Up
Included Excluded
Patients Admitted toInternal Medicine Service
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DRH Study PDA Database
Census infoimported via fileextract from PCIS
DRH StudyData Fields All Patients
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DRH Study Data Fields: DRH Positive
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PDA-based Documentation
Turn-key solutionsHealthprolinkPediswareClinitrend mobile
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RM Balen PharmD - PPC 2005 44www.healthprolink.com
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TWO-WAY DATA EXCHANGE
www.healthprolink.com
RM Balen PharmD - PPC 2005 46www.healthprolink.com
Clinical Intervention Documentation
RM Balen PharmD - PPC 2005 47www.healthprolink.com
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http://www.pidsware.com/index.html
RM Balen PharmD - PPC 2005 49www.ashp.com
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PDA-Based Documentation Infrastructure
Should you do it yourself?Benefits
Very customizableTarget to specific needs
Facilitate research DUE
CautionsHidden costsLacking formal IS support?Takes time and skills to developWhat if the “expert" leaves?
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PDA-Based Patient Tracking
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Commercially Available Patient Tracking Software
Patient Tracker
Patient Keeper
E-patient
www.handheldmed.com
http://www.patientkeeper.com/
http://www.iatrosoft.com/
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Patient Tracker
www.handheldmed.com
Commercially Available Patient Tracking Software
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http://www.patientkeeper.com/
Commercially Available Patient Tracking Software
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www.iatrosoft.com/
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PDA Patient Tracking
Issues:Data backupConfidentiality / securityVarying practice approachesCorporate strategy / support lacking
Recreating medical record
Lack of integration with hospital IT systemsRedundant data entry
Commercial databases aimed at MD approach
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Practice Challenge: Point of Need Access To Resources
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What’s New: PDA Hardware
R.I.P.
Dell AximTM X50v HandheldVGA displayAccelerated GraphicsIntegrated 802.11b and Bluetooth
Palm Tungsten T5256 MB memoryFlash memoryLarge screenBluetooth
Sony Clie
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What’s New: PDA Hardware
Wrist PDA FX2008Palm OS Personalized 'dial' when not in PDA modeA stylus is integrated into the buckle.
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What’s New: Resource Software
More titlesMore frequent updatesPractice guidelinesBetter office software integration
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Clinical References: More Titles
Major Vendors:Lexi-comp ( www.lexi.com )
Skyscape ( www.skyscape.com )
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www.skyscape.com www.skyscape.com
www.skyscape.comRM Balen PharmD - PPC 2005 67
PDA-Based Clinical Guidelines
http://www.guideline.gov/resources/pda.aspx
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PDA Clinical Resources: Guidelines
Mobile Medica – Apprisorwww.apprisor.com
Skyscapewww.skyscape.com
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Decision Support: Guidelines on PDA
www.apprisor.com
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Decision Support: Guidelines on PDA
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Decision Support: Guidelines on PDA
www.skyscape.com
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Decision Support: Guidelines on PDA
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PDA Guides: Clinical Trials Database
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PDA Guides: Clinical Trials Database
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PDA Drug Info Software
“Classics”
www.skyscape.comAHFS DI / ASHP
New
www.epocrtates.comePocrates Rx™ / ePocrates, Inc.
www.skyscape.comA2Z Drug Facts / Facts and Comparisons
www.lexi.comLexi-Drugs™ / Lexi-Comp, Inc.
Vendor WebsiteSoftware/ Publisher
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Lexi-Drugs
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Lexi-Drugs Categories of Information
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Drug Information: ePocrates qRxDrug Info: Adult & Pediatric dosing, Interactions, ADR, MOA, pregnancy & lactation
http://www.epocrates.com/RM Balen PharmD - PPC 2005 79
http://www.epocrates.com/
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The Best Drug Information Software
Many may meet your needsLightweight quick look up vs. comprehensive database
Few objective comparisonsLexi-Drugs one of the most comprehensive
Anecdotal experienceEnders SJ et al. Pharmacotherapy 2002; 22(8):1036-1040
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PDA Software: Disease Info
www.skyscape.comHandbook of Applied Therapeutics, 7/e) / Lippincott Williams & Wilkins
“Classics”
New
www.skyscape.comWashington Manual Wash Mnl™/Lippincott William & Wilkins/
www.skyscape.comwww.lexi.com
Griffith's: 5 Minute Clinical Consult / Lippincott William & Wilkins
Vendor WebsiteSoftware/ Publisher
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5-Minute Clinical Consult: Categories of Information
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Handbook of Applied Therapeutics
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Handbook of Applied Therapeutics
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PDA Software:Drug Interaction Analysis
ePocrates Rx™/ ePocrates, Inc.
MosbyIx™ (2002)/ Mosby, Inc.
Lexi-Interact™/ Lexi-Comp, Inc.
