John Luo, MD

The Internet has transformed the way we get information. No one uses the telephone book anymore to find a phone number or a physical map to determine traveling directions. Smartphones and tablets have even supplanted laptop and desktop computers as the portal to the vast amount of information available online. Typing is not necessary-calling out “Hey Siri” and “Hey Google” have become the preferred method of finding information on these devices. Perhaps librarians are at risk of becoming an endangered profession as the public has become more dependent on digital assistants to find the information that they need.

Thirty years ago, websites were mostly about distribution of information, usually curated by someone who may have been an authority in that arena but not necessarily so. The concept Web 2.0 may be largely forgotten, but it highlighted how the Internet and software have changed to harness collective intelligence or knowledge of the masses as well as how the web has become a platform.

 Blogs are a great example of the web as a platform. Technology has enabled everyone to put their opinion and other comments online and made them easier to find. Amazon has changed the retail industry as a platform for commerce, helped in part by its presentation of customer reviews and ratings as well as questions and answers that facilitate purchase decision making.

It is no surprise that finding health information online is a common activity. Google Trends has shown that since 2004, 70% of queries on average are health-related.

 Insurance companies use the web to provide information about health plan benefits as well as providers in their network. Searching for psychiatrists is even easier by entering the terms “psychiatrist,” “desired city,” and “appropriate state,” in any Internet search engine. This search also reveals a new web resource-the physician rating site.

Physician rating sites are just what you would imagine. The sites allow individuals to review their physician and add their opinion. Many of these websites list information such as where the physician trained (eg, medical school, hospital affiliations, board certifications), and what insurance plans he or she accepts. Some of this information comes from the American Medical Association while other information comes from partner websites such as 

. Healthgrades will conduct a background check that includes disciplinary actions, malpractice claims, and board actions.

The majority of these sites use metrics to rate the psychiatrist, such as how easy it is to make an appointment, the friendliness of the staff, promptness of the physician, and how much time he or she spends with the patient. A typical rating scale ranges from zero to five stars. More significantly, an open comments section provides a platform for patients to state whatever they wish. Some sites allow anyone to rate and remain anonymous, while for other sites a valid email address is necessary to post reviews.

The implications of reviews are straightforward. Positive reviews help the online reputation of the physician, potentially increasing the number of patients who will contact the office to set up an appointment. Negative reviews will do the opposite. Many of these physician rating sites suggest several physicians with higher ratings for the prospective patient.

Given the impact on both reputation and referrals, what can physicians do to address this situation when negative reviews appear? One strategy is to hire a lawyer and sue the patient, which a New York gynecologist did when a patient posted negative reviews on Yelp.

 The patient took down the negative reviews, but the lawsuit persisted because the doctor stated that he suffered defamation, libel, and emotional stress. While this strategy may sound just and appropriate, in the field of mental health, some would consider this approach to be a bit draconian.

Hiring a professional firm such as Reputation Defender might also make sense.5 This firm says that they can help with search engine optimization so that positive reviews stay at the top search result and negative reviews are found on the last pages of the search. They accomplish this approach by creating new content and using metadata and link content on these pages to increase the presence of this content. However, this service comes at a cost of $3,000 to $25,000 per year depending on the number of personalized websites, professional content, and unique direct website desired. Keep in mind, they do not delete negative reviews, but help physicians to “bury” them.

Similarly, many of these physician rating sites offer premium accounts in addition to the free ones. Besides providing higher search result placement, they offer additional tools that may mitigate the negative review. They do not allow for negative reviews to be deleted as that practice would impact the integrity of the review platform. Instead, they improve attention to the profile by eliminating advertising and competitor ads. Healthgrades Advanced is $65 per month and Healthgrades Premium is $780 per month. Healthgrades Premium also provides the ability to promote your practice profile on other physician profile pages as well as to be featured on the website. Patient testimonials are utilized to combat anonymous negative reviews.

