Professional Documents
Culture Documents
Palmtop Computer (Report of Early Usage)
Palmtop Computer (Report of Early Usage)
Palmtop Computer (Report of Early Usage)
Abstract
This research project6 investigated the applicability and usefulness of portable palmtop
personal computers (P/PCs) in the development and utilization of computer-based forms
to assist data capture by lay community health workers at the site of contact and subse-
quent transfer of recorded data to a desktop platform for processing at a central site. The
project's expected result was to abolish paper forms, which were replaced by digital forms;
introduce consistency checking procedures at the time of data capture; abolish data tran-
scription and entry; and test data transfer from the P/PC to a desktop computer for proc-
essing by a public-domain epidemiology software. The authors discuss the results of a pi-
lot project conducted in a community household surveillance program, and review meth-
odological and technological issues regarding the implementation of P/PC-based applica-
tions. Compared to laptop and handheld computers, P/PCs have limited processing capa-
bilities, but are capable of supporting many mobile requirements, including simple data-
base operations and data communication. Large data volumes can be recorded, trans-
ported, and uploaded in generic format to a desktop personal computer for processing
and analysis. Technological and market trends, increasing machine resources and capa-
bilities, ease of use by individuals with limited skills, and diminishing costs suggest that
palmtop computers are useful mobile tools for health data recording and transport. The
new generation of palmtop devices is most appropriate to field conditions. They are rug-
ged, operate on batteries for long periods of time, and can support a vast range of public
health, primary care, home care, environmental health data capture, and data communi-
cation needs.
1
Regional Advisor, Health Services Information Technology, Essential Drugs and Technology Program,
Division of Health Systems and Services Development, Pan American Health Organization / World
Health Organization, Washington, D.C., USA
2
Professor and Head, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal
University of São Paulo (UNIFESP), São Paulo, Brazil
3
Senior Researcher, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal
University of São Paulo (UNIFESP), São Paulo, Brazil
4
Consultant, Greater Recife Community Household Surveillance Program, Pernambuco, Brazil
5
Technical Consultant, Omniamedia – Solutions for Mobile Communications, São Paulo, Brazil
6
This Project was partially funded by the Pan American Health Organization, Division of Health Systems
and Services Development (Contract ASC-98/00176-0). Prototype application development and testing
were conducted in the Greater Recife Community Household Surveillance Program of the State of Per-
nambuco Health Secretariat, Brazil, a program implemented with financial resources of the Government
of the State of Pernambuco and the Municipality of Recife Integrated Actions in Health, Education, and
Environment Project, supported by the United Nations Educational Scientific and Cultural Organization
(UNESCO)
September 1999
Full-fledged palmtop computers (P/PCs) are increas- There are two major bottlenecks in the operation of
ingly finding their place in situations where data nearly all paper-based information systems — data
must be collected, processed, and communicated. In capture and data entry. Except for instances where
community health, the focus on population requires data capture and transcription are performed auto-
mobile capture of large data volume and speed in matically, a condition that exists only in limited
the transfer and processing operations. Small bat- cases, major hindrances, errors, delays, and cost
tery-operated pen-based P/PCs are especially ap- are associated with the cumbersome and labor-
propriate for data capture at the site and time where intensive utilization of data collection paper forms
data are generated and they replace, with great ad- and the keying-in of data by an operator.
vantage, the traditional paper data collection form.
As capabilities increase and prices fall, palmtop per- Data Transcription Problems
sonal computers are bound to become ubiquitous.
Data transcription (form to form or data entry), usu-
Recording Data at the Site of Origination ally done at a site away from where data were col-
lected, poses its own set of difficulties: quality con-
There are important reasons that uphold the desir- trol and error detection limitations, the return and
ability of recording data when they are generated. In tracking of incomplete forms, readability issues, and
the case of health information systems, ideally data the need for personnel dedicated to the task of key-
should be captured at the site and time of contact, ing-in data. Even in the best circumstances, an error
care, or intervention, since consistency checking rate of two to three percent is related to data tran-
and error detection are best carried out at that point. scription alone. Timeliness, completeness, accuracy,
and backlog are ensuing common problems.
