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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 
5 
 
Abstract
This research project
6
investigated the applicability and usefulness of portable palmtoppersonal computers (P/PCs) in the development and utilization of computer-based formsto 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. Theproject'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 processingand analysis. Technological and market trends, increasing machine resources and capa-bilities, ease of use by individuals with limited skills, and diminishing costs suggest thatpalmtop computers are useful mobile tools for health data recording and transport. Thenew 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 publichealth, primary care, home care, environmental health data capture, and data communi-cation needs.
1
 
Regional Advisor, Health Services Information Technology, Essential Drugs and Technology Program,Division of Health Systems and Services Development, Pan American Health Organization / World Health Organization, Washington, D.C., USA
2 
Professor and Head, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal University of São Paulo (UNIFESP), São Paulo, Brazil 
3 
Senior Researcher, Department of Health Informatics, Escola Paulista de Medicina (CIS/EPM), Federal University of São Paulo (UNIFESP), São Paulo, Brazil 
4 
Consultant, Greater Recife Community Household Surveillance Program, Pernambuco, Brazil 
5
 
Technical Consultant,
 
Omniamedia – Solutions for Mobile Communications, São Paulo, Brazil 
 
6
 
This Project was partially funded by the Pan American Health Organization, Division of Health Systems and Services Development (Contract ASC-98/00176-0). Prototype application development and testing were conducted in the Greater Recife Community Household Surveillance Program of the State of Per- nambuco Health Secretariat, Brazil, a program implemented with financial resources of the Government of the State of Pernambuco and the Municipality of Recife Integrated Actions in Health, Education, and Environment Project, supported by the United Nations Educational Scientific and Cultural Organization (UNESCO)
 
 
September 1999
Introduction
Full-fledged palmtop computers (P/PCs) are increas-ingly finding their place in situations where datamust be collected, processed, and communicated. Incommunity health, the focus on population requiresmobile capture of large data volume and speed inthe transfer and processing operations. Small bat-tery-operated pen-based P/PCs are especially ap-propriate for data capture at the site and time wheredata 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. Inthe case of health information systems, ideally datashould be captured at the
site and time of contact,care, or intervention,
since consistency checkingand error detection are best carried out at that point.While in certain well-controlled environments, as isthe case of inpatient care and survey studies, struc-tured data recording at the site of care or contact isgenerally possible, such a situation usually is notfound in primary care, home care, environmentalhealth 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 designedand printed. Frequently many changes are made tothe original design, requiring reprinting and disposalof unused previous versions. Storage, distributedinventory management, and supply of forms to theend-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 inothers.Perhaps the most important limitation of paper formsis that, in contrast to computer-based programmedforms, paper forms do not allow the incorporation ofautomatic consistency checks, build-in calculationroutines, use of programmable variables, and defaultentries. Conditional jumps, easy to program andchange in electronic format, are restricted to fixedand limited rules in paper forms.
Data Capture and Data Entry 
There are two major bottlenecks in the operation ofnearly all paper-based information systems —
data capture 
and
data entry 
. Except for instances wheredata capture and transcription are performed auto-matically, a condition that exists only in limitedcases, major hindrances, errors, delays, and costare associated with the cumbersome and labor-intensive utilization of data collection paper formsand 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 andtracking of incomplete forms, readability issues, andthe need for personnel dedicated to the task of key-ing-in data. Even in the best circumstances, an errorrate 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, epidemiologistsand field researchers pioneered the use of such mo-bile devices, and integrated software products havebeen developed for the creation of forms, data entry,and data analysis. The best known application inthis area is
Epi-Info 
, a public-domain software de-veloped by the United States Centers for DiseaseControl and Prevention and the World Health Or-ganization. Obstacles to the generalized use of lap-top and notebook mobile computing equipment arerelated to size, high unit cost, power consumption,relatively fragile critical internal moving parts (harddisk), and the need for a fair level of computer skills.Since 1997 a new generation of cheap, rugged,diskless, small computer devices have reached themarket. They have limited processing capabilitiesand mass storage but are an ideal platform for elec-tronic data capture forms that use pen-based touchscreen and hand character recognition technologies.Typically these devices presently cost from one-tenth to one-fifth of a low-end laptop or notebookcomputer. Accumulated data can be uploaded to adesktop computer for further processing using a va-riety of means, by cable and wireless connections.
 