The solutions discussed above involve a significant investment of time, energy, and capital. There are other options available with a little effort. While it may appear to be colluding with the enemy, physicians should claim their profile on the various physician rating sites. One reason to do so is that there may be erroneous information about your practice that may impact how patients perceive your practice.

Another reason is that a more accurate site will be higher on search engine hits. It sounds counter intuitive to help a site with negative reviews appear higher in search findings, but it is better exposure for your practice online. One thing to consider regarding negative reviews is that if the comments are full of vitriol, then many rating sites will consider removing these posts because they don’t wish to be perceived as a platform that enables scathing comments because it will diminish their reputation as well. They believe that a negative review should be factual such as “the psychiatrist was consistently running 30 minutes late for appointments” versus ‘the psychiatrist was a jerk and didn’t give me the time of day.”

It is common knowledge that most patients who post reviews are those who are dissatisfied with the service. Often, the psychiatrist knows exactly which patient wrote the anonymous post because of an identifying feature. For example, the patient didn’t get the medication he or she was seeking.

While it sounds like making lemonade out of lemons, it is important to keep in mind that prospective patients who read a negative review regarding denial of medications and decide to not make an appointment are likely patients whom you may not want as a patient anyway. A savvier prospective patient may choose to make an appointment with you because he or she understands that the person who wrote the negative review may have an ulterior motive such as drug seeking and find that the you were correct in declining to participate in the abuse.

You may be tempted to ask patients that you know appreciate your care to post reviews to drown out the negative ones. This strategy sounds appropriate, but it is risky because asking patients for reviews may be a boundary crossing in the psychiatrist-patient relationship. It is better to have a card or sign in the office waiting room with a link to a physician review site for all reviews, not just positive ones. Likewise, office staff should not prompt or remind patients to review the practice, which will appear to be coercion.

Staff and other colleagues could technically post positive reviews as well, but that would be disingenuous. Unlike retailers who often respond to negative reviews online, it is recommended that physicians and staff do not respond to reviews online because a response may lead to a HIPAA privacy breach because of the public nature of such communications. Instead, if a physician can ascertain the identity of the patient who posted a negative review, it is reasonable to engage with the patient in person with an open and nonconfrontational manner to better understand the patient’s concerns.

It is easy to create your own content online without spending extravagant amounts of money. A blog that highlights your professional activities or articles that you find interesting to read is easy to create on services such as WordPress. Registering a URL is fairly inexpensive, and today’s technology has made website creation easy without any programming skills.

By creating a website with links to physician rating sites that have more positive reviews as well as other social media such Twitter or LinkedIn, these sites will be placed higher on search engine hits over time. These “homemade” tactics will work just like hiring a professional service, no different from deciding to change the oil in the car yourself versus going to an automotive service shop.

The sting of negative reviews online hurts both professionally and personally. Feelings such as betrayal, shame, or disgust will certainly be evoked by negative online reviews. It is all too easy and understandable to fall into the void of negativity. However, you must remain objective and process your feelings. It is helpful to commiserate with trusted colleagues, especially those who have experienced the same situation. The challenge is to take that leap of faith that your colleagues won’t judge you but have empathy for your negative experience. Stay positive and well-balanced, understand that there are many patients who have benefited from your care and typically the disgruntled few use the physician rating forum to vent and bully you.

Given that social media can be taken out of context, it is better to share in person than to vent online with your peers. The court of social media is often too quick to judge before all the facts are available. For that reason, while it may be tempting to be open and share your feelings and experiences on all your posts, it may be wise to stay professional and neutral to political and social issues. Unfortunately, it comes down to the perception-not the intent of your post, which you have little control over.

Damage to your online reputation is unfair and much too easy to accomplish with the easy to use tools that the Internet has today. It is important to be resilient and keep in mind that it is a new climate to which we must adapt. Bullying hasn’t gone away but has found a new avenue on the Internet. We can take some comfort in that physician rating sites today have an Achilles’ heel. There are too many of them and most practices and physicians have a paltry number of reviews.

