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An interview with Joshua Steinberg (part II)

Posted Jan 07 2009 5:12pm

Continuing the interview from part I:

PD: What are your personal favorite PDA software - medical and non-medical?
JS: That’s easy! The stuff that I use constantly, which work, and which provide helpful medical info, that’s the stuff I like the most. Probably like everyone else, I use ePocrates, the free version. Right up there is STAT Cholesterol. I do not believe one can treat cholesterol for primary and secondary prevention of heart attacks without calculating Framingham cardiac risk. This is the difference between disease oriented and patient oriented, evidence based practice. I don’t care about cholesterol, I care about risk of heart attack and preventing those heart attacks. STAT Cholesterol looks at all the risk factors, calculates a risk, and allows me to have a patient-centered discussion with my patient about treatment options. I probably use it more than ePocrates. Next is Tim Allen’s OB Wheel, fantastic for its simplicity and value in obstetric care, can’t do squat in OB without carefully determining due date, so it all starts with his outstanding product (and the Bishop score he included is an added gem of a bonus). Next is Essential Evidence Plus, which used to be called InfoRetriever. It is a massive searchable database of nothing but evidence based resources and calculators — all of Cochrane, all of JFP POEMs (patient oriented evidence that matters), all of National Guidelines Clearinghouse. Love Shots2008, an indispensable resource for anyone who gives shots, especially anyone who takes care of children needing shots. I actually broke down and bought the Sanford ABX Guide, my only non-free software app, but I’ve never found a truly great ID/ABX resource, all are good, none are great. Then I have Up-To-Date, free since I was a beta-tester for the Palm version! Fantastic resource, but does anyone want to read long tracts of medical info on a tiny screen? I get Up-To-Date access at work on big PC screens, so I don’t use my Palm version much. And with modesty aside for a moment, I really like and use my programs — and that’s why I put 20-30 hours into each making them! I use PreOp Eval all the time when I do medical clearance before surgery, likewise I use Pneumonia to check the definitions of hospital acquired pneumonia for the tricky cases and indicated w/up tips.

Non-medical software… is there non-medical software? Ok, ok, I’ve played 8889 games of Klondike solitaire on Sol Free (and counting). But the rest is the Palm PIM stuff which I think is great as-is. I use Pics&Videos to carry pictures of my son with me everywhere. I use Tasks for grocery store lists, lists of medical topics I need to brush up on, lists of movies and books I want to get to, lists of everything. I use Memos to keep track of what the proper billing E&M codes are for hospital stuff like a vaginal delivery, a med consult, a 23 hour observation, etc. And my Contacts list is my lifeline to staying connected to everyone else, all my friends, all my family, all my partners, all my residents, all my consultants, all the take-out Indian food places, and ditto goes for managing my entire schedule with Calendar. Come to think of it, Calendar is probably my #1 most important Palm app, right up there with Contacts.

PD: What do you hope to see with regards to Palm’s pending release of the Nova platform and new devices?

I hope to see viability and resurgence! That’s it, really, I’m not hot for any special new features. If my Treo 680 had an awesome battery life, free 3G data service, and AM/FM radio reception for when I go running, it would be PERFECT, yes, perfect… for me. (I don’t even have data service on my Treo, I don’t need the e-mail and I don’t want to surf the web on a 2×2″ screen, and most of all I don’t want to pay!) I think the Palm OS is still fine as-is from a medical PDA user point of view. But the typical consumer wants accelerometers, streaming app stores, video conferencing, and probably aromatherapy, too, so I see the slick appeal of iPhone. And I know that developers have complained for years that Palm OS is busting at the seams of what it can handle, and I guess that’s important so that those developers can continue to bring us great things which keep the Palm OS platform thriving. Oh, wait, I am a developer. So easy to forget when I’m just an amateur. I certainly have no dreams of making the Palm OS old or new do dazzling things, I’m just a small-time medical app maker.

PD: Do you see potential in the trend towards cloud computing versus stand alone software?

JS: I don’t know enough to see the pros, cons, potential, need, etc. “Cloud computing” is me sitting here on a Saturday morning working on a programming project in the second cloudiest city in the country, Binghamton! Concrete gray skies from November through March, same as Syracuse. What was I thinking…

PD: Do you have any advice for anyone thinking of writing their own medical software?

