c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38

journal homepage: www.intl.elsevierhealth.com/journals/cmpb

Development of a comprehensive medical

recorder on a cellphone

Akihiro Takeuchi a,∗ , Noritaka Mamorita b , Fumihiko Sakai c , Noriaki Ikeda a

a Department of Medical Informatics, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa
228-8555, Japan
b Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan
c Department of Internal Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Paper medical diaries have effectively been used in chronic diseases for self-management
Received 11 September 2008 without information and communication technology for many cases. To facilitate self-
Received in revised form control in chronic diseases, and observe one’s own condition objectively and continuously,
16 January 2009 we developed a cellphone-based medical recorder (MedData) for patients with chronic dis-
Accepted 19 May 2009 eases. The MedData is based on the Java2 Micro Edition and DoJa-3.5 (NTT DoCoMo, Inc.),
and it runs like a scheduler with a calendar, diary, and data entry canvas. The MedData
Keywords: stores laboratory data, such as blood pressure, BUN (blood urea nitrogen), creatinine, Hb
Cellphone A1c (glycosylated hemoglobin), and other pertinent comments, into a cellphone memory.
Java2 Detailed graphic displays of the data are automatically visualized. The MedData can cus-
Medical records tomize recording events, items, prescriptions, and graphics all on the cellphone. These can
Medical diary then be transferred via an infrared port between a cellphone and a PC.
Infrared transmission © 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction is no formal format, the American Diabetes Association has

A medical diary is intended as an aid for patients, as a
reminder to collect useful data regarding their chronic dis-
eases, and as a bridge between a patient and the specialized
care services [1]. The most well known of such diaries is
the Booklet of Mother and Child Health, which has been pro-
vided to every pregnant mother in Japan since 1942 and is
used to record a mother’s and her child’s history from preg-
nancy to school entrance [2]. For an asthma patient, a daily
diary and a periodic self-assessment form are recommended
[3]. The daily diary includes respiratory symptoms, and/or
peak flow, medication use, and restrictive activity [3–5]. The
periodic self-assessment sheet is intended to capture the
patient’s impression of asthma control, self-management of
skills, and overall satisfaction with care [3]. Although there
recommended a self-monitoring of blood glucose and record
keeping with doses of insulin three or more times daily for
most patients with type 1 diabetes [6–8]. For chronic headache,
several diaries have been specially developed for each type of
event [9,10]. A diagnostic headache diary is to prospectively
record headache attacks and medicine consumption [11]. A
structured migraine diary can be a valuable aid in improving
communication between physicians and patients regarding
migraine disability and treatment outcomes [12].
Information and communication technologies (ICT) have
developed rapidly over the last few decades. The Inter-
net is having a radical impact on health care models and
particularly on home health care [13]. Web-based medical
diary/record systems have independently been developed
in many groups [4,9,14–23]. Self-management might signifi-

∗
Corresponding author. Tel.: +81 42 778 9164; fax: +81 42 778 9654.
E-mail address: take@kitasato-u.ac.jp (A. Takeuchi).
0169-2607/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.cmpb.2009.05.006
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
cantly improve outcomes in asthma [14,15,23] and diabetes
[16–18,24,25]. Although online systems facilitate recording,
reliability, and data processing, they are also more costly and
complicated than paper versions [9]. Anhoj and Nielsen [23]
reported that their Web service for asthma patients was gener-
ally considered a trustworthy and reliable site by both patients
and doctors, but it was still not integrated into people’s every-
day lives. They suggested explorations of other methods for
data entry and feedback than conventional Web forms. Per-
sonal digital assistants (PDAs) and smart phones have become
the most appropriate devices for clinical practices and studies
[24,26–30]. Research indicates that data collection is more reli-
able with a palmtop computer than with paper diaries [31,32].
Although cellphones have not officially been integrated into
hospital life, they have become an essential communication
tool for modern society [29,30,33]. In our experience, although
such systems are used for gathering and presenting data, it
may be difficult for an application to have individually tai-
lored functions as far as communicating with a data server is
concerned. Since a cellphone is able to run a Java application
as a standalone application, it may be suitable as a personal
medical recorder similar to the Wellness Diary [30]. Although
data types recorded in chronic disease diaries are widely var-
ied from a simple numeric value, a choice of questionnaires
to symptomatic comments, on a cellphone-based application
may correspond to various questionnaires by implementing a
customizing function. Our objectives are the same as those of
the Wellness Diary other than the program implementation.
This paper reports the development and implementation of a
multipurpose event recorder with customizing functions on a
cellphone with some early experiences.
2. System description
The application is designed as a multipurpose event recorder
for integrating personal medical data. The recorder can simul-
taneously handle various types of disease diaries, and the
user interface for the diaries can be customized by its owner.
The application will most likely be used by healthy people
and patients who are familiar with functions of cellphone. A
summary of the application requirements would be: (1) sim-
ple usage, (2) visualization of clinical events to the owner for
self-management, (3) customization of the user interface to be
adapted to the owner’s disease(s) and prescription(s), and (4)
a tally of recorded data on a PC.