Dr Luo is Chief Medical Information Officer, University of California Riverside School of Medicine. 

Dr Luo reports no conflicts of interest concerning the subject matter of this article.

https://www.oreilly.com/pub/a/web2/archive/what-is-web-20.html

https://trends.google.com/trends/explore?date=all&geo=US&q=health

 Rozner L. Manhattan Doctor Sues Patient For $1 Million For Posting Negative Reviews Online. 2018. 

https://newyork.cbslocal.com/2018/05/29/million-dollar-online-review-lawsuit/

https://www.reputationdefender.com/lp/business/

Articles

The Internet has transformed the way we get information. It is no surprise that finding health information online is a common activity.

Turning a Negative Into a Positive: Ways to Avoid and Overcome Negative Reviews

It’s been 15 years since I wrote my first article for 

 in 2002, highlighting how technology will affect psychiatric practice. I’ve been fortunate to have written several articles for 

 since then regarding technology and its potential impact on our field. I think it has come full circle now that I am the chair of this Technology Special Report, with contributions from wonderful authors. I believe it reflects the ease of use and the fertile ground for innovation that have made technology the next domain for delivery, access, and improvement of psychiatric care.

The authors in this Special Report illustrate that the technology itself is no longer a barrier toward adoption, and many creative people have found ways to incorporate technology to address a variety of barriers in the clinical care of our patients. Medical informatics has come a long way from a hobby or interest to now being a clinical subspecialty. While there is certainly a need for those who have received their PhD in biomedical informatics or a master’s degree in health informatics to lead our field in academic, industry, or government positions, it is my hope that more psychiatrists will join me in pursuing fellowship training in clinical informatics. This training provides us with the credibility and credentials to innovate with new mediums of social media and smartphones as well as to serve as leaders in the health care enterprise.

I am certain that you will find the articles in this Special Report of great interest. Smartphones are ubiquitous nowadays, and using apps or sensors on the phone will certainly extend the care of the patient in many ways. Telepsychiatry has been tremendous in eliminating the barriers of access to care, especially in populations where the stigma of mental illness prevents patients from going to a mental health clinic. Incubation of innovative technologies in psychiatric care is critical so that great ideas become products we can use to take better care of our patients. Join me in reading this Technology Special Report-I’m sure you will be inspired!

How is technology affecting psychiatric practice and addressing barriers in the clinical care of our patients? 

Introduction: Innovations to Improve Mental Health Outcomes

[[{"type":"media","view_mode":"media_crop","fid":"45287","attributes":{"alt":"","class":"media-image","id":"media_crop_5352190679357","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5173","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image"}}]]John Luo, MD, Associated Clinical Professor at UCLA, discusses his course on exploring technologies in psychiatry at the 

Annual Meeting of the American Psychiatric Association

The course covers a variety of topics including encryption, cloud computing, security, and social media. In addition, he is deeply involved in the American Association for Technology in Psychiatry meeting on Saturday, May 5, 2012, at the Courtyard by Marriot.

Podcasts

Exploring technologies in psychiatry, including topics such as computing, security, and social media.

Podcast: Exploring Technologies in Psychiatry

The role of technology in health care has taken a prominent role in many different specialties including psychiatry. Psychotherapists are using virtual reality to treat posttraumatic stress disorder (Kaplan, 2005). Many mental health clinics have Web sites with online screening tools for depression and anxiety. A few practices are offering online appointment scheduling as well. Electronic medical record systems provide reminders and alerts for lab tests and critical values. There are still many new technological innovations that have potentially groundbreaking implications in the future such as nanotechnology. However, this article will focus on the two technologies that will certainly play a significant role in the future--computer-based therapy and radio frequency identification (RFID).