While in certain well-controlled environments, as is
the case of inpatient care and survey studies, struc- Computer-based Forms for Data Capture,
tured data recording at the site of care or contact is Transport, and Entry
generally possible, such a situation usually is not
found in primary care, home care, environmental Portable laptop and notebook computers and elec-
health inspection, field social and health interven- tronic data forms are well established and exten-
tions, and many situations of community health prac- sively used. In the health sector, epidemiologists
tice. and field researchers pioneered the use of such mo-
bile devices, and integrated software products have
Constraints of Paper Forms been developed for the creation of forms, data entry,
and data analysis. The best known application in
Paper-based data capture forms must be designed this area is Epi-Info, a public-domain software de-
and printed. Frequently many changes are made to veloped by the United States Centers for Disease
the original design, requiring reprinting and disposal Control and Prevention and the World Health Or-
of unused previous versions. Storage, distributed ganization. Obstacles to the generalized use of lap-
inventory management, and supply of forms to the top and notebook mobile computing equipment are
end-user pose a number of logistical constraints, related to size, high unit cost, power consumption,
especially when the forms are used in a large num- relatively fragile critical internal moving parts (hard
ber of facilities — while there may exist an abun- disk), and the need for a fair level of computer skills.
dance of forms in some sites there may be none in
others. Since 1997 a new generation of cheap, rugged,
diskless, small computer devices have reached the
Perhaps the most important limitation of paper forms market. They have limited processing capabilities
is that, in contrast to computer-based programmed and mass storage but are an ideal platform for elec-
forms, paper forms do not allow the incorporation of tronic data capture forms that use pen-based touch
automatic consistency checks, build-in calculation screen and hand character recognition technologies.
routines, use of programmable variables, and default Typically these devices presently cost from one-
entries. Conditional jumps, easy to program and tenth to one-fifth of a low-end laptop or notebook
change in electronic format, are restricted to fixed computer. Accumulated data can be uploaded to a
and limited rules in paper forms. desktop computer for further processing using a va-
riety of means, by cable and wireless connections.
3 September 1999
Early experimentation with electronic data forms re- In the initial stage of the Community Household Sur-
siding in palmtop devices at the Department of veillance Program, data collection was done with
Health Informatics, Escola Paulista de Medicina printed forms. Those forms were found to be inap-
(CIS/EPM), Federal University of São Paulo, Brazil, propriate due to the cost and time required in de-
involved the development, in 1996, of a nutritional signing, redesigning, and printing; the logistics in-
assessment application on a pen-based Newton volved in storing and supplying paper forms; and the
platform. Although the users were enthusiastic about poor writing skills of the community workers. The
the possibilities of the device, high unit cost (around change in a single data element required the design
US$800), weight, and poor resources in terms of and printing of new forms and the loss of unused
processor capacity and speed, memory, and screen forms from previous print runs. Those issues and
size and quality did not recommend its widespread nagging problems of readability, inconsistencies,
utilization. With the appearance of new options on and the need to manually key-in about 200,000
the market, price reduction and better machine re- forms per month, led to the development of a more
sources, a hospital auditing and evaluation applica- structured data capture form and a change in the
tion was developed in 1997, under contract for the data entry procedures by the introduction of optical
State of São Paulo Regional Medical Board reader technology.
(CRM/SP). The project selected a Hewlett-Packard
LX Series platform, a handheld computer, running Although forms designed for automated optical read-
MS-DOS 5.0. The application was successfully im- ing reduced the incidence of human errors in data
plemented and utilized to collect data in periodic in- capture and transcription, problems remained re-
spection visits conducted in 680 hospitals. Field data lated to the development and printing of those forms,
were periodically uploaded to a desktop platform for necessarily demanding a very accurate design. The
processing. process of entering text by filling mark-sense fields
was quite cumbersome, and a seven percent error
occurred in the optical reading process that required
Problem Statement manual input of correct data. Irrespective of the
method used (manual keying-in or optical reading),
The State of Pernambuco (Brazil) Health Secretariat paper data collection forms do not permit consis-
and the United Nations Educational Scientific and tency checking, and there are many operational
Cultural Organization (UNESCO) implemented a situations in which it would be desirable to have a
social program (Greater Recife Community House- way to calculate field values and introduce default
hold Surveillance Program) in poor areas of the Mu- responses, impossible to do in paper forms.
