Things in the Newton world are changing so fast, I simply cannot keep this site up to date. I never finished The Paperless Intern, and now the MP-2000 is out and about to be made obsolete by the MP-2100! Still, the number one question I get asked all the time is how I actually use the MessagePad in my practice. Here's a look at one typical (albeit composite) day of mine.
At the end of this story is a list of products mentioned.
I am not an intern any more, but my day still begins early. The soft crowing of Roosta off in the distance nudges me awake. At the same time, the soft green glow of Newton's screen helps me re-orient in case I'm waking up in an unfamiliar call room. If I ignore Roosta, he gets progressively louder until I respond, but a flip of the Newton's power switch or a fingernail against the large Snooze button will put Roosta to sleep for a bit.
Even before I get out of bed, I activate DateMan and look at my schedule for the day. DateMan is a marvelously flexible program which I'll refer to many times during the day, but for now the default view gives me one listing showing all of the appointments I have for the day and another showing a prioritized To Do list. That's usually enough to convince me that I can't sleep in, and I actually separate myself from the Newton long enough for a shower.
Once dressed, I strap a fanny pack around my waist and put the Newton in it. Whether you use a coat pocket, fanny pack, or one of the many holster options for the MessagePad, it's essential to have a place for it that's attached to your person. It should be easier to put the Newton away than to set it down, lest it be left on a counter when you're called away in a rush. I bought my fanny pack, an inexpensive version by Eagle Creek, from REI, but almost any one will do.
I often forego the traditional white coat. It seems the primary purpose of the white coat is to provide numerous pockets for the storage of pocket reference books, note cards with patient data, a notebook to use as a peripheral brain, a calculator, and an address book. I don't need any of those things, as the Newton more than substitutes for all of them. I do carry a Tarascon Pocket Pharmacopoeia drug reference (it's one low-tech reference that's hard to beat) and a few note cards (in case I have to write something down for someone else), but these fit neatly into my fanny pack. I'm travelling light, though I have an array of references at my fingertips that rivals some clinics' entire libraries.
I don't have to preround very often, but when I do the Newton is invaluable. I arrive on the hospital floor and grab a computer terminal to look up labs, and copy any new results onto each patient's daily progress note (an outline note in Super NotePad). I'm working on a project where I can connect to the Med Center's lab computer using PT-100 and transfer labs directly onto the Newton, but for now it's a manual process.
Super NotePad looks almost identical to the built-in Notepad, but has a handful of extra features that add a lot of power. For one thing, I can display a list of notes sorted by title. I wrote a Gesture Launch macro called Title It which will, with a single stroke of the stylus, title a note with the selected text. Since my progress notes always start out with the patient's floor, room number, and name, I transfer that to the title whenever I create a new progress note. When I'm ready to preround, I just tap on my "Inpatients" folder and Super NotePad gives me a list of the patients I need to see in geographical order.
Using Super NotePad's convenient navigation buttons, I can go from note to note and room to room in order, checking on patients and recording vital signs. My backlighted MP-2000 screen even works in darkened patient rooms when it's way too early in the morning. My progress notes are based on an outline template to which I can quickly refer to see if the patient has any special issues. The collapsed note takes up less than half a screen, so I can add topics to the end of the outline to remind me if there is anything special to do for the patient later in the day. A single gesture then invokes Can Do Two, which adds all of those items to DateMan's To Do list (or to the built-in To Do list), with the patient's location and name added to each item. If DateMan is installed, Can Do Two will even link each To Do item back to the patient's progress note so that I can painlessly navigate between my To Do list and my patient data.
Rounds is where the Newton can really shine, but I've got to be careful because I'm really on the spot: everyone will be watching to see just what my little toy can do. While I found my old MP-110 and MP-120 to be just barely fast enough to keep up with lightning rounds, the MP-2000 keeps up with ease. Right at my fingertips, I have each patient's complete progress note for the day. Each progress note has a DateMan link to the patient's complete history and physical, so if I need historical information, I can grab it with ease. Even better, if a question comes up about patient care during rounds, I have a ready source of valuable data; not just pocket books, but textbook-sized references such as Griffith's Five Minute Clinical Consult, the complete text of the DSM-IV, the LexiComp Drug Handbook, Fred Ferri's Practical Guide to the Care of the Medical Patient, Daniel Onion's Little Black Book of Primary Care Pearls, plus my own extensive collection of clinical pearls. Often I can provide authoritative answers on the spot to questions which would otherwise have to be deferred until after rounds.
Of course, rounds is also a time when treatment plans are made and modified. No sweat. I just add new scut to the end of each progress note just as I did while prerounding, and Can Do Two then adds them to my To Do list.
Now it's time to get some work done. The key to effectiveness on the wards is organization, and here is where Newton really shines. Once again I summon DateMan. Though it can provide overviews of as many days as I desire, I have the default view set to concentrate on the current day. DateMan displays a small calendar with the current day highlighted and marks to indicate what other days have events and appointments scheduled, but the rest of Newton's screen is taken up with a list of appointments and events at the top and a much larger area for my (generally extensive) To Do list. I take a moment before I start work to organize my day. First, I notice that I have clinic this afternoon, so I know I'll have to work fast. I scan the To Do items and prioritize them with a series of quick taps. I use a 1-15 priority scheme, but DateMan also supports a variety of other schemes that should prove useful to those with different organizational styles.
