CORD-19_Custom_license_subset  

CORD-19:06559dd625491d6474ee88f08c12fc17c1830995 JSONTXT 9 Projects

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Id Subject Object Predicate Lexical cue
T1 0-133 Sentence denotes Towards evidence-based, GIS-driven national spatial health information infrastructure and surveillance services in the United Kingdom
T2 135-143 Sentence denotes Abstract
T3 144-328 Sentence denotes The term "Geographic Information Systems" (GIS) has been added to MeSH in 2003, a step reflecting the importance and growing use of GIS in health and healthcare research and practices.
T4 329-410 Sentence denotes GIS have much more to offer than the obvious digital cartography (map) functions.
T5 411-556 Sentence denotes From a community health perspective, GIS could potentially act as powerful evidence-based practice tools for early problem detection and solving.
T6 557-957 Sentence denotes When properly used, GIS can: inform and educate (professionals and the public); empower decision-making at all levels; help in planning and tweaking clinically and cost-effective actions, in predicting outcomes before making any financial commitments and ascribing priorities in a climate of finite resources; change practices; and continually monitor and analyse changes, as well as sentinel events.
T7 958-1067 Sentence denotes Yet despite all these potentials for GIS, they remain under-utilised in the UK National Health Service (NHS).
T8 1068-1717 Sentence denotes This paper has the following objectives: (1) to illustrate with practical, real-world scenarios and examples from the literature the different GIS methods and uses to improve community health and healthcare practices, e.g., for improving hospital bed availability, in community health and bioterrorism surveillance services, and in the latest SARS outbreak; (2) to discuss challenges and problems currently hindering the wide-scale adoption of GIS across the NHS; and (3) to identify the most important requirements and ingredients for addressing these challenges, and realising GIS potential within the NHS, guided by related initiatives worldwide.
T9 1718-1909 Sentence denotes The ultimate goal is to illuminate the road towards implementing a comprehensive national, multi-agency spatio-temporal health information infrastructure functioning proactively in real time.
T10 1910-2059 Sentence denotes The concepts and principles presented in this paper can be also applied in other countries, and on regional (e.g., European Union) and global levels.
T11 2061-2270 Sentence denotes "A new wave of technological innovation is allowing us to capture, store, process and display an unprecedented amount of information about our planet and a wide variety of environmental and cultural phenomena.
T12 2271-2391 Sentence denotes Much of this information will be 'geo-referenced' -that is, it will refer to some specific place on the Earth's surface.
T13 2392-2775 Sentence denotes The hard part of taking advantage of this flood of geospatial information will be making sense of it, turning raw data into understandable information." -Former American Vice President Al Gore [1] The need for an evidence-based, spatio-temporal approach to public health Geography plays a major role in understanding the dynamics of health, and the causes and spread of disease [2] .
T14 2776-2963 Sentence denotes The classic public health triad composed of man, agent/vehicle and environment emphasises the importance of geographic location (environment or space where we live) in health and disease.
T15 2964-3021 Sentence denotes Interactions within this triad can also change with time.
T16 3022-3371 Sentence denotes Today's health planners aim at developing health policy and services that address geographical and social inequalities in health, and therefore should benefit from evidence-based approaches that can be used to investigate spatial aspects of health policy and practice, and evaluate geographical equity (or inequity) in health service provision [3] .
T17 3372-3680 Sentence denotes Besides policy development, and provision and management of health services, public health practitioners have other important and related tasks including prioritisation of interventions and programmes, responding to health alerts and concerns, intersectoral engagement, and community development initiatives.
T18 3681-3970 Sentence denotes In all these tasks, they should strive to incorporate searching and using best evidence in their everyday decision-making processes in order to minimise investment of efforts and funds in areas where there is solid evidence of no effect, or evidence of harm, or of poor cost-effectiveness.
T19 3971-4138 Sentence denotes Evidence-based approaches can also highlight areas where the evidence may be less than reliable, requiring further assessment before expending large funds and efforts.
T20 4139-4357 Sentence denotes Ideally, the tools to achieve this goal should be accessible and usable by mainstream practitioners, transparently embedded into routine workflows, and seamlessly incorporated into existing busy work environments [4] .
T21 4358-4495 Sentence denotes According to the US Federal Geographic Data Committee (FGDC), geographic location is a key feature of 80-90% of all government data [5] .
