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    The Medical Palm Review

    December, 2004 (V5N11) -

    My Palm's screen grows harder to read. No, the batteries don't need recharging. I'm just getting older. Reading glasses overcame my problem (for now). But that set me to wondering: what would it be like if I were completely blind?

    In the Land of the Blind....

    ... the one-eye man is king. He can see part of the picture. All the others around him have no (in)sight at all. Most of us imagine disability to be comparable: a state of being which is the polar opposite of "abled". This is a misperception. In between those who are completely blind and those who have perfect vision there is a spectrum of visual impairment: reading glasses, colour blindness, progressive macular degeneration, and so on. Furthermore, these situations are rarely set for life. Illness or trauma can rob us of abilities for a time or forever. As we age all of us are destined to lose some of our visual acuity. The evidence is clear, if unsettling: those who are currently abled are likely to join the ranks of the disabled sooner or later.

    An uncheery thought at this time of year? Quite the contrary. I can't avoid getting older. The vision grows dim, hearing faint, the fingers shake... Hell, you get the idea. As a computer enthusiast I have a particular motivation to continue to use my toys. What's a geek to do to stay in the mobile computing game? And how is a physically challenged person to get into the PDA game in the first place?

    It turns out that there's lots of ways to overcome difficulties and continue to benefit from handheld computers. There are two aspects to this. The first, more obvious one, is related to the basic issues that all designers of handheld electronic devices must face: How to make hardware and user interfaces friendly to users, full stop. Any fuser might not be able to handle a tiny thumb keyboard or see the text on a very small screen. In a sense, disabled users are only a subset of the general user population. Making the keyboard easier to use and the screen better or larger are tasks all designers must grapple with anyway.

    If the PDA lacks features that would make life easier for you, there is a thriving community making add-on hardware and software or specialized tools. Examples of simple enhancements include screen projectors, such as Presenter-to-go, which can enlarge the display at the cost of mobility and portability. Or on-screen keyboards like FatFinger which allow you to do away with the stylus or the built-in screen keyboard on Palm devices.

    However, making a PDA friendly for the disabled is not the same as making it helpful to the disabled! An excellent introduction to this topic can be found in a position paper from 2003 (a year of international recognition for disabled persons). The article goes on to consider carefully data handling and system interface questions. They use as an example a portable Braille keyboard that can be linked to a cell phone. You can also find an excellent discussion at CloudWorld on how increasingly complex graphical interfaces challenge the visually-impaired. There may also be a role for PDAs in teaching the learning-disabled (see the Spring 2002 issue of LDOnline. TechDis is a good example of how to do up an education website to be friendly to those with visual impairment.

    There has been a great deal of creative thinking about this and many innovative solutions proposed for those with physical disabilities. There are lots of customized, bespoke ideas with hefty pricetags. However, it turns out that PDA technology can do more than just compensate for clumsy fingers or aging eyeballs. For example, FatFinger, mentioned in the preceding paragraph, can be programmed with your own shortcuts for commonly used words or phrases of computer commands. This can considerably speedup text entry for those with movement disorders, or speech impediments. Linked to text-to-speech (TTS) software or a cellular phone, FatFinger can help the mute to communicate.

    Before I give some examples of what PDAs can do for the disabled, let me tell you about some of the negatives:

    • Fiddly. You may have to find a way to make several pieces of hardware and software work together.
    • Extras. If you can't hold a stylus, chances are you can't hold the PDA either. So you don't just need an alternative keyboard, but also a way to mount the whole device (strapped to your arm, bolted to your wheelchair or furniture, etc.).
    • Cost. Even off-the-shelf software is an extra expense. Customized hardware or mounting devices for PDAs or Braille keyboards really start to add up. Good thing it's Christmas....
    • Speech. TTS software requires a powerful computer and a good speaker but also a way to enter text quickly. PDAs don't have great keyboards as a rule and the stylus can be slow too. Speech-to-text is, like translation software, not really ready for prime time.
    • Competition. Many niche applications may be better served by custom devices. Generally speaking, frail or immobile individuals may be better served by cell phones and emergency paging devices than customized PDAs which are pricey and fiddly for what you get.
    • Reliability. Don't start me on battery life and recharging issues. Generally, pagers and cell phones have decent operating time between charges and PDAs do not.
    • Redundancy. I like having a PDA with a built-in cell phone. But if it stops working I lose both capabilities. Would a dependent person be better served by multiple devices in case one fails?