Many patients with depression or anxiety first seek medical care with their primary care physicians. After a few trials of antidepressant or anxiolytic medications, the primary care physician will make a referral to the psychiatrist for the more difficult cases. Some patients will obtain traditional psychotherapy and medication treatment. However, there are significant numbers of patients who will not seek mental health care. These patients often turn to self-help materials available online or in the bookstore. With today's sophisticated computers and the large amount of storage available on DVDs, computer-based assessment and treatment software is becoming more commonplace.

These programs are quite sophisticated, utilizing specialized heuristic techniques to produce a more natural response to patient-entered information. Natural language processing allows software to determine the nature of queries and responses. Most programs use a cognitive model of treatment, since a more structured therapy lends itself to programming. These software programs present several key concepts, such as the relation between automatic thoughts and feelings, and highlight techniques to control these thoughts. These programs utilize multimedia with audio and video to enhance the experience. They have the ability to store responses to exercises, which creates a more personalized experience and allows the user to proceed at a comfortable pace. Many of the programs implement rating scales to assess depression or anxiety in order to provide feedback. Ratings may also determine the next module for treatment or recommendations for other exercises. Several computer-based therapy Web sites are listed in the 

There are numerous advantages to computer-based therapy. Patients can work at their own pace in the privacy of their own home. There are no social cues and dynamics of relationships as in psychotherapy, so patients may disclose feelings that they would normally feel uncomfortable sharing. Patients with panic attacks may benefit since they may initially not be able to travel to therapy. In addition, software programs are not susceptible to the frustrations of traditional treatment such as changed appointments, therapist boredom, absences and ethical misconduct.

Patients have a more active learning role while using a program versus the potential role as dependent in therapy, thereby providing a sense of empowerment. Treatment is accessed with a minimum of delay, and the programs are quite affordable.

Although almost all patients should benefit from self-help, there is a small subset that will not benefit from computer-based therapy. They may be too depressed or anxious in order to focus on the material, which could be exacerbated if they are unable to navigate the program. Age, personality and adaptability play a role in predicting which patients may benefit from self-help treatments. In addition, factors such as poor eyesight, reading skills and computer proficiency may affect use of computer-based therapy. Many patients may not be able to afford sufficiently powerful computers or have a fast enough Internet connection to run these programs.

The literature supporting the effectiveness of computer-based therapy has been growing. One of the first studies compared a six-session, computer-based version of cognitive-behavioral therapy (CBT) with six sessions of therapist-administered CBT and a waiting list control group (Selmi et al., 1990). In this study, both treatment groups were significantly improved on the Beck Depression Inventory (BDI) and the Automatic Thoughts Questionnaire, with no difference between the treatment modalities. Patients at a community mental health center who were waiting for CBT were offered an opportunity to use computerized CBT (van den Berg et al., 2004). This study demonstrated improvements in well-being, problems and functioning in the Clinical Outcomes in Routine Evaluation Outcome Measure, a self-report questionnaire with sub-domains for subjective well-being, problem/symptom severity, life functioning, and risk to self and others. Even use of computer-based therapy in the general practitioner's office has been demonstrated to be effective with significantly lowered ratings on the BDI, Beck Anxiety Inventory, and Work and Social Adjustment Scale (Proudfoot et al., 2003).

Computer-based therapy programs offer many benefits with limited risks. While they are not touted as replacements for traditional therapy, they are very useful supplements. More studies are needed to determine the level of therapist involvement to produce better outcomes for patients using these programs.

Radio frequency identification has been in the media lately and touted as the replacement for bar code scanning. 

 is a mechanism to store and retrieve data using devices called tags or transponders. An RFID tag is attached to an object that has an antenna to enable it to receive and respond to radio-frequency queries from an RFID transceiver. There are two types of tags: passive and active. A passive tag has no energy source and transmits information when activated by the minute electrical current induced in the antenna by the incoming radio frequency scan. A passive tag only transmits limited information, and the range of scanning is up to 20 feet. In contrast, an active tag has its own power source and can transmit more information at greater distances of up to 50 feet.