2.1. System overview
The application is a kind of database management system
that handles laboratory numeric values and clinical findings
(string type), “event record,” simultaneously (Fig. 1). An event
is what the user wants to record, such as numerical data,
calories, pharmaceuticals, clinical conditions, and comments.
Event records are interactively displayed, modified, added,
or deleted by the user as in a scheduler. Event records are
searched and selected to make graphs for certain items listed
in a “plot item.” Event records are sorted by a time stamp of
the event and stored in an array memory. All event records are
transferred between the array memory and non-volatile mem-
29
Fig. 1 – System overview.
ory (named, “ScratchPad”) when the application is opened or
closed.
Prewritten messages are ready for the user to easily add one
or several items to an event record all at once. Although record-
ing most events can easily be done just by clicking some items,
it is somewhat troublesome to select items from predefined
list of substantial items for every event. Then the application
handles a set of items as a “prescription” such as a so-called
recipe describing a set of pharmaceutical items and comments
for each patient. The prescription is convenient but implicitly
requests users to answer all the items in order to avoid data
deficits. Items used in the application are “controlled items” and
should be registered in a resource file or a memory. Although
it is impossible to automatically adjust and have ready many
items for each patient, the application has creating, customiz-
ing, and deleting functions of items and prescriptions.
The application functionally consists of a calendar canvas,
a diary canvas, a data entry canvas, a plot canvas, and an
infrared module (Fig. 1). The first three canvases are layered
chronologically: per month, day, or time of day. On the diary
canvas, selecting an event record gives a list of pairs of a medi-
cal item (laboratory name, event name) and its value (numeric
value, intensity or clinical findings) on a data entry canvas.
New values are manually entered on the data entry canvas.
Event records are interactively modified, added, or deleted by
the user, and then automatically stored onto a “ScratchPad”
when the application is closed. All data are stored in text form
in the memory of the patient’s cellphone (maximum 200 kB).
The resource file that contains initial values of items and sam-
ple events is loaded once at the first run after installation of
the application.
The event records, items and prescriptions can be exported
as a formatted text file to a PC through an infrared (iR) hard-
ware module plugged into a cellphone and a PC (with an
iR-USB [universal systems bus] adaptor). The infrared module
exports event records in units of a day or a month to a PC with
a format described in Section 2.2. The exported records on the
30 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
Fig. 2 – Data structure of the system.
PC are tabled and tallied on an Excel worksheet with an origi-
nal VBA (visual basic for application) program. The application
can also import new items, new prescriptions, and/or new
setting values to revise the user interface of the application
through the iR communication.
The application does not handle the data of the scheduler
or address book preinstalled in cellphones to avoid confusing
business data with private medical data of the application.
2.2. Data structures of the system
The “event record” is constructed with a time stamp and one
or more pairs of an item’s name and its value (Fig. 2). The data
structure of an “item” used in the system is defined as a set
including a name, the data type, a default value, the minimum
and maximum of normal (or target) range, plot level (plot or
no plot), line color, graph type (bar, line, or mark), and the
upper and lower limits of the plot canvas. Properties of the
item require obligatory plot-related values as many plot items
are distinguished from others when two or more are presented
in one plot canvas. Plotting data naturally requires two scales,
one for the x-axis and one for the y-axis, for a simple graph.
The x-axis is arbitrarily selected in day, week, month, or year.
Although the upper and lower limits of each plot item are used
for the y-axis, these limiting values are varied among items
and patients. For example, a blood sugar range from 50 to 200
is relevant for normal patients, but one from 0 to 300 or more
is needed for diabetes mellitus patients. And if the target for
daily calorie intake is 1600 for some person, the y-axis lim-
its may be set from 1100 to 2100. Whereas, if the target daily
calorie intake is 2000 for another person, then the y-axis limits
may be set from 1500 to 3000. These plot-related values should
be manually customized by each patient. If an off-scale plot
occurs, the graph will indicate that to the user. The applica-
tion does not automatically change the scale range because
any automatic adjustment, such as Excel Chart Wizard, may
cause a misinterpretation and/or a misunderstanding.
Fig. 3 – Sample descriptions in a resource file. The upper
nine lines show sample items, integer type, decimal type,
and text type. The middle seven lines show examples of
the special function for calorie control. Line 17 shows a list
of plot items. The lower part shows two prescriptions
including the items defined above.
Data types are available for integer, decimal, list, text, and
expression. The list-type item has a nickname, a selected
value, and predefined selections. The maximum number of
the selection is 32 for a list-type item. A “plot item” is a kind
of list-type item with the registered name, “PlotDataName”
and contains the names of the items for data plots. Graph-
ics for those items will be shown on the plot canvas with each
item’s properties, color, and mark. An expression (calculation)
item is constructed with a nickname, a calculated value, sev-
eral factors and operators. Predefined operators are: +, −, *, /,
sigma, mean, and both left and right parentheses. If an expres-
sion contains a registered item’s name as a factor, the item’s
numerical value is automatically substituted to calculate the
expression.