T22 4496-4633 Sentence denotes The same can be also said about government data in other countries, including data generated by the health sector in different countries.
T23 4634-4830 Sentence denotes This locational or spatial reference is a "main key" in the transformation of data into information, and for linking and integrating different datasets covering same and contiguous locations [6] .
T24 4831-4895 Sentence denotes Spatial data are a resource on a par with employees, funds, etc.
T25 4896-5005 Sentence denotes Use of spatial information opens up the possibility to increase efficiency in the public and private sectors.
T26 5006-5093 Sentence denotes Unlike other resources, spatial data do not suffer any wear and tear from repeated use.
T27 5094-5206 Sentence denotes On the contrary, reusing data increases the possibilities for improving the content quality of data collections.
T28 5207-5313 Sentence denotes The real benefit of investments in spatial data increases dramatically with the multiple use of data [6] .
T29 5314-5675 Sentence denotes In 2003, the US National Library of Medicine added the term "Geographic Information Systems" to its controlled vocabulary thesaurus known as MeSH (Medical Subject Headings -see http://www.nlm.nih.gov/cgi/ mes200MB_cgi?term=GEOGRAPHIC+INFORMATION+S YS TEMS, a step reflecting the importance and growing use of GIS in health and healthcare research and practices.
T30 5676-5856 Sentence denotes The US FGDC defines GIS as "computer systems for the input, storage, maintenance, management, retrieval, analysis, synthesis, and output of geographic or locationbased information.
T31 5857-5928 Sentence denotes In the most restrictive usage, GIS refer only to hardware and software.
T32 5929-6007 Sentence denotes In common usage (by organisations), they include hardware, software, and data.
T33 6008-6102 Sentence denotes For some, GIS also imply the people and procedures involved in GIS operation" (cited in [7] ).
T34 6103-6447 Sentence denotes The inclusion of "people" (properly trained staff with adequate work time to spend on GIS activities) and "procedures" as part of the above definition is essential for GIS applications in a public health context, given the need to link the science and methods of epidemiology to GIS output to avoid producing invalid or misleading results [7] .
T35 6448-6792 Sentence denotes GIS are potentially powerful resources for community health for many reasons including their ability to integrate data from disparate sources to produce new information, and their inherent visualisation (mapping) functions, which can promote creative problem solving and sound decisions with lasting, positive impacts on people's lives [8, 9] .
T36 6793-6889 Sentence denotes Our experience in applying GIS to health issues has increased considerably over the last decade.
T37 6890-7201 Sentence denotes However, GIS have been usually applied to time-limited, single, isolated aetiological research or surveillance issues processing mainly retrospective data rather than to ongoing, broad efforts and wide-scale applications processing real-time or near-real-time data for health planning, promotion and protection.
T38 7202-7483 Sentence denotes This may be due to the problems encountered in identifying, acquiring and integrating a wide range of geo-referenced data relevant to community health in order to support decision-making and problem solving in community health planning, service delivery, and health promotion [8] .
T39 7484-7580 Sentence denotes In the early 1990s much attention was focused on GIS as a basis for spatial information systems.
T40 7581-7807 Sentence denotes Soon it became obvious that the pure technical approach had to be replaced by a more holistic approach encompassing organisational, political and technical matters at the different local, national, regional, and global levels.
T41 7808-7875 Sentence denotes The concept of "Spatial Data Infrastructure" became a reality [6] .
T42 7876-8047 Sentence denotes Spatial information management is a discipline for the individual organisation, administration or enterprise, the micro level, and for society in general, the macro level.
T43 8048-8190 Sentence denotes On the micro level there will be a technical approach whereas on the macro level political and organisational issues will be highlighted [6] .
T44 8191-8240 Sentence denotes Both levels are interdependent and complementary.
T45 8241-8600 Sentence denotes Spatial information management is based on the idea that data, people, software and hardware interact, and that it is practicable to obtain synergy by coordinating changes and development to help users have a better overview of both simple and complex problems, and give them the possibility to create comprehensible, acceptable solutions and/ or compromises.
T46 8601-8800 Sentence denotes The concept covers various disciplines such as capture, storing, maintenance and upgrading of data and information, information technology, organisational issues and spatial data infrastructure [6] .
