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Discussion

We identified 2 randomized trials that tested two different handheld mobile electronic medical records and both found improved documentation with use of handheld computers. In the study that measured documentation time, the group using PDAs took longer to document. In the study looking at number of diagnoses, the group using PDAs documented more correct diagnoses, but also recorded more redundant or false diagnoses.

There are several previous reviews of handheld applications in health care including reviews by Lu et al[13] and Fischer et al[27]. Both of these reviews provide a comprehensive picture of handheld adoption in healthcare and possible roles of PDAs. Lu characterizes current devices, benefits seen, adoption and complaints. Fischer describes specific uses from descriptive studies. Both articles summarize the literature to describe the functions that PDAs can perform as documented from a variety of study types including before-after and cohort studies. This research complements these papers by systematically reviewing the literature, using rigorous methodology to determine an estimate of the benefit from the highest quality evidence available.

A recent systematic review found that data collection by handheld computers is an effective alternative to paper methods[28]. There is some similarity between their systematic review and ours. Both review RCTs of handhelds, and both found studies that primarily assessed data collection or documentation. Yet the perspectives are different. Our review focused on the use of handheld electronic medical records, while their review included any form of handheld data collection. None of their included studies involved the use of handheld EMRs by clinicians. Instead, patients or healthy volunteers performed the data collection. Their review did find that data collection by handhelds was faster and preferred by users. The decreased handheld data collection time is different than what we found, but this is likely a result of different users and different applications.

There are several limitations to this study. The results are limited by the quality of studies included. Studies included different 'home-grown' handheld EMR systems so it is hard to generalize to other handheld EMRs. As well, both studies were in orthopedic patients. This clinical setting may be much more uniform and straightforward than other settings with greater variability such as the emergency department. As well, none of the studies looked at impact on clinical outcomes. Finally, studies had to be a RCT to be included in our review. However, it is important to note that there were no controlled trials excluded (Figure 1), minimizing the chance that a high quality study was missed. Less rigorous study designs such as before-after studies were not included.

The strength of this research is that it does synthesize what is currently known and it highlights areas for future research. More rigorous evaluations are required in multiple populations. Preferably, clinical outcomes should be measured. With our search, we found no primary or secondary outcomes evaluating changes in reviewing information, ordering by clinicians or improvement in patient care.

We note that neither study used wireless technology and instead used periodic synchronization. This may be due to wireless being a relatively newer technology. These RCTs were likely conceived years ago prior to widespread adoption of wireless technology. While wireless may have its benefits, it is unclear how well it will work in clinical practice.



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