Fig. 3 shows examples of data formats of items, plot items,
prescriptions, and event records. This data format is used in a
resource file and data transport to and from a PC through an
infrared communication. Properties of items are described by a
command key “myVar=” and separated by a comma. For exam-
ple, the initial properties of item “BUN (blood urea nitrogen),”
are: data type integer, default value 10, minimum of normal
range 5, maximum of normal range 15, the lower limit of a
vertical axis 0, the upper limit of the axis 110, plot mode 3 (sin-
gle plot), graph-type line, mark and line color yellow (red 255,
and green 255 in tone). Items of “Insulin human”and “Neutral
insulin” are integer-type items for an injection dose of insulin.
“Tolbutamide (Orinase) mg” and “Acetoheamide (Acetohex-
amide) mg” are examples of decimal-type items. In the list
type, the name of the item is followed by some recommended
values. Plot items are defined in an item “PlotDataName” that
contains “BUN,” “blood sugar (BS),” “Day calories,” etc., in this
case. The expression item “Day calories” totals “(the number
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
Fig. 4 – Overview of user interface. Each arrow shows a link to the next canvas or menu as examples as all relations
between menus are too complicated to show at once. Each numeric key is programmed to call each function at anytime.
of) Calories” per day. The expression item “Mean number of
calories for 7 days” calculates “(the mean number of) Calo-
ries” during the previous 7 days. The command item “set Day
calories” sets properties of “Day calories” for the graphics:
minimum of normal range 0, maximum of normal range 2000,
the lower limit of the vertical axis 0, the upper limit of the axis
3000, plot mode 3 (single plot), graph-type Bar2, mark and line
color, light purple (red 255, and blue 192 in tone).
A prescription is followed by a command key “RP)=” and
contains a nickname, several pairs of an item’s name and
its default value. These prescriptions of “Calorie balance”
and “Weekend calorie check” will be listed in a menu under
“Add prescriptions” on a diary canvas. An “event record” is
described in between the command key “BOR=” with a time
stamp and “EOR=;” such as a prescription.
2.3. User interface
The calendar canvas is a main window and interactively
responds to user operation by a selection key, arrow keys, and
two soft keys (Fig. 4). On the calendar canvas, selecting a day,
shows a list of daily event records and/or prescriptions on a
diary canvas. The user interface on the data entry canvas is
automatically adjusted to input for the data type of the item,
e.g., time, integer, decimal, selection, or comment. To enter
an integer value, only numeric keys are available, not alpha-
betic keys. For the selection type, a list of predefined answers
is automatically shown such as a pull-down menu.
The right soft key on the calendar canvas pulls up a menu
that includes “Copy,” “Paste” and “Delete” to handle event
records during a day in bulk, “Items” and “Plot items” to modify
each item, “System” to modify system values, “Infrared (send)”
and “IR (receive)” to transfer event records via an infrared
module, “Memo” to record a comment at any time, quickly
31
and simply, “Search” to find any event records including the
keywords, “Help” and “Exit.” The menus of “Items” and “Plot
items” are ready to list items or plot items to edit their proper-
ties. A submenu on the “list item” canvas links to functions to
create a new item, create a new selection item, to create a new
expression item, to change the order of items, and to delete
an item.
The “plot items” canvas shows a list of plot items with tog-
gle switches for plot or not, and has a submenu for changing
plot properties, selecting (redefining) plot items from all items,
and deleting an item from the plot list. The “redefine” sub-
menu shows a list of items selected for a plot. The “Infrared
(send)” menu sends all event records during the month shown
on the canvas. The “System” menu includes submenu “Font,”
“Data transfer,” “Control level” to modify items, “ID,” “Name,”
“Birthday,” and “Private Memo.” The “Control level” sets an
item’s data (plot) property to a constant (not to be modified,
0), system level (1), no plot (2), single plot (3), or multiple plot
(4).
The right soft key on the diary canvas pulls up a menu
including, “Add item” and “Add prescription.” The “Add item”
menu is to add any items to the daily event records. The “Add
prescription” menu is to add any prescriptions to the daily
event records, and to create or delete a prescription. A new
prescription is set by certain items marked on a selection can-
vas. The “Infrared (send)” menu sends daily event records on
the same day.
Pushing the left soft key of the calendar canvas shows a
plot canvas. A graph of each item is drawn sequentially in the
order of the list of plot items. The vertical scale of each item
is automatically adjusted to a graph property of the item. The
horizontal scale of the graph must be set arbitrarily according
to each item’s characters from day to year. For example, a BS
varies quickly in a short term and can be measured a few times
32 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38

Fig. 5 – Captured screen of a calendar canvas (left), diary canvas (middle), and data entry canvas (right) in a case requiring
hemodialysis.

a day. On the other hand, Hb A1c (glycosylated hemoglobin) is
measured monthly in a clinic, not daily or weekly.
A numeric key on a cellphone directly calls a function. A
horizontal scale of the graph is set to day, week, month or
year by pushing 2, 5, 8 or 0, respectively. Pushing 4 or 6 shows
the previous or the next graph in order of the list of plot items.