nicipality of Recife with the goal of bringing to poor
communities a set of integrated developmental ac-
tions involving health, education, and the environ- Methodology
ment. This highly successful project employs around
1,200 community workers with the objective of con- Due to the characteristics of the Greater Recife
ducting household visits to assess needs related to Community Household Surveillance Program, it was
the project’s areas of interest. Pertinent data must considered as an ideal environment for the investi-
be recorded to support program planning, monitoring gation of the applicability and usefulness of portable
of activities, and evaluation. palmtop personal devices in the development and
utilization of computer-based forms.
Most community workers, recruited among the
poorly educated and low-income population of the The goal of this research project was to identify and
project area, have a low literacy level and no special test a low-end pen-based palmtop computer and
skills but, because they live in the neighborhood, investigate tools and issues related to the design
they have easy access to households and first-hand and creation of electronic data collection forms for
understanding of the social, health, and environ- field data capture by unskilled lay community health
mental problems of the community. With little train- workers. The expected result of the project was to
ing they develop into very useful agents for the pro- eliminate paper forms by the introduction of digital
active identification, reporting, and follow-up of forms, introduce consistency checking at the time of
health, educational, and environmental problems. data capture, abolish paper form data transcription
Each community worker visits an average of 200 and entry, and experiment with data transfer and
households per month, presenting the need to print processing by generic and public-domain epidemiol-
and process around 200,000 data capture forms ogy software in a desktop computer at a central site.
each month.
4 September 1999
P/PCs products intended for general use, such as became dominated by a few companies. Standardi-
the Newton, Psion, and Zaurus machines, failed to zation of the palmtop platform is still incipient but this
gain market acceptance and disappeared in a very situation is already rapidly changing — one example
short time. being the consolidation of the initial variety of operat-
ing systems. In the beginning there were a large
The seminal debut of the PalmPilot in 1996, running number of operating systems (OS): Newton, GEOS,
on a proprietary operating system (Palm OS), MS-DOS, Psion EPOC/16, Zaurus, which were
opened up a whole new range of possibilities and quickly superseded by Windows CE (Microsoft Cor-
expandability. Since 1997, and driven by the release poration) and Palm OS (3Com Inc.), the two domi-
of the Windows CE operating system (WinCE) and nant and competing options in today’s OS market.
the Compaq PC Companion [9], the first of WinCE
machines running on AA batteries and with a weight As an indication of the standardization drive, the Mi-
of less than 450 grams, there was renewed interest crosoft Corporation has required that all WinCE sys-
in palmtop devices. As the market evolved, differ- tems comply with specific formats and provide stan-
ences among machines became more significant dard Windows-compatible desktop applications, ex-
and functions more specialized [10]. pansion capabilities, communications, and even size
and weight. The most compelling feature of these
P/PC products fit into two basic categories: organiz- systems is their built-in ability to synchronize and
ers and pocket computers. Organizers are, in gen- exchange files with a desktop or a laptop and inter-
eral, less expensive due to their limited functional- act with existing Windows-based applications and
ities and are mostly used for storing phone numbers systems.
and addresses and maintaining schedules and to-do
lists. Organizers' primary limitation is the lack of ex- Trends
pansion capabilities, as they do not offer card slots
or expansion ports. Pocket computers range in func- In the current year (1999) it is expected that five and
tionality from low-end to high-end units character- half million H/PCs and P/PCs of all types will be
ized by hardware expandability, sophisticated oper- market, a 47% increase over the previous year. It is
ating systems, and diversity of possible application. projected that the installed base will reach more than
32 million such devices in the next three years. The
Cable, infrared, and wireless connectivity to the PalmOS and WinCE operating environments will
desktop became a central feature enabling file trans- have by that time captured 92% of the market from
fer and synchronization of applications. The devel- the 67% of 1998, squeezing out the share held by
opment of devices that offer standardized, simple, Psion’s EPOCH and Sharp’s Zaurus operating sys-
and reliable access to telecommunication links, in- tems [11].