    I did some looking on the web and found many interesting ideas and products. The first thing I discovered is that there are far more solutions for Pocket PC than Palm. Examples include Palmtop Impact, Acapela, or TextAloud for communicating. There are also custom hardware/software solutions like PC6 (teaches writing skills to kids using headphones to give audio feedback). If you are not already committed to the Palm platform then I encourage you to cast a wide net when searching for what you need.

    Here is a selection, in no particular order, of Palm-based tools and programs you may find useful for turning text into speech or vice versa:

    • Write: Outloud for the Dana AlphaSmart Palm OS-based portable PC for schools lets you hear what you are typing but that's it
    • pSpeak is a text-to-speech software engine (a trial version can be had from PalmBlvd). It has a Memo reader, and is used in Mapopolis software to give spoken directions, but it has little other utility at this time. If you need more than this, and are prepared to write your own software, then you may want to check it out.
    • HipTalk by DigitalDan is similar to pSpeak but has better on-the-fly transcription. It needs a higher powered PDA if you want the speech to be intelligible
    • If you are mute but have good eyesight and finger control you can use either of the two foregoing programs to enter text into the PDA's clipboard to generate speech in English. You can even use "cut and paste" to transfer text from other sources on the PDA into the clipboard but this is an awkward strategy.
    • Speakeasy Reader is a way to get talking books for your PDA.
    • Afforda Speech has a PDA-based solution for people who can't speak but have good vision and fine-motor skills.
    • The Hephaestus Project has a helpful discussion of specialized solutions (as of 2002) with some links. The Hephaestus Project reviews enabling technologies for the disabled (but not necessarily for PDA users)
    • Audible Corp creates downloadable content for iPod and other platforms. You could use them to transcribe texts or reference material if you lack the in-house resources to do it yourself.
    • Total Recorder can take sound card input or other sources and save them to WAV or MP3 files for later playback. So you could collect material to listen to later but it is not much help to visually-challenged in real time, only for collecting reading material or lecture notes, etc.
    • Why not forget about driving text-to-speech at the PDA end? Why not convert TTS on servers and stream it to wireless PDAs? This is a particularly good strategy for e-mail, map/directions, reference texts, etc. FlexVoice Mobile is moving along these lines. Some assembly is required (i.e. your business, university or government needs to set it up)so end users needn't look here. But the potential is there.

    What about speech-to-text or voice control of your PDA? This is an extremely demanding application that exceeds the capability of typical handheld devices. It is possible to extract dictation files from PDAs with voice-recorders and run them through converters on desktop PCs. Many smartphones will accept limited voice instructions. The speech comprehension of phone systems, however, is relatively quite advanced and powerful (all the heavy lifting gets done on their big central computers, not on your handheld device). The future of this approach is pretty bright.

    Text Entry is a challenge for some people. Whether you have difficulty with Graffiti, or have significant loss of fine motor control of your hand, EdgeWrite can help improve your ability to enter text on your Palm. Oversized on-screen virtual keyboards like FatFinger or Fitaly can provide some of the same capability and programmable macros to reduce complex instructions or phrases to a keystroke or stylus movement. An excellent review of text entry software tools can be found on PalmSource. Even if you have no mobility, sight, speech or hearing issues, some of the software described there can enhance your text entry significantly.

    Cell phones or smartphones (PDAs with a built-in cell phone) offer improved communication tools to deaf individuals. Even PDAs with a wireless Internet link can provide phone service. Soundbytes sells a variety of hardware and software to meet the cell phone and pager needs of deaf folk. Lormar Logic sells mobile TTY services in the US market. You can access it with a smart phone like the Treo or using AOL Instant Messaging with a web-browser on a Palm device with wireless web access. You can text messages to others or you can contact a phone company relay operator who can convert your text into speech for a hearing-enabled person using a conventional phone. These services would work better if the keyboard was bigger on smartphones and PDAs. It's hard to type fast and maintain the flow of a conversation. But if you combine the Lormar service with a text macro or word completion program and an on-screen keyboard then things start to happen.

