September 1999

Palmtop Computers in Community Health

Roberto J. Rodrigues 1 , Daniel Sigulem 2 , Meide Anção 3 ,

Reginaldo H. Albuquerque 4 and André C.T. Aubers 5

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)

Introduction
Full-fledged palmtop computers (P/PCs) are increas-
ingly finding their place in situations where data
must be collected, processed, and communicated. In
community health, the focus on population requires
mobile capture of large data volume and speed in
the transfer and processing operations. Small bat-
tery-operated pen-based P/PCs are especially ap-
propriate for data capture at the site and time where
data are generated and they replace, with great ad-
vantage, the traditional paper data collection form.
As capabilities increase and prices fall, palmtop per-
sonal computers are bound to become ubiquitous.
Recording Data at the Site of Origination
There are important reasons that uphold the desir-
ability of recording data when they are generated. In
the case of health information systems, ideally data
should be captured at the site and time of contact,
care, or intervention, since consistency checking
and error detection are best carried out at that point.
While in certain well-controlled environments, as is
the case of inpatient care and survey studies, struc-
tured data recording at the site of care or contact is
generally possible, such a situation usually is not
found in primary care, home care, environmental
health inspection, field social and health interven-
tions, and many situations of community health prac-
tice.
Constraints of Paper Forms
Paper-based data capture forms must be designed
and printed. Frequently many changes are made to
the original design, requiring reprinting and disposal
of unused previous versions. Storage, distributed
inventory management, and supply of forms to the
end-user pose a number of logistical constraints,
especially when the forms are used in a large num-
ber of facilities — while there may exist an abun-
dance of forms in some sites there may be none in
others.
Perhaps the most important limitation of paper forms
is that, in contrast to computer-based programmed
forms, paper forms do not allow the incorporation of
automatic consistency checks, build-in calculation
routines, use of programmable variables, and default
entries. Conditional jumps, easy to program and
change in electronic format, are restricted to fixed
and limited rules in paper forms.
September 1999
Data Capture and Data Entry
There are two major bottlenecks in the operation of
nearly all paper-based information systems — data
capture and data entry. Except for instances where
data capture and transcription are performed auto-
matically, a condition that exists only in limited
cases, major hindrances, errors, delays, and cost
are associated with the cumbersome and labor-
intensive utilization of data collection paper forms
and the keying-in of data by an operator.
Data Transcription Problems
Data transcription (form to form or data entry), usu-
ally done at a site away from where data were col-
lected, poses its own set of difficulties: quality con-
trol and error detection limitations, the return and
tracking of incomplete forms, readability issues, and
the need for personnel dedicated to the task of key-
ing-in data. Even in the best circumstances, an error
rate of two to three percent is related to data tran-
scription alone. Timeliness, completeness, accuracy,
and backlog are ensuing common problems.
Computer-based Forms for Data Capture,
Transport, and Entry
Portable laptop and notebook computers and elec-
tronic data forms are well established and exten-
sively used. In the health sector, epidemiologists
and field researchers pioneered the use of such mo-
bile devices, and integrated software products have
been developed for the creation of forms, data entry,
and data analysis. The best known application in
this area is Epi-Info, a public-domain software de-
veloped by the United States Centers for Disease
Control and Prevention and the World Health Or-
ganization. Obstacles to the generalized use of lap-
top and notebook mobile computing equipment are
related to size, high unit cost, power consumption,
relatively fragile critical internal moving parts (hard
disk), and the need for a fair level of computer skills.
Since 1997 a new generation of cheap, rugged,
diskless, small computer devices have reached the
market. They have limited processing capabilities
and mass storage but are an ideal platform for elec-
tronic data capture forms that use pen-based touch
screen and hand character recognition technologies.
Typically these devices presently cost from one-
tenth to one-fifth of a low-end laptop or notebook
computer. Accumulated data can be uploaded to a
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-
siding in palmtop devices at the Department of
Health Informatics, Escola Paulista de Medicina
(CIS/EPM), Federal University of São Paulo, Brazil,
involved the development, in 1996, of a nutritional
assessment application on a pen-based Newton
platform. Although the users were enthusiastic about
the possibilities of the device, high unit cost (around
US$800), weight, and poor resources in terms of
processor capacity and speed, memory, and screen
size and quality did not recommend its widespread
utilization. With the appearance of new options on
the market, price reduction and better machine re-
sources, a hospital auditing and evaluation applica-
tion was developed in 1997, under contract for the
State of São Paulo Regional Medical Board
(CRM/SP). The project selected a Hewlett-Packard
LX Series platform, a handheld computer, running
MS-DOS 5.0. The application was successfully im-
plemented and utilized to collect data in periodic in-
spection visits conducted in 680 hospitals. Field data
were periodically uploaded to a desktop platform for
processing.