IFactsTM (Drug Interaction Facts)/ Facts & Comparisons
Vendor WebsiteSoftware/ Publisher
www.epocrates.com
www.skyscape.com
www.lexi.com
www.skyscape.com
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iFacts Drug Interaction Analysis Categories of Information
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ePocrates qRx:Drug Interaction Analysis
http://www.epocrates.com
Multi drug interaction check available
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PDA Software: Infectious Diseases
Miller SM, Beattie MM, Butt AA. Personal Digital Assistant Infectious DiseasesApplications for Health Care Professionals. CID 2003; 36:1018–29
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John Hopkins ABX Guide
Search by diagnosisSearch by pathogenSearch by antibiotic
http://hopkins-abxguide.org/
New
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John Hopkins Antibiotic Guide
http://hopkins-abxguide.org/download_center/learn_to_use.cfm?device=palm§ion=diagnosis
Search by diagnosis (HEP C)• Click on the Diagnosis tab on right
• Select GI from the pull out menu
• Click diagnosis tab on right
• Select GI
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Infectious Diseases: Sanford Guide
PDA Print
Electronic may not always be better
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PDA Software: Natural Medicines
Classic
Natural Medicines Comprehensive Databasewww.naturaldatabase.com/skyinfo.asp
NewNatural Standard the Authority on Integrative Medicine
www.naturalstandard.com
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www.naturalstandard.com
RM Balen PharmD - PPC 2005 94www.kingguide.com/palmos_edition.htm
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IV Compatibility Software: King Guide
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Clinical Pharmacology OnHand IV AlertIV compatibility report tool for checking the compatibilityof two or more intravenous products and/or solutions whenmixed in solution or a syringe, or via a Y-site administration
http://www.cponhand.gsm.com/
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Creating Your Own Resource Material Office Software Integration
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Office Software Integration
Word Processing / Spreadsheet / PresentationDocuments to Go
Word Processing / SpreadsheetQuick Office
Word Processing OnlyWordsmith
Adobe acrobat filesAdobe reader for Palm OS
www.dataviz.com
www.cesinc.com/quickoffice/
www.bluenomad.com/
www.adobe.com/products/acrobat/readerforpalm.html
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www.dataviz.comRM Balen PharmD - PPC 2005 101
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http://www.quickoffice.com/
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WordSmith
http://www.bluenomad.comRM Balen PharmD - PPC 2005 105
http://www.adobe.com/products/acrobat/readerforpalm.html
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Clinical References: The “VGH Package”
Clinical resourcesLexi-drugs, Lexi-interact, 5MCC
CalculatorsScientificMedicalKinetics spreadsheet
Documentation & Research DatabasesPendragon Forms
Relevant practice guidelines – coming soon
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Practice challengeData Security
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Data Security / Pt Confidentiality
RequirementsHIPPA (USA)PIPEDA (CAN)
For commercial transactions
GoalsAccess controlAudit control
StrategiesPassword protectionData encryptionHardware security
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Data confidentiality: Options
Database software featuresPassword protection
Palm OS featuresPassword protectionData encryption on some
Commercial security softwarePDA Defense Pro
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PDA Defense Pro
PDA Defense ProPassword protectionBombing features
Erases data
Data encryption
http://www.pdadefense.com/RM Balen PharmD - PPC 2005 111
Some PDA Defense Options
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PDA Defense: Data Encryption
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Future Implications
Bunny or a duck? Depends how you look at it
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Future Implications
↑ PDA presence in clinical information environmentEasier access to dataIncreased “client” expectationsTechnology To Facilitate Practice Goals
Covenant with patientsMeet medication therapy needsPrevent and solve drug related problems
New essential skills for pharmacists
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Practical Technology Integration
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Easier Access To Information & Sharing
Systems IT InterfaceWireless
resource accesscommunication
DocumentationData collection & sharing
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Wireless Access To Data
WIFIBluetooth
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www.jmir.org(J Med Internet Res 2004;6(4):e42)
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Conclusion: This study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases)…
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Patient Monitoring: Wireless
N Engl J Med 2003;348:2526-34RM Balen PharmD - PPC 2005 123
PDA & PCIS Interface: Mercury MD
www.mercurymd.com
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Mercury MD: MData
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Using MData With Pendragon Forms
Customize Data Fields• ADR• DRP• Research• Outcomes• Interventions
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Summary
Practice ChallengesDocumentationPoint of need resource materialData confidentiality / security
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Conclusion
Competent PDA use skills are a valuable component of an optimal professional practice information management strategy.
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Optimizing Personal Digital Assistant Use in Your Pharmacy Practice: A Look at What’s New, What’s Useful and Future Implications.
…Questions?
Robert M. Balen BSc(Pharm), PharmDInformatics Coordinator CSU Pharmaceutical SciencesVancouver General HospitalEmail: [email protected]