Pushing 1 returns a plot canvas to the calendar canvas with a
text screen. Although a calendar canvas can only show a part
of the daily data on a small screen at a time, pushing 9 shows
daily event data in bulk on an edit-text screen (Input method:
edit on a cellphone). The key “7” starts the function to draw
a small graph on each day on the calendar canvas. Pushing 3
shows the simple usage of the system.
2.4. Hardware and software specifications
To develop and test the application, an ordinary PC (Dell
DIM4400, Pentium 4 1.90 GHz; NVIDIA GeForce2 MX, Mem-
ory: 1 GB) with Windows Xp is used. The Java 2 Platform (Sun
MicroSystems) provides the Java environment to run on a
cellphone and to develop Java applications on a PC. To use
the application, one needs to use version 1.4 or later. The
application was based on the Java 2 Platform, Micro Edition
(J2ME), and developed with an “i-␣ppli Development Kit for
DoJa-3.5” [34] on a PC. DoJa is a version of the Java platform spe-
cially tailored to the mobile environment of NTT cellphones.
The application, a medical recorder (MedData.jar 100 kB), was
uploaded with two files (MedData.jam and MedData.html)
into our server. Then the medical recorder was once down-
loaded via the Internet and automatically installed into a
Java-enabled cellphone in the ordinary way of a Java appli-
cation. The application emulator is not capable of perfectly
emulating the behavior of cellphones and each cellphone
has its own particular memory capacity and other limita-
tions. For example, a cellphone SO902i has a memory for a
Java application (100 kB), persistent storage for an applica-
tion (ScratchPad 400 kB), a screen resolution: 240 (width) × 300
(height) and an infrared module. The application was tested on
several cellphones: N903Li, N905imyu, P903i, SO902i, SH902i,
and SH903iTV (NTT DoCoMo, Inc.).
3. Status report
For clarity in the present report, the PC screens are shown in
the regular order of usage rather than using photographs of

Fig. 6 – Diary canvas and entry canvas in a case of chronic headache.

 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
Fig. 7 – Headache intensity (red), analgesics (light blue), and
pharmaceuticals (blue) for 1 day (left). Headache intensity
during 1 week (right). (For interpretation of the references
to color in this figure legend, the reader is referred to the
web version of the article.)
cellphone screens. The application operates like a scheduler
(Fig. 5). “Today,” on the calendar, is highlighted in yellow. The
selected day is highlighted in light blue and moved by oper-
ating the arrow keys. Each colored line on any day, e.g., the
7th and 21st, corresponds to each clinical event or set of data
and appears with comments and/or a graph in the lower area.
Two records, pairs of the time of day and prescriptions, with
laboratory data, are shown in this case of a chronic patient
requiring hemodialysis. The current record is moved by the
up or down key. Pushing the select key on a target record
shows a data entry canvas with laboratory item names and
values. The patient types are in numeric data or text. When
a current cursor is moved on an item whose data type is a
list type, an adaptive submenu is automatically shown on
the right side of the item along with a blood-flow setting for
hemodialysis.
In a patient with chronic headache, three records and two
submenus of headache intensity and analgesics are shown in
Fig. 6. All these values, including the time span, can later be
edited on the data entry (edit) canvas. Daytime diaries and
nighttime symptoms can be completed and edited at any time,
each evening before bed or each morning upon waking up. The
left soft key “Back” moves back to the previous canvas without
saving data, and the right soft key “Save” to save data edited
at the time. Fig. 7 shows a daily graph of headache intensity,
analgesics and headache pharmaceuticals on February 19. A
Fig. 8 – Calendar canvas with a graph (left), plot canvas (middle), and edit canvas for creatinine (right).
33
Fig. 9 – An example of a selection canvas.
trend graph of headache intensity for 1 week is shown in red.
A condition of mild intensity is shaded in light red.
Pushing the left soft key “Plot” of the calendar canvas shows
a graph of all plot items on the lower area of the canvas and
as a simple graph for each plot item on a new canvas (Fig. 8).
The normal range is shaded with the same line color of the
item but in a halftone. The trend graph of potassium for 1
year is shown in light blue (Fig. 8, middle). The values in the
last half of the year are higher than the target range shaded
in the same color as the item in halftone. Graph properties of
each item (vertical scale, normal range, line color, mode and
symbol) can be customized via a submenu on the calendar
canvas (Fig. 8, right).
Selecting one of the submenus: “Add item,” “Plot items,”
“Redefine plot items” or “Create prescription” shows a check-
list of items on a new canvas and selection boxes. Pushing the
select key on an item exchanged a head mark to the white
squares or black diamonds in turn (Fig. 9). Only the checked
items were selected and stored. The exported event records
are tabled and tallied on Excel (Fig. 10). How to interpret and
use the tabled data is dependent on the object of each disease
diary entry.
Fig. 11 shows sample screens of creating a new item and a
new selection item. The properties of the item “Exercise dura-
34 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
Fig. 10 – An example tabled and tallied on an Excel worksheet.
tion” are modified and can be seen on the canvas. An answer
list for “Sport” is also made available. These values can be
modified at a later time. To confirm the data transfer through
iR communication and the interpreter function of our applica-
tion in response to the reviewers’ comments, we reproduced
functions of the data entry and a graph of the Wellness Diary.