    Experimental ideas in a variety of areas may eventually pay off for all PDA users, but will probably be of greatest value to people with a range of disabilities:

    • Translation software development will lead not only to easier life for travelers but also to more capable text-to-speech capabilities that mute individuals will find useful. Already, PalmOne has crammed translation software and a speech engine into a speaking translator on an SD expansion card.
    • Chording keyboards and other alternative data entry tools can be modified to use with a PDA. There are lots of models of external folding keyboards you can plug in but none optimized for handicapped users as far as I can tell. Still, for users with only one working hand they represent an exciting possibility. tifaq has a list of most of the important products available for desktop PCs. DeafandBlind has some background on the subject - and their site is also a good example of minimalist design to facilitate browsers that don't support visual elements like frames and pictures.
    • Japan's Railway Technology Research Institute wants to use wiLAN equipped PDAs to help guide the blind around stations and platforms, or provide information on assistive services
    • caps with scalp electrodes or sensors have been used to teach patients without motor control to operate wheelchairs. How about turning them loose on PDAs so they can make phone calls or control the PDA operating interface?
    • The MAPS project aims to develop a PDA or PC-based "script" to help the cognitively impaired deal with various tasks - basically anything that can be scripted and displayed (or make use of speech output to give directions)
    • The Pebbles project at Carnegie Mellon University is overflowing with techie gadgets and software to assist people with many aspects of life. Some employ a PDA. Edgewriter (also mentioned above) improves text entry on a PDA with a stylus, Remote Commander uses a PDA instead of a mouse or keyboard to control a PC. Speech interface and device controllers are also being explored. This may in fact be one good use for the seemingly inane idea of putting wireless networking or Internet interfaces into home appliances. Carnegie Mellon troops even created robots controllable by Palm PDAs.

    As the foregoing demonstrates, the correct term for the opposite of "disabled" is not "able" but "enabled". Palm devices have a big role to mitigate the challenges of life for all of us.

    Content is King

    The second, complementary, approach to enabling PDA users is to make sure that content and data are formatted to be accessible. This aspect is critical in, for example, website design. When putting a site together, will there be a way for readers to magnify text, or navigate without mouse clicks? Will there be meaningful picture captions and page titles for people whose web browsers read aloud? Multiple frames and menus are hard for Text-to-speech browser interfaces to negotiate also.

    WebIncredible lists a number of issues that website developers must deal with on behalf of the visually challenged (relevance to PDAs in brackets):

    • colour-blindness (or users with only grayscale LCD screens on their PDAs)
    • poor vision (or screen and font size issues)
    • portability (the tradeoffs between weight, screen size, battery life)
    • graphical menu bars, frames and tables (these user interfaces reproduce badly on PDA-based web browsers or software)
    • fine motor control issues such as whether users can navigate around the site with keystrokes instead of a mouse (who hasn't struggled with the little buttons and rocker switches on a typical PDA)

    There are lots of other places to look. WebMonkey has an article that asks good questions about how to approach the core issues of designing for the small screen and limited access. AvantGo has a Channel Developer Guide which is particularly good in the second chapter when discussing AvantGo limitations, off-line and hardware differences from PC and PDA web browsing experience. These differences make a good place to start thinking about users with disabilities too. In a recent issue the Ontario Medical Review had an article on some of the basics with links to other resources. Dive Into Accessibility is passionate about web programming standards and website usability. Their downloadable text file offers lots to think about for making websites friendly to all users and technologies.

    We will explore and try to implement some of these ideas on the Review's own website in the coming months.

    Medical "Doc" of the Month

    Sometimes missing my publication deadline (yes, this issue is late) can pay off in surprising ways. If we had gone live at the beginning of the month I would not have had a chance to post this information (provided by Ian Billingsley).

