Laptop Computer Allows Bedside Assessment of Pain and Automated Tracking of Medications

HOUSTON-A male cancer patient receiving opioids for pain is reluctantto tell the female pain specialist at the clinic about his constipationuntil she hands him a small computer and shows him how to usea pen device to indicate his side effects from a list on the screen.

A hospitalized teenage cancer patient feels trapped and powerlessuntil the pain specialist comes by to assess his pain on a computerizedpain map (see figure). "Just give me the computer. I cando it faster than you," he says, eager to help with his managementand feel in control again.

These are just two examples of how a handheld pen-based computerwith customized software can improve assessment of pain in theclinic and hospital, Sonja W. Chandler, PharmD, of M.D. Anderson'sPain and Symptom Management Service, said in her demonstrationof the new system.

However, the system, developed independently at M.D. Andersonwith input from pain specialists across the country, has the potentialto be far more than just a computerized version of the WisconsinBrief Pain Inventory, she said at a symposium held in conjunctionwith the 8th World Congress on Pain.

The software also has the capability to record patient admissionsand discharges, medications, drug allergies, and side effects;summarize patient information and suggest treatment plans; makedosage conversions and compare the costs of equianalgesic opioiddosages; and store and recall protocols for chemotherapy and emesismanagement.

Using hypertext technology, it can display the entire AHCPR clinicalpractice guidelines for cancer pain management, as well as speciallyprepared monographs on specific cancer pain syndromes such asbone pain. These texts are indexed and can be searched for appropriatetreatment recommendations at the bedside.

Dr. Chandler referred to the program as a decision-support tool,and stressed that it is not a replacement for the physician'sjudgment.

Perhaps the most innovative part of the program allows the patientto be followed readily at home, so that pain or symptom interventionscan take place before problems escalate and require expensivehospitalization.

"We've all had patients who try to stay at home with painof 9 or 10 on a 10-point scale and then end up in the hospital,"Dr. Chandler said.

The technology for this aspect of the program involves an IVR(interactive voice response) telephone system. Using IVR, thecomputer program has the ability to generate periodic phone callsto patients, but this technology has not been used for fear ofbreaching confidentiality.

Rather, at present, patients are asked to call the computer ona regular basis, using a preassigned number, rather than theirname, to preserve privacy. The patient then answers questionsgenerated by the computer on his or her clinical status, sideeffects, quality of life, etc.

"Since it takes only 2 or 3 minutes to complete the assessmentby phone, patients are very responsive," Dr. Chandler said.

The system can be programmed so that certain patient responseswill trigger physician intervention. For example, if patientsreport worst pain in the last 24 hours as 7 or greater, the computerwill ask them to enter the phone number where they can be reachedso that a clinician can be paged (by the computer) to call themback.

Dr. Chandler noted that the program is now in "beta"testing at a number of different sites; she hopes it will be availableby the spring of 1997.

In an abstract presented at a poster session of the Vancouvermeeting, Dr. Chandler reported that the pen computer has beenused successfully in the pilot phase at M.D. Anderson in 79 patientsevaluated over 90 admissions, to document the impact of pain consultationson patient outcome.

To date, three computer modules-on pain management, emesis treatmentand intervention, and anemia management-have been developed andare being tested as part of the Glaxo Wellcome Supportive CareManagement Program.

Although the pain management software is designed to run on mostlaptop computers, at M.D. Anderson, the Fujitsu Stylistic 500computer is used as the standard model. This machine has a 486microprocessor, 8 megabytes of RAM, 170 megabytes of hard diskspace, weighs 3 lb, and has a 2-hour battery life.

The pen apparatus can be used to point to items on the screen,as with a mouse, and to handwrite notations on the screen. Anon-screen keyboard is also available for entering data by touchingthe letters with the pen, or data can be entered via the externalkeyboard.