We only created a text file with our data format of items and
prescriptions that were based on their report (Fig. 12). The text
file on a PC is imported through iR communications. The items
and prescriptions are incorporated in a menu of our applica-
tion. Fig. 13 shows the calendar, data entry and plot canvases.
Fig. 11 – Examples of creating a new item (left) and a new
selection item (right).
Although a captured screen may be different from the screens
of the Wellness Diary, the data entry and graph functions are
completely reproduced in our application.
The initial responses from the pilot users were pos-
itive. Through interviews, we assessed user satisfaction
and their pros and cons regarding the system. They
agreed that it was easy to use, that the graphics could
be easily understood, and said that they would like to
continue using it. Accesses to the systems for DoCoMo
cellphones are freely provided via an application provider
at http://appget.com/im/pc/apview 045759.htm for chronic
headache and http://appget.com/im/pc/apview 045756.htm
for metabolic syndrome.
4. Discussion
4.1. Aims of the cellphone application
By using a diary, a chronically ill person is able to gain an
overview of his situation [1]. Such information is helpful in
supporting behavioral changes in patients with chronic dis-
eases [3,35]. On the other hand, mobilization has become
a major trend, and mobile devices offer great potential
for improving quality in health care [29,36]. Data collec-
tion proved more reliable with a palmtop computer than
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38 35

Fig. 12 – Items (left) and prescriptions (right) to reproduce a Wellness Diary. These variables are manually transformed
according to a table of variables and implementation of the Wellness Diary. The default value and properties of each item
were arbitrarily predefined.

with paper diaries [8,31,32]. Burke et al. [37] identified the
strengths and limitations of paper diaries and PDAs in a
review of the literature on the use of paper diaries for self-
monitoring food intake. Although some negative aspects
are listed as: “requires some training, requires user to be
computer literate, requires user to recharge battery regu-
larly, or if battery is not charged, data are lost,” regular
cellphone users are used to dealing with these matters
without too much difficulty. Therefore, we developed a
cellphone-based medical recorder whereby patients can flex-
ibly enter, maintain, compare and analyze their own clinical
data.
4.2. Manual data input
Strenuous efforts in the system design and implementation
successfully achieved making an input canvas and a visualiza-
tion canvas to simplify the users’ operations. Our main focus
during development of this system was, “the system should
be easy to use,” which was also stated in the development of
a diagnostic headache diary [11]. A Web service for asthma
patients and health-care “LinkMedica” was provided, but it
was not integrated into the patients’ everyday lives [23]. In our
system, we used four key concepts from the patients’ six sug-
gestions: “daily data entry, mobile phone, a diary overview, and
36 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
Fig. 13 – Captured screens of a reproduction of functions
from a Wellness Diary. Sample screens show prescriptions
corresponding with “Study 1 (obligatory)” and “Study 2” as
defined in Fig. 12. Figures show two kinds of graphs, all
plot items, or a single item. The hatched area in the bottom
figure indicates the target line in this case—“duration of
exercise.”
graphing facilities.” Three layered canvases: a calendar canvas,
a diary canvas, and a data entry canvas, are natural and easy
to use. The user can arbitrarily access the canvases by only
using the select keys and soft keys. Captions of soft keys on
the canvas are simple: “Plot, Back, Save, and Menu.” These cap-
tions are defined according to four recommendations: “avoid
abstract expressions, generic terms, similar words or phrases,
and double negatives” [38]. Because designs of soft keys on
Japanese cellphones are similar from make to make, the user
might not be confused by the variations in cellphones.
Our system imposes upon the user to manually enter his or
her own clinical data, even laboratory numerical data, without
having firsthand information and/or the required expertise in
communication technology. Although entering data is trou-
blesome, the operation of doing so and seeing the graphics
one’s self may enable a person to recognize and deepen their
awareness of their own symptoms, laboratory data, diseases,
and prescriptions to help them manage their own diseases.
Tufano and Karras reported, “an act of actively processing and
managing information improves their (the patients’) under-
standing and situational awareness” and “over automation of
data entry and information processing may diminish both the
users’ situational awareness and the usefulness of the infor-
mation, . . .” [39]. Self-monitoring blood glucose allows patients
to recognize and prevent severe hypoglycemic episodes [6].
Patients who monitor their own blood glucose are empow-
ered to be more active in their treatment [40]. Record keeping is
almost as important as blood glucose monitoring itself [6]. Fre-
quent reminders may be helpful for newly diagnosed patients
or those with uncontrolled diabetes [41]. It is reported that
daily reporting was therapeutic for some of the participants
[9]. Nappi et al. stated, “The study did not provide any conclu-
sive evidence, but it would be interesting to test the hypothesis
that the diary may have a positive influence on the headache
course” [9]. Our system draws daily data each day, and trend-
grams of all plot items together on a calendar canvas and
separately on a plot canvas. Graphs of clinical data are use-
ful for realization, awareness and self-management of chronic
diseases.