Problem Statement
The State of Pernambuco (Brazil) Health Secretariat
and the United Nations Educational Scientific and
Cultural Organization (UNESCO) implemented a
social program (Greater Recife Community House-
hold Surveillance Program) in poor areas of the Mu-
nicipality of Recife with the goal of bringing to poor
communities a set of integrated developmental ac-
tions involving health, education, and the environ-
ment. This highly successful project employs around
1,200 community workers with the objective of con-
ducting household visits to assess needs related to
the project’s areas of interest. Pertinent data must
be recorded to support program planning, monitoring
of activities, and evaluation.
Most community workers, recruited among the
poorly educated and low-income population of the
project area, have a low literacy level and no special
skills but, because they live in the neighborhood,
they have easy access to households and first-hand
understanding of the social, health, and environ-
mental problems of the community. With little train-
ing they develop into very useful agents for the pro-
active identification, reporting, and follow-up of
health, educational, and environmental problems.
Each community worker visits an average of 200
households per month, presenting the need to print
and process around 200,000 data capture forms
each month.
In the initial stage of the Community Household Sur-
veillance Program, data collection was done with
printed forms. Those forms were found to be inap-
propriate due to the cost and time required in de-
signing, redesigning, and printing; the logistics in-
volved in storing and supplying paper forms; and the
poor writing skills of the community workers. The
change in a single data element required the design
and printing of new forms and the loss of unused
forms from previous print runs. Those issues and
nagging problems of readability, inconsistencies,
and the need to manually key-in about 200,000
forms per month, led to the development of a more
structured data capture form and a change in the
data entry procedures by the introduction of optical
reader technology.
Although forms designed for automated optical read-
ing reduced the incidence of human errors in data
capture and transcription, problems remained re-
lated to the development and printing of those forms,
necessarily demanding a very accurate design. The
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
manual input of correct data. Irrespective of the
method used (manual keying-in or optical reading),
paper data collection forms do not permit consis-
tency checking, and there are many operational
situations in which it would be desirable to have a
way to calculate field values and introduce default
responses, impossible to do in paper forms.
Methodology
Due to the characteristics of the Greater Recife
Community Household Surveillance Program, it was
considered as an ideal environment for the investi-
gation of the applicability and usefulness of portable
palmtop personal devices in the development and
utilization of computer-based forms.
The goal of this research project was to identify and
test a low-end pen-based palmtop computer and
investigate tools and issues related to the design
and creation of electronic data collection forms for
field data capture by unskilled lay community health
workers. The expected result of the project was to
eliminate paper forms by the introduction of digital
forms, introduce consistency checking at the time of
data capture, abolish paper form data transcription
and entry, and experiment with data transfer and
processing by generic and public-domain epidemiol-
ogy software in a desktop computer at a central site.
 4 September 1999
Pen-based Palmtop Computers
Of the many options available in the P/PC market,
the authors decided on utilizing a device running
Windows CE version 2.0 operating system (WinCE)
since such devices have, as essential features, the
following aspects: compatibility with the desktop
Windows environment, existence of a variety of
third-party software for WinCE platforms, and the
availability of WinCE development tools compliant to
ODBC (Open Database Connectivity) standards.
During September 1998 a market review was done
including all Windows CE P/PCs in the US$300-500
price range.
Based on price and technical characteristics (proc-
essor type, input facilities, display, expansion slots,
battery life, and ruggedness) the Casio Computer
Corporation Cassiopeia model E-11 P/PC, priced
just above US$300, was selected. The Cassiopeia
E-11 is a pen-based "pocket computer" with the fol-
lowing specifications: VR4111-100 MHz processor; 8
Mbyte flash memory mass storage; 4-scale mono-
chrome liquid crystal display 240 x 320 dots; serial
(RS-232C 115.5 Kbps maximum) and infrared inter-
faces; expansion slot for flash memory card; power
supply by two AAA batteries, AC adapter, and
CR2016 lithium backup battery; main battery aver-
age life of 30 hours; dimensions 18.2 mm H x 81.5
mm W x 124 mm D; weight 186 g including batteries.