Radio frequency identification technology has tremendous implications for health care. The U.S. Food and Drug Administration is reviewing whether hospitals can use RFID implants to identify patients and allow staff access to medical records without violating patient privacy. In October 2004, the FDA approved the injection of RFID technology in humans. John Halamka, M.D., chief information officer at Harvard Medical School, decided to have an RFID tag from VeriChip Corporation implanted last December to test its use in the emergency setting (Gilbert, 2005).

Last November, the SurgiChip Tag Surgical Marker system was approved by the FDA for marketing. The system consists of a passive RFID tag, a printer, an encoder and an RFID reader. The patient's name and surgical site are printed on the SurgiChip tag. The tag is encoded with the date of surgery, type of procedure and name of surgeon. This information is scanned prior to surgery for verification of data and is adhered to the surgery site on the date of surgery. In the operating room, the tag is scanned, and the encoded information is verified with the patient's chart.

A similar process could be used with psychiatric patients in board-and-care facilities and hospitals using RFID wristbands from Precision Dynamics Corporation to ensure that they received the proper medications. In the emergency room at Mercy Hospital in Coon Rapids, Minn., vulnerable patients who posed a threat to themselves or others were monitored via RFID bracelets using the RF Technologies system (Depass, 2005). When these patients attempted to leave their rooms, radio sensors would trigger alarms that would automatically shut and lock the emergency room doors, preventing escape. If nurses did not reset the alarm within a preset time, guards would then appear as part of the response system. The hospital found that the RFID system decreased one-on-one staffing needs and costs, as well as maintained some privacy for patients since they no longer had a security guard outside their door.

Similarly, patients with Alzheimer's disease living in residential facilities can be monitored. In the Aware Home Initiative, Wendy Rogers, Ph.D., and her team at the Georgia Institute of Technology use RFID tags embedded in the shoes of seniors to monitor their activity level, allowing family members to review their activity remotely. Embedded RFID tags such as those offered by VeriChip may provide critical information in identifying comatose or profoundly psychotic patients who are unable to indicate their past history or drug allergies.

In the hospital setting, RFID-tagged identification cards could serve to authenticate staff for access to electronic medical records, along with a fingerprint scan. Unisys and SupplyScape Corporation have started an "electronic drug pedigree" program using RFID to track the distribution system of oxycodone (Atkinson and Hagans, 2005). The technology will be used to decrease counterfeit medicines and to make obtaining drugs difficult for addicts by accurately tracking the pedigree of the drug, indicating which pharmaceutical entity was in possession of the drug as it moves along the supply chain. The RFID tags can also be embedded in bottle caps to record when medications have been taken from a bottle, creating a compliance record. These are only some of the potential applications of RFID technology in health care.

Despite the numerous potential benefits of RFID technology, the main source of criticism and hindrance to implementation has been the issue of privacy. Tags do not require line-of-sight to be read; therefore they can be scanned without their knowledge and consent. At Brittan Elementary School in Sutter, Calif., the administration attempted to implement the InClass system by InCom Corporation, which would automatically record attendance of the students in class. Parents were extremely upset about the privacy issues with these ID cards and forced the school to withdraw the system in February. Consumers Against Supermarket Privacy Invasion and Numbering (CASPIAN) stands quite firmly against the use of RFID technology on the basis of privacy because purchasing behavior and patterns are monitored. The Electronic Privacy Information Center (EPIC) has proposed a four-tier framework for RFID regulation of medical information that outlines privacy rules for RFID use in patient identification and product distribution. More information regarding this regulation can be found at the EPIC Web site at <www.epic.org>.