Validation checks of data entered and appropriate error
messages must be incorporated into a system to maintain
the data accuracy. However, because even a simple error
message often confuses the user, our application validates
only numeric keys where actually a numeric value should
be entered: hour, minute, number of tablets, etc. Alphabetic
characters are only validated for entering comments. A list
menu is automatically shown when answers are prepared.
These ideas hide a certain obstacle error message when enter-
ing data. Even if a mistake is made in entering data such as
omitting a decimal point and saved, the user with a chronic
disease should see the invalid data on a graph canvas and
catch the mistake in the next phase of data entry and/or in a
communication with medical services staff. Although inten-
tionally entering invalid data may extinguish data availability,
there is no sure way of preventing this in any system. The
system has “Memo” and “Search” menus that, as far as we
know, are not reported in any Web-based or server-based cell-
phone application. The “Memo” menu automatically records
a time stamp, a function that one operator said was unex-
pectedly very reassuring. This application may be especially
useful for commenting on each event in cases of Holter ECG
recording. The time stamp can be modified easily at any time
such as when an event record is being accessed. Though the
“Search keyword” menu is not indispensable and not main-
tained in a preinstalled simple scheduler or diary application,
it has turned out to be convenient beyond our expectations.
4.3. Customization
A customizing function provides the possibility for a user to
create and maintain new, original variables and templates [42].
In our system, the user can easily modify any prescription,
questionnaire and/or item using the menus. Also, as the appli-
cation runtime behavior presented in the examples is driven
by items in the system, this mechanism is a highly flexible
and adaptive integral part of the system. Because the data
structure of a questionnaire is defined as several pairs of an
item’s name and its value such as a prescription, even long
names, the system can handle a questionnaire the same as
it does a prescription. A new prescription (or questionnaire)
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
and/or an item are created on an edit canvas. The question-
naire includes some questions (items) that are registered in
an item list. To be able to answer a question more simply,
some quick answers are preset in a list. The questionnaire
can include even emotional or environmental factors, such
as nutrition, stress and/or psychological complaints. However,
each question might have a numerical scale to allow data to
be entered more easily, and it might be preferable to link the
question to an established, standard code or classification to
facilitate analyses and tallying at a later point in time.
Although the nature of a Web-based application can be
helpful in design and implementation [13], most Web-based
systems do not allow users to customize data items or graph-
ics output. Self-configuration and mass-customization may
be two of the key features of newly converged technologies
to successfully run public and/or organizationally sponsored
informational interventions [29]. The customization can be
done by interactive keyed operations on a cellphone. Our
application can also be modified by importing a set file from a
PC that includes new definition of items and/or prescriptions
as shown in Fig. 12. This method is advantageous especially
in major modifications of the application. Moreover, if a user
wants, event records can be import in the same way.
4.4. Cellphone memory
DoJa is a version of the Java platform specially tailored to
DoCoMo’s mobile environment and competes with the MIDP
(Mobile Information Device Profile). Although the DoJa classes
are related to the user interface, high-level and low-level APIs
(Application Programming Interfaces), we must use the low-
level user-interface classes to directly plot clinical data on the
small screen using primitive graphics. Because J2ME has no
database management class such as SQL (Structured Query
Language) interpreter and the “ScratchPad” is a contiguous
chunk of memory, we made several procedures to structure
and handle data strings as database records. Although new
cellphones have an increased memory size for an executable
code and resource files, several exception errors, especially,
“Out of Memory,” occurred in a case with large event records
in the developing phase of our system. The amount of appli-
cation execution memory and storage memory ScratchPad
must be taken into consideration. The ScratchPad memory
model implements a portion of the transaction concept and
is either written in full or totally rejected [43]. That means
that a large amount of memory is simultaneously requested,
at least the sum of memories: an I/O buffer memory to
read/write ScratchPad data in bulk, and an array memory
of event records to operate and keep them on a runtime.
We have manually optimized and improved the program
codes as much as possible to allow storage of more event
records.
In any Web-based database system, protecting the server
and clients is one of the most important tasks. Accessing the
database is protected by passwords, and the database itself
is encrypted in some cases [13,22]. Our application on the
cellphone has no security code because: (1) entering a pass-
word declines the usability of the system, (2) memory area
of each i-appli is absolutely isolated from other applications
on the cellphone [43], (3) our application runs only in a stan-
37
dalone mode without the Internet, and (4) the cellphone can be
secured with a protection key in case it is lost or stolen. Conse-
quently, the application code was made as simple as possible,
and its size was reduced. Although the application dose not
use the Internet, records are directly exported to a target PC
by the user’s operations with an infrared communication. The
exported records must be secured in the PC.
5. Future plans
We developed and reported on a multipurpose event recorder
with customizing functions on a cellphone as a functioning,
self-managing tool, and not merely a concept. Although we
have started trials of our application with patients suffering
from chronic renal failure, chronic headache, and diabetes
mellitus, the evaluations of the clinical outcomes should be
studied statistically in clinical trials in each field. This cell-
phone application will be a private data repository available
anytime and anywhere for a better, safer, and more healthful
personal life.