Database Management System (DBMS)
A small-footprint ODBC-enabled development tool
(Visual CE 3.0 Professional Database Management
System from SYWARE, Inc., Cambridge, Massa-
chusetts) was elected for building custom database
applications for the WinCE environment, featuring
simple relational capability, multipaging, and drag-
and-drop controls for data entry form creation. Con-
trols can be text, notes, check boxes, radio buttons,
and pick lists. Dialog boxes allow inclusion of prede-
fined field values, calculated fields, and default re-
sponses. Databases are assembled by using the
built-in creation tool, or starting from a table devel-
oped in any ODBC-enabled database. Visual CE
Runtime occupies only 150 Kbyte and just one run-
time per machine is required, regardless of the
number of applications residing on the mobile de-
vice.
Data Requirement Definitions and Application
Development
Data definitions for application development repro-
duced, without changes, the specifications defined
for the last version of the data capture form being
used by the Greater Recife Community Household
Surveillance Program. Record structure (164 bytes)
included the following data elements:
• Health Worker ID Number
• Household ID Code
• Family ID Code (if more than one family in
household)
• Individual Sequential Code (for members of
the same family unit)
• Name
• Birth Date
• Degree of Family Relationship
• Gender
• Occupation
• School Attendance
• Educational Level
• Pregnancy (at time of each visit)
Digital form development, installation of developed
form in the palmtop device, and the uploading of
collected data require the installation of the Visual
CE DBMS in at least one desktop computer and in
all P/PCs used in the field. A digital data capture
form was developed in a desktop platform using the
Visual CE application development environment,
which runs on Windows 95/98 or NT, and is com-
patible with any Windows CE device. Communica-
tion between the desktop and the P/PC was made
via the serial port and the developed form down-
loaded to the mobile device where the empty data
form occupied only 16 Kbyte.
Data entry in the field was done directly via touch-
screen, using a combination of programmed screen
controls. Numerical values and characters were en-
tered through a screen keyboard or by direct charac-
ter recognition. Collected data can be transferred to
the desktop (uploaded) in different manners — syn-
chronization with any ODBC database, importing
into MS-Access or MS-Excel, or exporting the
WinCE database to an ASCII comma-delimited text
file. In this project, the third option was used. In this
project's application a typical maximum daily load of
200 record entries uses up 42 Kbyte of mass stor-
age. For the configuration utilized, a single machine
has the capacity of storing up to 20,000 records.
The ASCII text file, created in the P/PC through the
export function of the Visual CE DBMS, can be up-
loaded via serial connection to the desktop by using
the WinCE Services file explorer to copy the ASCII
file from the palmtop root directory to the desktop.
Once uploaded it can be imported into a number of
applications. In this project Epi-Info was used for
data consolidation and analysis.
 5 September 1999
Results
The database management systems (Visual CE 3.0)
had a number of limitations, compared to equivalent
desktop products. This was an expected feature, as
the design of the product is focused on the technical
characteristics of the portable device and the WinCE
operating system. Forms must be planned and de-
signed carefully and there is little flexibility and few
options for the design of input masks and field defini-
tions. Desired consistency-checking features that
are present in all desktop DBMS do not exist in Vis-
ual CE. Despite the limitations of Visual CE, devel-
oped application proved to be adequate for the level
of complexity of data manipulation required by the
Greater Recife Community Household Surveillance
Program.
Field use by health workers was possible with mini-
mal training. The P/PC selected for the project oper-
ated without trouble under a variety of environmental
conditions. Screen quality, ease of use, and accept-
able battery life were positive elements in the
evaluation.
Discussion
Appropriate information technology, when combined
with a dependable health information infrastructure,
facilitates and improves health data capture, integra-
tion, analysis, and communication. Data capture rou-
tines, processing tools, and methods to store, ma-
nipulate, access, and analyze information are essen-
tial components of every health program and health
service. In addition to addressing many of the com-
pelling present-day health problems and providing
tools for bettering health and human prosperity
globally, the establishment of a health information
technological infrastructure can assist in the solution
of the major challenges faced by the health sector:
access, quality, finances, knowledge management,
and better clinical and administrative practice. Al-
though technology, per se, obviously does not re-
place the interaction between individuals and institu-
tions, it can be effectively used to enhance such re-
lationships [1, 2, 3, 4, 5, 6, 7, 8, 9]. The World Health
Organization played a pioneer role in early experi-
mentation with handheld computers in field health
data collection [10].