In the field of mental health, the topics of computerized therapy and privacy may be not out of the ordinary, but technologies to expand these subjects are making inroads toward everyday patient care. It is difficult to determine how national policies and public opinion will shape the implementation and success of computer-based therapy and RFID. However, the advantages that they offer are powerful and tangible. They are poised to make an impact on health care professionals and delivery of health care, just as the Internet has changed access and distribution of health care information.

Dr. Luo is assistant professor of psychiatry at the University of California, Los Angeles, Neuropsychiatric Institute. He is also president of American Association for Technology in Psychiatry.

Atkinson J, Hagans A (2005), RFID to crack down on fraudulent prescriptions. Available at: 

Depass D (2005), Using RFID to keep track of patients. Available at: 

www.infowars.com/articles/bb/rfid_tracking_patients.htm

Gilbert A (2005), Implanted ID chip finds way into ERs, bars. Available at: http://news.com.com/Implanted+ID+chip
+finds+way+into+ERs,+bars/2100-1041_3-5545802.html. Accessed Sept. 9.

Kaplan A (2005), Virtually possible: treating and preventing psychiatric wounds of war. Psychiatric Times 22(4):1, 7-10.

Proudfoot J, Goldberg D, Mann A et al. (2003), Computerized, interactive, multimedia cognitive-behavioural therapy program for anxiety and depression in general practice. Psychol Med 33(2):217-227 [see comment].

Selmi PM, Klein MH, Greist JH et al. (1990), Computer-administered cognitive-behavioral therapy for depression. Am J Psychiatry 147(1):51-56.

van den Berg S, Shapiro DA, Bickerstaffe D, Cavanagh K (2004), Computerized cognitive-behaviour therapy for anxiety and depression: a practical solution to the shortage of trained therapists. J Psychiatr Ment Health Nurs 11(5):508-513.

Advances in technology allow more options for treating patients, tracking medications and preventing errors. What are some of these emerging technologies, and what are their benefits and their drawbacks?

Technology in Clinical Practice: Computer-Based Therapy and Radio Frequency Identification

Technology has become an essential component in the practice of medicine, largely due to high information demand. The information and computing needs of the physician are tremendous, especially in light of newer federal regulations regarding security and confidentiality. Information management for the busy physician involves storage, retrieval and speedy access at the point of care. In the last several years, personal digital assistants (PDAs) or handheld computers have become an essential information tool to meet this information need.

Many articles in both health care and technology magazines have been written regarding the use of PDAs in medicine, with diverse topics such as prescription ordering (Hicks, 2001), reference tools (Kelly, 2001) and charge capture (Terry, 2001). Even magazines devoted to handheld computing have had articles specific to the field of medicine (Johnson, 2002). The journal 

 has already published three articles regarding PDA use (Grasso and Genest, 2001; Luo et al., 2002; Luo et al., 2001). Clearly, PDAs have become a topic of interest.

The issue of PDAs has also piqued the interest of many health care organizations. The California Healthcare Foundation published a report last October on wireless and mobile computing, examining how soon and to what extent these applications might be integrated into standard health care practice (Turisco and Case, 2001). The Agency for Healthcare Research and Quality has funded four research projects involving personal digital assistants to prevent medical errors <www.ahrq.org/qual/ newgrants/it.htm>. This interest demonstrates how PDA use has become more of an enterprise and systems issue.

In addition to the numerous articles that have been written on PDAs, there are several books (

)  and over 1,000 Web sites devoted to PDAs according to Google <directory.google.com/Top/Computers/Systems/
Handhelds/?tc=1>. Organizations such as the Michigan State Medical Society (Chin, 2001) and the American Psychiatric Association <www.psych.org/sched_events/ ann_mtg_02/
brochure02.pdf> have offered classes to teach physicians how to use their PDAs. Given the tremendous amount of information available, this article will introduce essential concepts and serve as the portal to the wealth of information relating to PDAs in psychiatry.