T47 8801-8991 Sentence denotes Spatial information managers and responsible politicians will become the main catalysts in the development, implementation and maintenance of the necessary Spatial Data Infrastructures [6] .
T48 8992-9075 Sentence denotes To conclude this introduction, we indicate how the rest of this paper is organised.
T49 9076-9264 Sentence denotes In the next section on "GIS methods and technologies", we cast some light on the richness of GIS toolbox, which goes far beyond the mere production of simple maps (or digital cartography).
T50 9265-9506 Sentence denotes The section that comes after, titled "GIS applications in health and healthcare", examines with examples the main uses of GIS in the health sector (apart from real-time GIS applications, which are covered in a separate section near the end).
T51 9507-9685 Sentence denotes We then discuss the current state of GIS affairs in the UK NHS in the section titled "On the under utilisation of geo-information and GIS in the UK NHS: problems and challenges".
T52 9686-10020 Sentence denotes This is followed by a section on "Geo-information and real-time GIS infrastructure requirements" in which we review the most important technical and organisational elements that are required for a successful implementation of a national geo-information infrastructure that can also support real-time GIS applications in public health.
T53 10021-10266 Sentence denotes The section that follows, titled "Problematic issues and solutions", is a direct continuation of the one preceding it, and discusses tricky issues like data confidentiality and data/analysis errors, together with solutions that can address them.
T54 10267-10452 Sentence denotes We next present examples of Spatial Data Infrastructures (SDIs) at different levels of development from around the world in the section on "Existing SDIs and SDI initiatives worldwide".
T55 10453-10723 Sentence denotes Then in the section on "Proactive, real-time, GIS-enabled health and environmental surveillance services", we describe a wide-scale vision for, and some early real-world applications of, realtime GIS in emergency management, and in health and environmental surveillance.
T56 10724-10883 Sentence denotes Such applications currently involve limited SDI-like arrangements, and would certainly benefit from the development of mature SDIs in their respective regions.
T57 10884-11106 Sentence denotes The final section titled "Discussion, recommendations and concluding remarks" very briefly reiterates and wraps up the main points made in this paper, and provides some final recommendations and directions for future work.
T58 11107-11256 Sentence denotes This section on GIS methods and the following one discussing GIS applications are complementary to our review of the subject published in 2001 [10] .
T59 11257-11413 Sentence denotes Freier also provides one of the best thorough, but concise and easy-to-follow descriptions of the main GIS methods available today for emergency management.
T60 11414-11689 Sentence denotes These methods, which also apply to other types of health-related analyses using GIS, include overlay analysis of thematic data and spatial intersection, buffer generation, neighbourhood analysis, vector-based grid generation, network analysis, and (raster) surface modelling.
T61 11690-11832 Sentence denotes These GIS methods should be coupled with proper spatio-temporal statistical methods to ensure valid analyses and robust conclusions [11, 12] .
T62 11833-11931 Sentence denotes GIS offer powerful features not available to users of either paper-drawn or electronic map images.
T63 11932-12450 Sentence denotes In GIS, geographic boundaries of study areas can be accessed and modified, data class intervals and symbologies restructured, map layers (variables) vertically overlayed and integrated, new independent map variables added for multivariate spatial statistical analysis, spatial weights computed, spatial autocorrelation on predictor variables assessed, and probability scenarios of mapped variables explored based on modelled changes in regression coefficients over time, with unparalleled computational speed and ease.
T64 12451-12593 Sentence denotes GIS also enable multi-dimensional surface images to be drawn to scale, a feature important in studies involving elevation or subsurface shape.
T65 12594-12732 Sentence denotes The mathematical treatment of topographic or surface statistical values can be used as a filter against other variables or other surfaces.
T66 12733-12934 Sentence denotes A range of statistical techniques have evolved that are well suited to GIS analysis, including density kernel estimation, grid and probability estimation, and kriging (see "Smoothed maps" below) [13] .
T67 12935-13337 Sentence denotes Rushton suggests that GIS provide the capability to perform two types of spatial analysis that could not be performed without GIS: finding areas of high disease incidence that can be labelled as statistically significant and worthy of further investigation, and examining the spatial relationship between disease incidence and information that is geo-referenced differently from the disease data [14] .