cluding the Internet, and a broad base of third party
applications increased the market share for palm- The immensely popular 3Com Palm platform contin-
tops. Although most P/PCs still rely on desktop ues to gain access to applications and database
computers for network access, recent advances in management systems as well as to provide another
remote connectivity are creating an important market connectivity option to corporate data. Although at
segment for pocketable connected devices that can this time the Palm platform remains primarily a per-
be used in lieu of a portable or desktop machine. sonal information manager (organizer), the availabil-
ity of e-mail, Internet, and database access is trans-
A major problem with any mobile device, including forming the device into a dependable corporate tool,
laptops, continues to be the power supply. Plug-in especially for vertical applications.
cards and color screens consume a lot of power and
in P/PCs and H/PCs there is a trade-off between The WinCE platform has evolved to include new fea-
battery endurance and display contrast ratio; the tures and support to a large number of hardware
relationship is not linear — typically a 15% improve- add-ons and applications. There is a move to create
ment in contrast is accompanied by a 50% drop in a cross-platform operating system, possibly a “light”
battery life. version of the NT environment that would run in
servers and desktops all the way down to the sim-
The history of desktop computers can be used as a plest palmtop device. Regardless of the WinCE plat-
reference model for the anticipated development of form, there is a growing number of software prod-
palmtop computers in the coming years. When an ucts. A recent survey [12] reviewed more than a
open standard was defined for microcomputers and hundred business and general application products.
independent developers began to develop hardware Many are miniaturized versions of desktop applica-
platforms and applications based on such standards, tions but the most exciting are those that have been
the options became rather restricted and the market written with the mobile user in mind such as map-
7 September 1999
Technological and market trends, increasing ma- [4] Ebell MH, Gaspar DL, Khurana S. Family physi-
chine resources and capabilities, ease of use by in- cians' preferences for computerized decision-
dividuals with limited skills, and diminishing costs support hardware and software. J Fam Pract
suggest that palmtop computers (P/PCs) are useful 45(2):137-141, 1997
mobile tools for data recording and transport. P/PCs
have limited processing capabilities but they can [5] Bringing Health Care Online: The Role of Infor-
support many mobile requirements, including simple mation Technologies. Office of Technology As-
database operations and data communication. Large sessment, Congress of the United States, OTA-
data volumes can be recorded, transported, and up- ITC-624, September 1995.
loaded in generic format to a desktop personal com-
puter for processing and analysis. Not only are da- [6] McBride JS, Anderson RT, Bahnson JL. Using a
tabase management system (DBMS) products be- hand-held computer to collect data in an ortho-
coming a requirement on laptops to support a mobile pedic outpatient clinic: a randomized trial of two
workforce, but palmtop devices are now starting to survey methods. Med Care 37(7):647-651,
be used in corporate applications, especially in 1999.
health care and customer services that demand a
small footprint database and robust replication tech- [7] Worth ER. Recent developments in electronic
nologies. medical records. Mo Med 95(5):207-210, 1998.
When selecting a P/PC a careful review of features [8] Handheld computers are key to improving
and price must be made. Reviews rapidly become homecare operations for Colorado provider.
obsolete by reason of the fast-paced technological Health Care Cost Reengineering Rep 3(1):5-7,
changes. Little things such as heavy AC battery 1998.
charge adapters, desktop connection devices, but-
ton placement, and flimsy construction will cause no [9] Mandil, S. Health informatics: new solutions to
end of trouble in field situations. Because there is so old challenges. World Health Aug/Sep:2-5,
much variation in screen brightness and other fea- 1989.
tures, it is absolutely necessary to “test drive” a
number of different models before buying decisions [10] Lun, KC. Hand-held computers. World Health
are made. Aug/Sep:9-11, 1989.
The new generation of palmtop devices is most ap- [11] Plugged into a New Millenium. Infoworld, pp. 9,
propriate to field conditions. Those devices are rug- October 26, 1998.
ged, operate on long-lasting batteries, and can sup-
port a vast range of public health, primary care, [12] Good Things Come in Small Packages.
home care, and environmental health data capture Mobile Computing & Communications, October
and data communication needs. Issue, p. 104-124, 1998.
8 September 1999