Most people know that PDAs started as electronic counterparts to their cousins, paper-based organizers. The standard PDA features include a date book, an address book, a to-do list and a memo area for notes. These features function similarly to paper-based organizers but have significant additional capabilities. An obvious advantage is that the entries are made in machine text, which can then be exchanged with other electronic media or devices. What sets these devices apart from paper organizers is their capability to run medical applications or programs.

There are many other advantages to using a PDA. A key element involves their size, which ranges from a pack of cards to a thick checkbook. For the busy physician moving from office to office, a PDA is portable and unobtrusive. Almost all PDAs provide some linkage to information on desktop computers. This allows for the synchronization of data between the PDA and the desktop computer to keep information current. In addition, this synchronization process serves as a handy backup feature when data are lost.

Although the various models and manufacturers make the decision appear difficult, choosing a PDA is really a simple matter. One key concept to keep in mind is that technology improves and changes rather quickly. Within one year, newer models may offer additional features or capabilities that are desirable. Although a wait-and-see approach may mitigate your anxiety that your PDA is obsolete, it will also mean that you will not benefit from using a PDA as efficiently. A good plan of action is to consider keeping your PDA for at least one year, then upgrade only when new features are compelling, such as more memory or wireless capability.

Which PDA to purchase should be first determined based on its operating system (OS). Currently, there are four main operating systems available. Palm OS-based PDAs are currently the most popular, EPOC OS-based devices are more popular in Europe, Pocket PC-based PDAs are becoming more popular, and Linux OS-based PDAs have just begun to enter the market. Generally, all PDAs have similar basic capabilities, but what set them apart are their available software and hardware options.

Currently, Palm OS <www.palmos.com> PDAs are quite quick and portable. They are generally smaller than their counterparts and are noted for an "instant-on" capability, intuitive user interface and good battery life. They have the most medical software available. In addition, many hardware accessories are available such as modems, keyboards and wireless local area network (LAN) adapters. Manufacturers to consider include Palm, IBM, Sony, HandEra and Handspring.

Pocket PC-based PDAs are considered the powerhouses of the PDA market with more memory and a faster central processing unit (CPU) <www.pocketpc.com>. These devices are noted for enterprise-level capability but are notorious for poor battery life. Although the number of software developers for the Pocket PC is significantly smaller than the number of Palm OS developers, this trend is slowly beginning to change. Manufacturers include Toshiba, Compaq, Hewlett-Packard, Casio, Audiovox and NEC <www.microsoft.com/mobile/pocketpc/
hardware/default.asp>.

The EPOC OS PDAs and Linux OS PDAs are both quite versatile. However, both lack a significant software developer base. Psion <www.psion.com>, one of the primary manufacturers of EPOC OS PDAs, has withdrawn from the consumer market to focus on enterprise and vertical markets. Linux OS PDAs by Agenda <www.agendacomputing.com> and Sharp <www.sharpusa.com/products/ModelLanding/
0,1058,698,00.html> are quite feature-rich, but should only be used by those comfortable with the Linux OS.

The basic features of PDAs serve the psychiatrist well. One of the advantages of the calendar program is the ability to set repeating appointments, such as therapy sessions or meetings, which prevents double-booking of appointments. The address book program is quite versatile in storing information, such as demographics, preferred pharmacy and so on. The To-Do program keeps track of activities such as returned calls and prescription refills. Document editing is done via the memo or note program in the PDA, which is very useful for entering short notes such as drug information.

In the Palm OS PDAs, only short notes can be entered due to the 4 kilobyte file size limit, which represents less than one full page. More extensive text editing is available on Palm OS PDAs with software such as QuickWord <www.cesinc.com> or Wordsmith <www.bluenomad.com>. These pro-grams offer conversions between Microsoft Word and the Palm PDA versions of the document. On Pocket PC devices, there is no size limit, since Pocket Word is a standard application with linked conversion to documents on the desktop. Documents can be printed with the use of additional infrared printing software specific for the PDA.