    In honour of World Aids Day (December 1), Skyscape and SATTELIFE are teaming up to offer PDAs loaded with medical software to health care workers in Africa. The idea is to give them reference tools they can take into remote communities. If you are interested in donating an old PDA to this project, you can read more about it at the Skyscape link above. Previously, SATELLIFE was known for its innovative health projects for third world countries, including using satellites and PDAs to bring telehealth and medical reference tools to poor and remote communities.

    Bah, Humbug

    I know it's Christmas but you won't find lots of advice here about buying new Palm PDAs or accessories. Why not? Because the price of hardware will fall in the next month or two as new models arrive. I don't want you kicking me when you see how much you could have saved... That said, there are some specials on hardware to be had at the PalmOne site and probably others also. And some software vendors and medical text publishers are offering seasonal specials that may attract you. Check out SkyScape, PEPID and other publishers.

    NoviiRemote is a multi-role IR controller built into an SD card. The principal disadvantage of this arrangement is that the card slot needs to be pointing the right way or it's awkward to "aim" at your TV, VCR, etc. However, like other programmable infrared control devices, it presents interesting possibilities to those with mobility deficits.

    Hack of the Month

    - Adam Noheji at Loki Software has written to tell me about his PalmDoc to Mac document converter. I cannot test it (I don't have a Mac) but those who are interested should scope out his website. In a recent e-mail to me, Adam wrote:

    "I've read your article in which you mentioned some Palm Doc converters for Mac. I've just release a free application for Mac OS X, Palm Doc Converter. It offers a wide range of unique features including support for all common national encodings (Central European, Cyrillic, Hebrew, Chinese, ...) and integration with popular applications like TextEdit, Mail or Safari. I thought it might be interesting for you, as for a user if you have a Mac or to add it to your article to keep it up to date."

    Please, someone check it out! Let me know how well it works as I have no OS X Mac to try this application.

    Medical Computing

    EmedInformatics has some useful shareware applications and a tutorial discussing medical software you could use or buy

    Acute Care has a Palm page with some software, links to other sites and the inevitable buyer's guide to handheld computers.


    Sometimes, you read one or two news items that make you say "hmmm" and then the third item comes along that makes sense of it all.

    Motorola announced a smartphone that effortlessly links to MS Outlook. When I read this I acknowledged it as just another reason why Pocket PC devices and smartphones are putting pressure on Palm. Although the Treo is a nice machine, Palm lacks depth in the market and needs to get some Palm-enabled smartphones out there pronto! Even the Treo 650 (Palm's new cell phone and PDA combo) will have a staggered rollout in America, delaying its sales to.

    Then I found out that PalmOne (the hardware side of the business) has bailed out of China. The article observed that Palm is being clobbered in the Asian corporate market by Dell and Acer (who make Pocket PCs). Apparently, business users almost all buy PPC devices and individuals are opting for clever cell phones. For example GSPDA has a new Palm OS smartphone which is being pitched at individual users but not at businesses.

    Then the other shoe dropped. PalmSource (the software side of the Palm business) has just bought China MobileSoft. CMS just happens to make Palm based operating systems for cell phones and its stuff is found on thirty million phones in Asia. PalmSource even promise a Linux version of its OS for the Asian market - as Linux is increasingly popular for cell phones in the Eastern hemisphere.

    OK, so it looks like Palm's withdrawal from the China market was to position themselves to offer the Palm software on mobile phones instead of PDAs without the expense of manufacturing and marketing their own gizmos.

    I have a headache.

    In Times to Come

    January's issue may be a little late as we tinker with the MPR format and try to implement some of the accessibility features I have been reading about. We'll let you peek behind the curtain as we implement the changes.

    On behalf of the team at the Medical Palm Review, have a happy and safe holiday season.


    This is one of a continuing series of newsletters on Palm handheld computers, prepared for doctors, nurses, IT professionals, educators and other people who need tools that work. Feel free to pass copies around electronically of on paper. To subscribe, comment, or complain, contact the author

    Visit our website for the latest Medical Palm Review newsletter and the archive of back issues.