Two reviewers independently reviewed the search results and selected relevant publications that met the inclusion criteria. Disagreements were resolved by consensus. In cases of doubt, full text articles were retrieved for review and discussion. Full text articles of abstracts that met the inclusion criteria were retrieved. The investigators independently reviewed all full text articles to confirm that inclusion criteria were met. A standard data abstraction form was used to collect data from each article on the study design including study quality, participants, intervention, setting and relevant outcomes. Study quality was assessed using the following factors: blinding of participants or outcome assessors, concealed allocation, follow-up, and reliability of primary outcome measures. Differences in assessment by the reviewers were resolved through discussion.
Formal meta-analytic techniques including the pooling of data was not done due to the heterogeneous nature of the clinical interventions as well as the different outcome measures.
Selection process for studies included in the analysis
Studies of handheld electronic medical records
From 1773 citations that were screened, we retrieved 31 full text articles (Figure 1). Two articles met our criteria for inclusion (Table 1). The agreement between the 2 independent reviewers for article inclusion was excellent (kappa = 1.0). Reasons for excluding the articles were the following: 1) the study design was not a RCT (n = 22); 2) the intervention was not a mobile EMR (n = 5); 3) the intervention was clinician-focused (n = 1), and 4) there were no results reported (n = 1).
Description of studies
The two studies examined 9 practitioners and 152 patients25,26. Both studies involved the care of orthopedic patients, and PDAs were compared to paper charts for purposes of documentation in both studies (Table 1).
VanDenKerkhof? et al25 looked at the use of PDAs by anesthesiologists working on a pain service and caring for orthopedic patients. Patients were randomized to have the anesthesiologist document their clinical assessment and place orders either on a PDA or on the paper chart as usual. The primary outcomes were the encounter time (defined as the time from reviewing patient information to assessing the patient and completing charting) and comprehensiveness of documentation. The encounter time was 6.1 minutes in the PDA group and 4.6 minutes in the paper chart group (p value = 0.00). Documentation comprehensiveness was determined by looking at five pain and side effect variables for each group. This was significantly better in the PDA group for three of the five variables including nausea, pruritus and sedation. For the two other variables, pain score and hypotension, there was a trend to increased documentation with the PDA group, but this was not statistically significant (p value 0.07 for both).
Stengel et al26 studied 6 house officers providing care for orthopedic inpatients. Patients were randomized to have the house officers document diagnoses and clinical history for each patient using either the PDA or the standard paper form. The primary outcome was the number of documented ICD (International Classification of Diseases) diagnoses that were correct as determined by chart review. They found that more diagnoses were entered using the PDA (364 vs 150, P < 0.0001) after adjusting for false or redundant codes. Of note, there were 48 false or redundant codes documented in the PDA group compared with 7 in the control group.
Methodological quality assessment
Both studies described the method of randomization and the study by Stengel documented concealed allocation. Blinding of outcome assessors was not done in either study due to the nature of the intervention and the choice of primary outcomes. Follow up was excellent in both studies. The reliability of primary outcome measures was difficult to determine. Neither used clinical outcomes but focused instead on comprehensiveness of documentation.
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