Mobile Computing
Mobile computing is the ability to maintain continued
access to computing facilities and data while on the
move, at any location, while maintaining a consistent
working environment that seamlessly supports the
displacement of people, execution of applications,
and data traffic. This can be achieved by two ways:
users move and use fixed terminals or users move
with portable devices — the latter being the more
interesting option. Mobile data entry is accomplished
by users either by working online with the application
or by working offline and periodically transferring
captured data by a wired, wireless, or combination
communication link.
From the original “luggable” computer of the 80’s,
progressive reduction in size made possible the ap-
pearance of generations of laptop and notebook
computers. Further miniaturization and new tech-
nologies led to the development of diskless devices
of small dimensions and weight. Such computing
hardware has been around for several years, and
performance has improved significantly over the
past two years. As prices fell, larger memory and
100MHz-plus processors became the norm in mid-
to high-end machines. Screens, including color
screens, have improved, although there is a lot of
variation among different manufacturers and units.
Size, presence of a keyboard, and capability of run-
ning small footprint versions of word processing,
spreadsheet, and a variety of application software
define two classes of small mobile computers:
handheld (H/PC) and palm-top (P/PC) devices.
P/PCs have no keyboard and fewer capabilities than
H/PCs, but their low price, soon expected to fall to
US$100-150 for low-end devices, makes them ideal
tools for field data capture and transportation.
Mobile computing using palmtop and handheld de-
vices presents some limitations. They include: [a]
mobile resources are relatively poor when compared
to desktop and laptop platforms as represented by
slower processors, and smaller memory size, mass
storage, and screen size; [b] limited battery power;
[c] incipient standardization; [d] variable perform-
ance and reliability; and [e] scalability issues.
Palmtop (P/PC) Technology Issues
One of the first marketed products was the Hewlett-
Packard 95LX, released in 1991, weighing 312
grams (11 ounces), and running Lotus 123 software.
The 1992-1997 period showed a consistent growth
rate of about 20 percent annually, but products were
tainted by releases that failed to meet user needs,
baffling interfaces, limited machine resources,
handwriting-recognition problems, short battery life,
lack of application software and connectivity, and
prohibitively high prices. Most of the successful uses
of those machines were in specialized one-
application niches, such as utility companies meter
reading, stock control, car rental systems, etc. Early
 6 September 1999
P/PCs products intended for general use, such as
the Newton, Psion, and Zaurus machines, failed to
gain market acceptance and disappeared in a very
short time.
The seminal debut of the PalmPilot in 1996, running
on a proprietary operating system (Palm OS),
opened up a whole new range of possibilities and
expandability. Since 1997, and driven by the release
of the Windows CE operating system (WinCE) and
the Compaq PC Companion [9], the first of WinCE
machines running on AA batteries and with a weight
of less than 450 grams, there was renewed interest
in palmtop devices. As the market evolved, differ-
ences among machines became more significant
and functions more specialized [10].
P/PC products fit into two basic categories: organiz-
ers and pocket computers. Organizers are, in gen-
eral, less expensive due to their limited functional-
ities and are mostly used for storing phone numbers
and addresses and maintaining schedules and to-do
lists. Organizers' primary limitation is the lack of ex-
pansion capabilities, as they do not offer card slots
or expansion ports. Pocket computers range in func-
tionality from low-end to high-end units character-
ized by hardware expandability, sophisticated oper-
ating systems, and diversity of possible application.
Cable, infrared, and wireless connectivity to the
desktop became a central feature enabling file trans-
fer and synchronization of applications. The devel-
opment of devices that offer standardized, simple,
and reliable access to telecommunication links, in-
cluding the Internet, and a broad base of third party
applications increased the market share for palm-
tops. Although most P/PCs still rely on desktop
computers for network access, recent advances in
remote connectivity are creating an important market
segment for pocketable connected devices that can
be used in lieu of a portable or desktop machine.
A major problem with any mobile device, including
laptops, continues to be the power supply. Plug-in
cards and color screens consume a lot of power and
in P/PCs and H/PCs there is a trade-off between
battery endurance and display contrast ratio; the
relationship is not linear — typically a 15% improve-
ment in contrast is accompanied by a 50% drop in
battery life.