E-mail is a popular form of communication, and more physicians are using this medium specifically to communicate with patients. Screen size and ability to work with attachments limit e-mail on the PDA. E-mail can be handled either with a direct PDA-Internet connection or upon synchronization with an Internet-connected computer. An extensive list of Palm OS e-mail software can be found on 

 magazine's Web site <www.hhcmag.com> by searching the links for e-mail software. Although the Pocket PC provides Pocket Outlook for e-mail, PocketGear <www.pocketgear.com> has additional related software.

Pharmaceutical information at the point of care is one of the most valuable uses of a PDA. These programs cannot replace resources such as the Physician's Desk Reference, but they do provide portable versions. One of the more popular Palm OS clinical drug databases is qRx from ePocrates <www.epocrates.com>. Many of these programs have the capability to check for drug-drug interactions or will link to other programs that do. This is particularly important to psychiatrists due to the inhibition of the cytochrome P450 enzyme system by numerous psychotropic drugs.

Prescriptions that are more legible, thus decreasing potential transcription errors at the pharmacy, can be written with PDAs. These prescriptions are printed directly on specialized paper in standard printers or via specialized printers. Another advantage of handheld prescription writing is that the software can check for availability of the medication on the health plan formulary.

Psychiatrists rely upon reference texts such as 

. Only a few reference texts for psychiatry are now available in electronic form for review on the PDA; see <www.handheldmed.com>, <www.pdamed.com>. Many people have taken electronic versions and ported the codes and criteria into a variety of formats. Good resources for Palm OS 

 software are at PocketPsych <www.pocketpsych.com/Resources/dowloads.htm> and Memoware <www.memoware.com>.

Patient tracking can be done on the PDA using the To-Do feature or specific software. Although many programs exist, even for mental health purposes, organization of patient care information is a matter of preference. Some programs have integrated features such as charge capture and coding.

Use of the PDA must take into account security measures due to its portability, especially in light of sensitive mental health information. The Health Information Portability and Accountability Act (HIPAA) of 1996 was developed to improve the efficiency and effectiveness of electronic information. It mandates that all providers who conduct electronic billing directly or via clearinghouses implement security in these transactions to maintain the privacy of an individual's medical record. Information in electronic form on the PDA is quite vulnerable to theft. Although HIPAA does not specify the security mechanism to be used, the best mechanism for security on the PDA is to use encryption software (Brown, 2002).

As briefly outlined here, the PDA has many capabilities that make it an attractive information tool in the practice of medicine. Hardware peripherals, such as the ActiveECG <www.activecenter.com> for monitoring electrocardiograms, add amazing but real capabilities to these powerful devices. Most of the software mentioned is focused on the individual PDA user. As PDAs have gained popularity, an emerging trend has been for manufacturers and software developers to focus on enterprise level capability. Companies such as Oracle and Sybase have developed PDA clients to allow access in real time to main databases. With time, there will be more integration and seamless exchange of information across various computing platforms and health systems.

The PDAs are not replacements for desktop and notebook computers but should be considered in terms of how they extend desktop computing capabilities. Mobility is a clear strength, keeping in mind the drawback of limited memory and small screen size. There needs to be seamless and effortless integration of information flow with desktop and mainframe computers as part of the pervasive computing presence. Technology should adapt to fit physicians' work needs instead of physicians adapting to new technology. In this manner, the future will be in the palm of our hands (Briggs, 2002).

Briggs B (2002), Is the future in the palm of your hand? Health Data Management 10(1):44-62. Available at: 

Brown M (2002), Keep it in your pocket. PC Magazine. Available at: 

Chin T (2001), Tap class: learning to use a handheld. American Medical News 44(22):27-28.
 

Grasso BC, Genest R (2001), Clinical computing: use of a personal digital assistant in reducing medication error rates. Psychiatr Serv 52(7):883-884, 886.
 

Hicks M (2001), Hospitals getting IT prescription. Available at: 

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