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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

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Abstract

This research project 6 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.

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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

Professor and Head, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal University of São Paulo (UNIFESP), São Paulo, Brazil

Senior Researcher, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal University of São Paulo (UNIFESP), São Paulo, Brazil

Consultant, Greater Recife Community Household Surveillance Program, Pernambuco, Brazil

Technical Consultant, Omniamedia – Solutions for Mobile Communications, São Paulo, Brazil

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.

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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.

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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.

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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

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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.

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-

The seminal debut of the PalmPilot in 1996, running on a proprietary operating system (Palm OS),

ing systems. In the beginning there were a large number of operating systems (OS): Newton, GEOS, MS-DOS, Psion EPOC/16, Zaurus, which were

opened up a whole new range of possibilities and expandability. Since 1997, and driven by the release

quickly superseded by Windows CE (Microsoft Cor- 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 and functions more specialized [10].

dard Windows-compatible desktop applications, ex- pansion capabilities, communications, and even size

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 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.

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

Trends

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

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-

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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

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