In addition to prioritizing, DateMan also lets me file To Do's in folders, and then display them using special filters. I can, for example, have folders for each floor of the hospital, a folder for clinic scut, a folder for things I need to do at my house, and another folder for things to do while on line. I can then view folders for the specific location where I'm working at the moment, or create filters to view, say, all scut inside the hospital. No more taking the elevator from the eighth floor to the basement, only to realize I had one more chart to look at back on eight!
I'm busy calling for consults (using the built-in Names application to find pager numbers) and reviewing records, thinking that residency is not so bad after all, when my pager goes off. Ouch! It's the ER with an admission...
I head for the ER and, while waiting for the elevator, I open Super NotePad and select my Templates folder. I choose the H&P template and, with a single gesture, invoke SuperDuper, a simple macro which duplicates the template, unlocks it (before I had Super NotePad, with its note locking feature, I was forever ruining my templates by forgetting to duplicate before I scribbled on them), and moves it to my Unfiled folder. I was told the patient had Sjorgren's Syndrome, so while I descend in the elevator I call up Ferri and brush up on what I'll need to know for my interview.
As I interview the patient, I take some brief notes at the end of my template. These are mostly highlights and details of the history of present illness (HPI). I then go through the rest of my admission template and enter the data directly for details such as past medical history, current medications, family history, review of systems, and the like. Some time after the interview, I'll write a coherent HPI from my notes. The rest of the history is already done.
For the physical, I put the MessagePad away. I usually need both hands for my exam, and I try to avoid setting the machine down too often. It also breaks my stride to take notes during an exam. As soon as I've finished the exam, though, I whip out the Newton and open up the physical exam section of my H&P template. It consists of a complete screening physical for a normal patient, so all I have to do is amend for any anomalies and erase any part of the exam I decided not to do.
My admission note needs only an assessment and plan to be complete. I can usually complete this pretty quickly, sometimes copying relevant information about the workup and treatment directly from Newton's online references. Once I like my H&P, I can create a progress note by duplicating it, and replacing some of the detailed history with daily subjective information. That way my progress note automatically gets a comprehensive problem list, medication list, and treatment plan. If I make the duplicate using the GestureLaunch script Dup & Link, then I can reference the original history information from the daily progress via a DateMan link.
Now I can get back to whatever scut I was doing, but before that I open DateMan and check to see if there is anything I can accomplish on the first floor before I head back to the eighth. I also enter a new To Do item to remind me to finish the H&P I just wrote and print a copy for the chart.
I see that I can check on a chest x-ray before I go back upstairs, but before I do that my pager goes off again. This time it's the clinic, calling to tell me that one of my patients is requesting a medication refill. That's an easy one. I open the built-in Names application and select the Patients folder. I tap the patient's name, and up pops a name card with some basic information about the patient. There are also DateMan links to each of the patient's clinic progress notes, so I can double-check dosages and appropriateness. I can also pop up LexiDrugs (the complete LexiComp drug information handbook) if I have any questions about dosing, interactions, or adverse effects.
In this case the medication is an SSRI I prescribed a month ago and the patient has missed a follow-up appointment. Before authorizing the renewal, I call the patient (I'm already looking at the phone number) and verify that no serious side effects have occurred. I encourage the patient to make a new follow-up appointment, then call the pharmacy to authorize the refill. I suppose I could fax the refill directly from my MessagePad, but so far I haven't encountered a pharmacy that won't take a verbal.
No doubt I will be plagued by many other such interruptions during the day. Fortunately, they will be relatively easy to handle. When a floor nurse calls for clarification of an order, I'll be able to look at the patient's daily progress note and, if need be, H&P all without visiting the floor. I can use LexiDrugs and, for pediatric or renal dosing, use VI Calc, ProCALC Ex, or some special spreadsheets I've written in Quick Figure Pro to do the calculations.
By now, of course, I've forgotten what I was about to do, so it's back to DateMan to look at my list. I see that it's almost time for noon conference, so I tap on the link and bring up the conference schedule. It's on medical informatics, and I figure it will be more frustrating than educational, so I opt to finish my scut. I go to look at x-rays, and can enter the findings directly onto the day's progress note.