The history of desktop computers can be used as a
reference model for the anticipated development of
palmtop computers in the coming years. When an
open standard was defined for microcomputers and
independent developers began to develop hardware
platforms and applications based on such standards,
the options became rather restricted and the market
became dominated by a few companies. Standardi-
zation of the palmtop platform is still incipient but this
situation is already rapidly changing — one example
being the consolidation of the initial variety of operat-
ing systems. In the beginning there were a large
number of operating systems (OS): Newton, GEOS,
MS-DOS, Psion EPOC/16, Zaurus, which were
quickly superseded by Windows CE (Microsoft Cor-
poration) and Palm OS (3Com Inc.), the two domi-
nant and competing options in today’s OS market.
As an indication of the standardization drive, the Mi-
crosoft Corporation has required that all WinCE sys-
tems comply with specific formats and provide stan-
dard Windows-compatible desktop applications, ex-
pansion capabilities, communications, and even size
and weight. The most compelling feature of these
systems is their built-in ability to synchronize and
exchange files with a desktop or a laptop and inter-
act with existing Windows-based applications and
systems.
Trends
In the current year (1999) it is expected that five and
half million H/PCs and P/PCs of all types will be
market, a 47% increase over the previous year. It is
projected that the installed base will reach more than
32 million such devices in the next three years. The
PalmOS and WinCE operating environments will
have by that time captured 92% of the market from
the 67% of 1998, squeezing out the share held by
Psion’s EPOCH and Sharp’s Zaurus operating sys-
tems [11].
The immensely popular 3Com Palm platform contin-
ues to gain access to applications and database
management systems as well as to provide another
connectivity option to corporate data. Although at
this time the Palm platform remains primarily a per-
sonal information manager (organizer), the availabil-
ity of e-mail, Internet, and database access is trans-
forming the device into a dependable corporate tool,
especially for vertical applications.
The WinCE platform has evolved to include new fea-
tures and support to a large number of hardware
add-ons and applications. There is a move to create
a cross-platform operating system, possibly a “light”
version of the NT environment that would run in
servers and desktops all the way down to the sim-
plest palmtop device. Regardless of the WinCE plat-
form, there is a growing number of software prod-
ucts. A recent survey [12] reviewed more than a
hundred business and general application products.
Many are miniaturized versions of desktop applica-
tions but the most exciting are those that have been
written with the mobile user in mind such as map-
 7 September 1999
ping, synchronization, and communications soft-
ware. These are usually centered on the use of the
stylus for handwriting recognition. In another class
are products for the creation of P/PC software —
besides Microsoft's extensions of Visual Basic and C
programming languages, there are many other
choices that, however, require advanced program-
ming skills and machines with large memory.
The most recent generation of machines, released in
the past year, can connect to low-power plug-in
cards for Ethernet support, and serial communica-
tion and barcode add-ons. Many new machines use
rechargeable Ni-Cd battery packs, and some also
can run on AAA batteries, an interesting option for
situations were battery recharging cannot be done.
Conclusions
Technological and market trends, increasing ma-
chine resources and capabilities, ease of use by in-
dividuals with limited skills, and diminishing costs
suggest that palmtop computers (P/PCs) are useful
mobile tools for data recording and transport. P/PCs
have limited processing capabilities but they can
support many mobile requirements, including simple
database operations and data communication. Large
data volumes can be recorded, transported, and up-
loaded in generic format to a desktop personal com-
puter for processing and analysis. Not only are da-
tabase management system (DBMS) products be-
coming a requirement on laptops to support a mobile
workforce, but palmtop devices are now starting to
be used in corporate applications, especially in
health care and customer services that demand a
small footprint database and robust replication tech-
nologies.
When selecting a P/PC a careful review of features
and price must be made. Reviews rapidly become
obsolete by reason of the fast-paced technological
changes. Little things such as heavy AC battery
charge adapters, desktop connection devices, but-
ton placement, and flimsy construction will cause no
end of trouble in field situations. Because there is so
much variation in screen brightness and other fea-
tures, it is absolutely necessary to “test drive” a
number of different models before buying decisions
are made.
The new generation of palmtop devices is most ap-
propriate to field conditions. Those devices are rug-
ged, operate on long-lasting batteries, and can sup-
port a vast range of public health, primary care,
home care, and environmental health data capture
and data communication needs.
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