T68 13338-13551 Sentence denotes Rushton also argues that GIS are useful for exploratory spatial analysis but are less useful for confirmatory analysis [14] , although it is clearly possible to integrate confirmatory statistical methods with GIS.
T69 13552-13868 Sentence denotes By combining health datasets with other sources, such as census data for small areas, GIS can be used to investigate spatial patterns in health outcomes in relation to socioeconomic characteristics of areas, in identifying gaps in healthcare provision, as well as in monitoring the impacts of changes in policy [3] .
T70 13869-14102 Sentence denotes GIS point-in-polygon analysis, which overlays points on area features, can be used to attach census data relating to small areas such as enumeration districts (in the UK) to individual point level data such as patient postcodes [3] .
T71 14103-14224 Sentence denotes Higgs and Richards used GIS to examine the socio-demographic profiles of patients on a dental practice register in Wales.
T72 14225-14457 Sentence denotes By working at the individual patient (point) level, they have demonstrated the potential for GIS to work with spatially disaggregate data to address key concerns of policy makers towards, for example, equity of healthcare provision.
T73 14458-14660 Sentence denotes Their study also highlighted the importance of maintaining high quality (i.e., up-to-date, complete, accurate, fully postcoded, and one could also add clinicallycoded) health registers and records [3] .
T74 14661-14820 Sentence denotes Higgs and Richards explored the use of two different deprivation indices in their study, namely the Index of Multiple Deprivation (IMD) and the Townsend index.
T75 14821-14927 Sentence denotes Deprivation indices are frequently used in relation to health needs assessment and in resource allocation.
T76 14928-15063 Sentence denotes Different deprivation indices have different points of strength and weakness, and can yield different results in some studies [3, 15] .
T77 15064-15247 Sentence denotes Most traditional analyses of disease patterns examine disease rates at a given level of spatial resolution defined by spatial entities developed for administrative and other purposes.
T78 15248-15322 Sentence denotes Choropleth maps are commonly used to depict the patterns of disease rates.
T79 15323-15480 Sentence denotes Disease incidence and other spatio-temporal epidemiological events are portrayed on these maps as shaded polygons (each representing an administrative area).
T80 15481-15631 Sentence denotes Each of these polygons contains a numerical value of the mapped disease incidence represented as a shaded value within the covered national framework.
T81 15632-15748 Sentence denotes Visual communication of disease risk is over-simplified since all values appear evenly distributed within a polygon.
T82 15749-16149 Sentence denotes Moreover, values among contiguous areas (polygons) in a choropleth map can differ abruptly at adjoining borders, while in reality disease incidence and most other spatio-temporal events and phenomena such as deprivation levels are continuous variables distributed continuously across space and do not change abruptly at arbitrarily defined administrative, census and political boundaries (Figure 1 ).
T83 16150-16266 Sentence denotes Other limitations of the choropleth design include the visual dominance of larger areas over smaller ones [14, 16] .
T84 16267-16625 Sentence denotes Yet, despite all these limitations, the choropleth design remains in many cases the method of choice to communicate estimated spatial density of reported disease incidence, being quite easy and straightforward to construct compared to the use of geostatistics like kriging (see "Smoothed maps" below), which requires more complex computational choices [16] .
T85 16626-16865 Sentence denotes The choropleth map could be considered a filtered map using a non-overlapping, variable-size, spatial filter with filter shapes selected from available political or administrative regions (hence its limitations -see "Smoothed maps" below).
T86 16866-17534 Sentence denotes Rushton mentions three factors to explain why data is commonly made available for such oddshaped and different sized regions: (1) data for such areas can be easily encoded from the information provided; (2) information is often requested for such areas as people are familiar with them and use them to convey the spatial limits of their interest, and also to enable comparisons between different administrative regions, e.g., regarding success in implementing a particular directive, health promotion programme or other intervention; and (3) aggregating health data to areas is one easy method to reduce the risk of disclosure and protect privacy of individuals [14] .
T87 17535-17693 Sentence denotes To meet the purpose of exploratory spatial analysis, health data are better examined by methods that assume that disease rates are spatially continuous [14] .
T88 17694-17865 Sentence denotes One can display data collected at smaller geographic areas (with fewer individuals) and still maintain the stability of the estimated rates by constructing a smoothed map.