September 1999
3Early experimentation with electronic data forms re-siding in palmtop devices at the Department ofHealth Informatics, Escola Paulista de Medicina(CIS/EPM), Federal University of São Paulo, Brazil,involved the development, in 1996, of a nutritionalassessment application on a pen-based Newtonplatform. Although the users were enthusiastic aboutthe possibilities of the device, high unit cost (aroundUS$800), weight, and poor resources in terms ofprocessor capacity and speed, memory, and screensize and quality did not recommend its widespreadutilization. With the appearance of new options onthe market, price reduction and better machine re-sources, a hospital auditing and evaluation applica-tion was developed in 1997, under contract for theState of São Paulo Regional Medical Board(CRM/SP). The project selected a Hewlett-PackardLX Series platform, a handheld computer, runningMS-DOS 5.0. The application was successfully im-plemented and utilized to collect data in periodic in-spection visits conducted in 680 hospitals. Field datawere periodically uploaded to a desktop platform forprocessing.
Problem Statement
The State of Pernambuco (Brazil) Health Secretariatand the United Nations Educational Scientific andCultural Organization (UNESCO) implemented asocial program (Greater Recife Community House-hold Surveillance Program) in poor areas of the Mu-nicipality of Recife with the goal of bringing to poorcommunities a set of integrated developmental ac-tions involving health, education, and the environ-ment. This highly successful project employs around1,200 community workers with the objective of con-ducting household visits to assess needs related tothe project’s areas of interest. Pertinent data mustbe recorded to support program planning, monitoringof activities, and evaluation.Most community workers, recruited among thepoorly educated and low-income population of theproject area, have a low literacy level and no specialskills but, because they live in the neighborhood,they have easy access to households and first-handunderstanding 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 ofhealth, educational, and environmental problems.Each community worker visits an average of 200households per month, presenting the need to printand process around 200,000 data capture formseach month.In the initial stage of the Community Household Sur-veillance Program, data collection was done withprinted 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 thepoor writing skills of the community workers. Thechange in a single data element required the designand printing of new forms and the loss of unusedforms from previous print runs. Those issues andnagging problems of readability, inconsistencies,and the need to manually key-in about 200,000forms per month, led to the development of a morestructured data capture form and a change in thedata entry procedures by the introduction of opticalreader technology.Although forms designed for automated optical read-ing reduced the incidence of human errors in datacapture and transcription, problems remained re-lated to the development and printing of those forms,necessarily demanding a very accurate design. Theprocess of entering text by filling mark-sense fieldswas quite cumbersome, and a seven percent erroroccurred in the optical reading process that requiredmanual input of correct data. Irrespective of themethod used (manual keying-in or optical reading),paper data collection forms do not permit consis-tency checking, and there are many operationalsituations in which it would be desirable to have away to calculate field values and introduce defaultresponses, impossible to do in paper forms.
Methodology
Due to the characteristics of the Greater RecifeCommunity Household Surveillance Program, it wasconsidered as an ideal environment for the investi-gation of the applicability and usefulness of portablepalmtop personal devices in the development andutilization of computer-based forms.The goal of this research project was to identify andtest a low-end pen-based palmtop computer andinvestigate tools and issues related to the designand creation of electronic data collection forms forfield data capture by unskilled lay community healthworkers. The expected result of the project was toeliminate paper forms by the introduction of digitalforms, introduce consistency checking at the time ofdata capture, abolish paper form data transcriptionand entry, and experiment with data transfer andprocessing by generic and public-domain epidemiol-ogy software in a desktop computer at a central site.
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