When all the basic morning scut is finished, it's time to put things on paper. That is the time I have to be most flexible. I can go back to the ER, where there is a Hewlett-Packard LaserJet 6MP with an IrDA port, so I can just point the MessagePad at the printer and print out. Or I can use the PrintPack cable to attach to one of many networked HP laser printers around the hospital. Since they're all on a network, they have free parallel ports so I don't have to unplug or reconfigure anything. Lately, though, I've found that it's generally worthwhile to carry a small book bag that has an IrDA-equipped HP DeskJet 340, along with a Newton keyboard. (I attached the keyboard to the inside of a three-ring binder using Velcro dots. The binder holds various forms I need for consult services, and when I turn it inside-out the keyboard and MessagePad are held at a convenient angle for typing.) It means that I have to find a relatively safe place to stash a book bag for the day, but there is generally a call room or the equivalent where I can do that. The printer runs off rechargeable batteries and takes sheet-fed paper, so all I have to do is turn the printer on, point the Newton at it, and print. I can even print on the official forms, which keeps some of the more obsessive-compulsive administrators happy. Having the keyboard is a convenience for me because I type really fast, and can flesh out my HPI almost painlessly when I have the keyboard attached.
Of course, neither the built-in Notepad nor Super NotePad support formatted printing. For a long time, I just used the Casual typeface, which is bold enough to read easily even when it's printing over boilerplate or lines already on the form. I have received raves about my notes for their thoroughness and readability, but of course there's always someone who has to complain. I finally got asked to stop coloring outside the lines, so I wrote another GestureLaunch macro called Paper Changer that allows me to customize margins when printing from built-in applications.
Paper Changer also solves a couple of other problems with the DeskJet 340 (and I assume other) drivers. The Newton uses a least common denominator approach to paper sizes, which means that the right margin is often excessively generous. The bottom margin, on the other hand, is not large enough for the DeskJet, so using the built-in paper sizes causes the last line of each page to get cut off. Paper Changer works around those problems, but at the expense of device independence -- the same document may require different margin settings to print properly on different printers.
I'm busily distributing my freshly printed daily progress notes to the charts when an alarm chimes, reminding me that I have clinic this afternoon. No time to admire the progress notes, with their exhaustive problem list, current medication list, and running list of pertinent labs (remember, I don't have to re-enter this information -- it automatically copies over from the previous day). Instead I check DateMan for the hundredth time today, and to my relief the To Do section is blank (DateMan optionally hides completed items). I finish with the notes and pack up to leave.
Before I go, I have to let the cross-covering resident know about my patients so I don't get excessively bothered in clinic. I scan through my notes one by one, and clip out important data. Because I use Cliphoard, I can copy a large number of items before I have to paste them into a note. I then create a new note, drag all my saved goodies to it, and voilá, I have a sign-out sheet. If the other residents used Newtons, I could just beam it over, but instead I print out a copy, pull up the schedule to find out who's cross-covering, and go to sign out.
The MessagePad is as useful in clinic as it is on the wards. I am just beginning to develop a set of age-appropriate clinic templates, but I have long made extensive use of the reference materials. Often I find myself pulling up the Five Minute Clinical Consult during an interview to check some suspicions or refine my questioning. It also links directly to LexiDrugs, so I don't have to fumble for doses or dosage forms. The nicest part, though, is the continuity data I can keep on my patients. All my clinic patients have entries in my Names file, with links to all their clinic notes and basic history and health maintenance information. Since charts aren't always available in clinic, it gives me instant access to information that might be impossible to find otherwise.
When clinic gets really busy, it is great to be able to defer any actual note writing until there is a slowdown. The Newton lets me do this without risking losing information and without taking random notes on notecards or the clinic chart. When I have some free time, I can pull out the printer and turn out some great legible notes.
For a long time, I was spared the agony of coding. No longer. Our clinic (as well as some of my inpatient psychiatric services) requires that ICD or DSM codes be entered for each diagnosis. Even if the ICD-9 book hasn't been borrowed from the clinic, something about digging through that obtuse tome really turns me off. It's much more better cool to just clip the ICD-9 code out of the Five Minute Clinic Consult, and paste it right in the note. No manual lookup, and no hand-copying cryptic numbers.
Clinic finishes on time, and the paperwork is a breeze thanks to Newton technology. It would be great to go home and do some serious net surfing, but DateMan reminds me that I am on call. Drag.
I return to the hospital, but things have remained quiet. Believing that one should leave the wards spiritually if one cannot leave physically, I retire to the call room and pull up the latest edition of InterText to read some excellent short fiction. Since I always have the Newton with me, this diversion is available any time I have an unexpected wait.
Things otherwise proceed as they did during the day, with occasional admissions, random scut, but (thankfully) a good amount of time for relaxation. After admitting a particularly difficult case, however, I feel the need for more information. No problem. I grab the nearest analog telephone line, and the entire medical resources of the Internet are at my command. Of particular interest are practice guidlines and some late-breaking treatment strategies from Medscape. I also pull up some abstracts of review articles through Melvyl Medline and print out copies to place in the patients' charts. While I am connected, I can capture my email in case I need another diversion.
Eventually a miracle occurs and I am able to get some sleep. All too soon, though, a Roosta begins crowing softly in the eerie green light of dawn.
The MP-2000 is actually quite useful right out of the box, but there are a few goodies that I wouldn't want to be without.
I use all of these. I could live without most of them, but life is better because they're there.
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Date created: November 11, 1997
Last modified: August 15, 1999
Copyright © 1999 Ron Risley