Conflict of interest statement
There are no conflicts of interest that could inappropriately
influence this research work.
Acknowledgements
This work was partially funded by a Research on Psychiatric
and Neurological Diseases and Mental Health of the Health
Labour Sciences Research Grant for “Research on the develop-
ment of the innovative treatment for migraine headache.” We
thank Robert E. Brandt (MedEd Japan, Tokyo) for helpful advice
on the English language in this paper.
references
[1] H. Baert, P. Gielen, M. Smet, A health diary for the
chronically ill, WHO Reg. Publ. Eur. Ser. 44 (1992) 328–331.
[2] K. Wake, How to use a booklet of mother and child health,
Nippon Eiseigaku Zasshi 25 (1970) 248–264.
[3] National Asthma Education and Prevention Program, Expert
Panel Report 2: Guidelines for the Diagnosis and
Management of Asthma, US Dept of Health and Human
Services, Bethesda, MD, 1997.
[4] J. Finkelstein, M.R. Cabrera, G. Hripcsak, Internet-based
home asthma telemonitoring: can patients handle the
technology? Chest 117 (2000) 148–155.
[5] N.C. Santanello, Pediatric asthma assessment: validation of
2 symptom diaries, J. Allergy Clin. Immunol. 80 (5 Suppl.)
(2001) S465–S472.
[6] American Diabetes Association Resource Guide 2003, Blood
glucose monitors and data management, Diabetes Forecast
56 (2003) 77–79, 82–84, 86–87.
[7] American Diabetes Association: Standards of Medical Care
in Diabetes-2007, Diabetes Care 30 (Suppl. 1) (2007) S4–S41.
[8] A.A. Stone, S. Shiffman, J.E. Schwartz, J.E. Broderick, M.R.
Hufford, Patient non-compliance with paper diaries, BMJ 324
(2002) 1193–1194.
38 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 9 7 ( 2 0 1 0 ) 28–38
[9] G. Nappi, R. Jensen, R.E. Nappi, G. Sances, P. Torelli, J. Olesen,
Diaries and calendars for migraine. A review, Cephalalgia 26
(2006) 905–916.
[10] F. Sakai, K. Dobashi, H. Igarashi, Assessing new migraine
therapies in Japan, Cephalalgia 19 (Suppl. 23) (1999) 9–12
(discussion 12–4).
[11] M.B. Russell, K. Dremstrup Nielsen, C. Rasmussen, J.
Schoenen, T. Paiva, Multimedia education in headache: the
European Neurological Network, Eur. J. Neurol. 7 (2000)
355–362.
[12] V. Baos, F. Ester, A. Castellanos, G. Nocea, M.T. Caloto, W.C.
Gerth, I-Max Study Group, Use of a structured migraine
diary improves patient and physician communication about
migraine disability and treatment outcomes, Int. J. Clin.
Pract. 59 (2005) 281–286.
[13] R. Bellazzi, S. Montani, A. Riva, M. Stefanelli, Web-based
telemedicine systems for home-care: technical issues and
experiences, Comput. Methods Programs Biomed. 64 (2001)
175–187.
[14] H.R. Lee, S.K. Yoo, S.M. Jung, N.Y. Kwon, C.S. Hong, A
Web-based mobile asthma management system, J. Telemed.
Telecare 11 (Suppl. 1) (2005) 56–59.
[15] S. Guendelman, K. Meade, M. Benson, Y.Q. Chen, S. Samuels,
Improving asthma outcomes and self-management
behaviors of inner-city children: a randomized trial of the
Health Buddy interactive device and an asthma diary, Arch.
Pediatr. Adolesc. Med. 156 (2002) 114–120.
[16] A. Farmer, O. Gibson, P. Hayton, K. Bryden, C. Dudley, A. Neil,
L. Tarassenko, A real-time, mobile phone-based
telemedicine system to support young adults with type 1
diabetes, Inform. Prim. Care 13 (2005) 171–177.
[17] E.J. Gomez, M.E. Hernando, A. Garcia, F. Del Pozo, J. Cermeno,
R. Corcoy, E. Brugues, A. De Leiva, Telemedicine as a tool for
intensive management of diabetes: the DIABTel experience,
Comput. Methods Programs Biomed. 69 (2002) 163–177.
[18] B. Rami, C. Popow, W. Horn, T. Waldhoer, E. Schober,
Telemedical support to improve glycemic control in
adolescents with type 1 diabetes mellitus, Eur. J. Pediatr. 165
(2006) 701–705.
[19] M. Torchio, F. Molino, D. Sestero, C. Seidenari, G. Molino, An
electronic medical diary for computer assisted patient
management, Minerva Med. 94 (2003) 167–179.
[20] O. Ferrer-Roca, K. Franco Burbano, A. Cardenas, P. Pulido, A.
Diaz-Cardama, Web-based diabetes control, J. Telemed.
Telecare 10 (2004) 277–281.
[21] L. Lind, E. Sundvall, D. Karlsson, N. Shahsavar, H. Ahlfeldt,
Requirements and prototyping of a home health care
application based on emerging JAVA technology, Int. J. Med.
Inform. 68 (2002) 129–139.