JS: Sure. Go for it. However, since it will be a difficult steep learning curve no matter what route you choose, ask yourself some questions first. Has anyone else programmed what you have in mind? If so, don’t bother. Is there any other way of putting the info you want on your Palm PDA, such as using Docs-to-Go to hold key guidelines and PDF’s? If so, don’t bother. Is the info you need simple enough to memorize? If so, don’t bother. Is the info you need soooo rarely used that you’d be better off just looking something up elsewhere when you need it? If so, don’t bother. Is the info you need so trivial that it doesn’t matter whether you get it right or not, relying on memory? If so, don’t bother. So to turn this around from what not to program to what I do recommend be programmed, I do have criteria. My criteria for projects that I take on to benefit me, my residents, and my physician colleagues everywhere, are that the subject is too complex to memorize effectively, too commonly used/needed to keep looking it up, and too important for just guessing at mgmt (”winging it”) and hoping that it works out. Come to think of it, these are strikingly similar to the “relevance criteria” (patient-oriented, common, impact practice) that I use/teach in information mastery style evidence based medicine! Not surprising, they’re good criteria.

Josh is a man of many words ;) and has more to say, especially on his programming philosophy and upcoming projects:

I read a nice article a few years ago which outlined four dimensions of scholarly activity. The first is creation of new knowledge. That’s the sexy one which wins fame, fortune, NIH grants, and all that. I am not a research-doing kinda guy, I doubt I will ever contribute to the world by discovery and creation of new knowledge. But the other three dimensions of scholarly activity give me opportunities. Second is application of knowledge, third is dissemination of knowledge, and fourth is organization/archiving/preserving knowledge. By teaching students and residents one-on-one, by writing the rare publication explaining evidence, I am disseminating knowledge. Medical care won’t improve a bit from all the discovered/created new knowledge if no one figures out how to fit it into practical everyday practice and how to bring the information to the masses. I see programming for PDA’s as fitting into this. You may note that I do not really make programs that just give an answer, such as “cleared for surgery”. Instead I make programs which walk clinicians through thinking and evaluation processes to arrive at answers and, just as importantly, to teach the process itself. One of my current projects is very much about teaching process as much as yielding clinical answers.

Third, that brings me to my three new projects. One is done and posted for distribution/download, and the others are about to be.

1) PEWS. My hospital has implemented a pediatric severity-of-illness score which has had profound impact on the rate of preventable non-ICU arrests at Cinci Children’s Hospital. I wanted my residents to have the scoring system, evaluation tool, and action protocol in their PDA’s, so I wrote it. It is posted for free sharing at
and it should be posted at soon.

2) EFM glossary. ACOG (American College Ob & Gyn) put out new definitions of terms in Sept ‘08 for electronic fetal monitoring patterns. I programmed a little reference so that my residents (and this forgetful evidence-based attending who doesn’t like to use continuous electronic fetal monitoring during labor for low risk patients) can easily remember the details and do electronic fetal monitoring well. It will be posted at FMDRL and FreewarePalm when I get the final permission from ACOG’s publisher who owns the intellectual property rights.

3) … story first. I had an ABG a couple weeks ago while running the resident hospital service. I was mortified how unconfident I felt interpreting the ABG and acid-base status of the patient. There are at least two ABG interpretation tools that I know of on Palm’s, but they just spit out an answer (not necessarily the right full answer either), so I can’t scrutinize that answer for accuracy, nor does the answer teach anything about getting better at the skill. So I decided to tackle creating the tool that I want folks to have, one that provides answers and teaches the topic. My reading on the topic has taken me as far back as the medical literature of the 1970’s (which one cannot often get online, yikes!), and the programming of the topic has taken me a little farther beyond the limits of my previous skills. But the result is, I think, great! “ABG Acid-Base” is now at version 0.9, a beta version for sure. I’m testing it both for design and clinical accuracy currently. I’d be grateful if you took a look. I’m attaching it. I’ll post it for distribution real soon, either in beta 0.9 or else the first 1.0 release at my usual spots, FMDRL and FreewarePalm.

Josh also has a tip to share about the Hopkin’s ABX Guide:

It appears that the Johns Hopkins ABX guide has gone back to being free. Feb. 1, 2008, it shifted from free to paid subscription. I clicked on the Hopkins PDA site looking for HIV tools when I noticed the ABX guide has gone back to being free again. Don’t know why, but now is the time to download before they charge money again! I never completely liked the Hopkins ABX guide, but I never liked the Sanford one either. The Sanford paper version is still the best, oddly enough, in my humble meaningless opinion!

Thanks a whole bunch to Josh for taking the time to share with us his PDA journey. Next up we’ll be publishing an email interview we conducted with Andre “Statcoder” Chen!

from the Palmdoc Chronicles

An interview with Joshua Steinberg (part II)

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