[22] E.J. Gomez, C. Caceres, D. Lopez, F. Del Pozo, A web-based
self-monitoring system for people living with HIV/AIDS,
Comput. Methods Programs Biomed. 69 (2002) 75–86.
[23] J. Anhoj, L. Nielsen, Quantitative and qualitative usage data
of an Internet-based asthma monitoring tool, J. Med.
Internet Res. 6 (2004) e23.
[24] A. Kollmann, M. Riedl, P. Kastner, G. Schreier, B. Ludvik,
Feasibility of a mobile phone-based data service for
functional insulin treatment of type 1 diabetes mellitus
patients, J. Med. Internet Res. 9 (2007) e36.
[25] Z. Faridi, L. Liberti, K. Shuval, V. Northrup, A. Ali, D.L. Katz,
Evaluating the impact of mobile telephone technology on
type 2 diabetic patients’ self-management: the NICHE pilot
study, J. Eval. Clin. Pract. 14 (2008) 465–469.
[26] M. Al-Ubaydli, C. Paton, The Doctor’s PDA and Smartphone
Handbook. Personal digital assistant, J. R. Soc. Med. 98 (2005)
494–495.
[27] O. Aziz, S.S. Panesar, G. Netuveli, P. Paraskeva, A. Sheikh, A.
Darzi, Handheld computers and the 21st century surgical
team: a pilot study, BMC Med. Inform. Decis. Mak. 5 (2005) 28.
[28] J. Roelofs, M.L. Peters, J. Patijn, E.G. Schouten, J.W. Vlaeyen,
Electronic diary assessment of pain-related fear, attention to
pain, and pain intensity in chronic low back pain patients,
Pain 112 (2004) 335–342.
[29] E. Koskinen, J. Salminen, A customizable mobile tool for
supporting health behavior interventions, in: Conf. Proc.
IEEE Eng. Med. Biol. Soc. 2007, 2007, pp. 5908–5911.
[30] E. Mattila, J. Pärkkä, M. Hermersdorf, J. Kaasinen, J. Vainio, K.
Samposalo, J. Merilahti, J. Kolari, M. Kulju, R. Lappalainen, I.
Korhonen, Mobile diary for wellness management—results
on usage and usability in two user studies, IEEE Trans. Inf.
Technol. Biomed. 12 (2008) 501–512.
[31] R.N. Jamison, S.A. Raymond, J.G. Levine, E.A. Slawsby, S.S.
Nedeljkovic, N.P. Katz, Electronic diaries for monitoring
chronic pain: 1-year validation study, Pain 91 (2001) 277–285.
[32] M.E. Hyland, C.A. Kenyon, R. Allen, P. Howarth, Diary
keeping in asthma: comparison of written and electronic
methods, BMJ 306 (1993) 487–489.
[33] O. Aziz, A. Sheikeh, P. Paraskeva, A. Darzi, Use of mobile
phones in hospital: time to lift the ban? Lancet 361 (2003)
788.
[34] NTT DoCoMo, i-appli Development Tools for DoJa-3.5 Profile,
Development of a Personal Medical Recorder on Cell Phone.
http://www.nttdocomo.co.jp/english/service/imode/make/
content/iappli/about/tool foma2.html (accessed April 2007).
[35] J. Anhøj, C. Møldrup, Feasibility of collecting diary data from
asthma patients through mobile phones and SMS (short
message service): response rate analysis and focus group
evaluation from a pilot study, J. Med. Internet Res. 6 (2004)
e42.
[36] E. Ozdemir, M. Karacor, Mobile phone based SCADA for
industrial automation, ISA Trans. 45 (2006) 67–75.
[37] L.E. Burke, M. Warziski, T. Starrett, J. Choo, E. Music, S.
Sereika, S. Stark, M.A. Sevick, Self-monitoring dietary intake:
current and future practices, J. Ren. Nutr. 15 (2005) 281–
290.
[38] S. Bay, M. Ziefle, Children using cellular phones: the effects
of shortcomings in user interface design, Hum. Factors 47
(2005) 158–168.
[39] J.T. Tufano, B.T. Karras, Mobile eHealth interventions for
obesity: a timely opportunity to leverage convergence
trends, J. Med. Internet Res. 7 (2005) e58.
[40] S.A. Foster, J.V. Goode, R.E. Small, Home blood glucose
monitoring, Ann. Pharmacother. 33 (1999) 355–363.
[41] S.C. Durso, I. Wendel, A.M. Letzt, J. Lefkowitz, D.F. Kaseman,
R.F. Seifert, Older adults using cellular telephones for
diabetes management: a pilot study, Medsurg. Nurs. 12
(2003) 313–317.
[42] R. Chen, G. Enberg, G.O. Klein, Julius—a template based
supplementary electronic health record system, BMC Med.
Inform. Decis. Mak. 7 (2007) 10.
[43] NTT DoCoMo, DoJa 1.5 Overseas Edition DoJa Java Content,
Developer’s Guide, Release 1.2 November 22.
http://www.doja-
developer.net/downloads/downld.php?id=12 (accessed
August 2008).