T89 17866-18136 Sentence denotes One way to do this is to use Bayesian or empirical Bayes methods, calculating the estimated rates for each smaller area by incorporating information about the observed data from neighbouring areas together with priors concerning the spatial variation of the rates [17] .
T90 18137-18205 Sentence denotes Another approach is to use a spatial filter or ratio smoother [17] .
T91 18206-18479 Sentence denotes The principal reason to filter disease data spatially is to examine the spatial pattern of disease at different levels of spatial resolution and to compute disease rates that are not dependent on the specific boundaries of the areas used in spatially aggregated data [14] .
T92 18480-18592 Sentence denotes A spatial filter can be applied to individual point data, as well as to data aggregated into small census areas.
T93 18593-18751 Sentence denotes In its simplest form, the estimated rate at a particular location, or grid point, is defined as the observed rate within a fixed distance from the grid point.
T94 18752-18867 Sentence denotes The circles of neighbouring grid points are set to overlap to allow neighbouring grid points to share observations.
T95 18868-19041 Sentence denotes After assigning estimated rates to each grid point, contouring software is used to create isarithmic maps in which regions with a constant range of values can be recognised.
T96 19042-19115 Sentence denotes This enables the creation of a continuous smoothed map of the data [17] .
T97 19116-19326 Sentence denotes Talbot et al propose a modified spatial filter for creating smoothed disease maps, where the spatial filter is defined in terms of constant or near constant population size rather than constant geographic size.
T98 19327-19482 Sentence denotes This means that the circles will usually be larger in the rural areas (lower population density) compared to urban areas (higher population density) [17] .
T99 19483-19562 Sentence denotes Kriging can be also used to produce continuous map surfaces from sample points.
T100 19563-19717 Sentence denotes Croner and Cola provide some good examples from the literature of using the geostatistical procedure of kriging in disease epidemiology and public health.
T101 19718-20139 Sentence denotes They also describe their own experience in using the procedure to model and forecast the underlying A simple choropleth map of Townsend Deprivation Score distribution in Bath City Electoral Wards Figure 1 A simple choropleth map of Townsend Deprivation Score distribution in Bath City Electoral Wards A simple choropleth (graduated colour) map of Townsend Deprivation Score distribution in Bath City Electoral Wards (UK).
T102 20140-20455 Sentence denotes Abbey and Twerton are the most deprived wards (highest scores/darkest shade). (Prepared using ESRI ArcView GIS Version 3.1 http:// www.esri.com/software/arcgis/arcview/index.html and data from EDINA UKBORDERS and Census Dissemination Unit (CDU)/MIMAS. spatial structure of reported Lyme disease incidence in the US.
T103 20456-20631 Sentence denotes Kriged smoothed maps may strengthen our ability to visually communicate event patterns, especially over time (also possibly through the combined use of kriging and animation).
T104 20632-20813 Sentence denotes As a geostatistical modelling technique, kriging takes into account the existing underlying spatial structure of georeferenced information (distances among samples or observations).
T105 20814-21044 Sentence denotes Statistically optimal estimates and their standard errors for locations with missing data (unsampled locations) may be derived, and the actual and estimated data represented together as a smoothed surface or raster data structure.
T106 21045-21151 Sentence denotes Kriging can also take into consideration associative covariates when producing the final smoothed surface.
T107 21152-21307 Sentence denotes However, the accuracy of kriging results depends on the aggregation level of the data used (e.g., state-level vs. finer county-level data in the US) [16] .
T108 21308-21380 Sentence denotes Trend surface analysis is another technique for producing smoothed maps.
T109 21381-21533 Sentence denotes Trend surface maps are commonly used to report the spatial diffusion process of disease epidemics (the movement of epidemics across geographical space).
T110 21534-21751 Sentence denotes In their GIS-driven Drug Incidence and Prevalence Estimation Program (DIPEP), Field et al used trend surface maps to overcome the drawbacks of administrative boundary choropleth maps (e.g., ward-based maps in the UK).
T111 21752-21879 Sentence denotes They also used animated sequences of trend surface maps to study the waves of diffusion of problematic drug misuse across time.
T112 21880-22152 Sentence denotes Animated trend surface maps could be considered as illustrating a more accurate picture of the spatio-temporal characteristics of mapped events and phenomena, when compared to administrative boundary maps, since populations are distributed continuously across space [18] .
T113 22153-22763 Sentence denotes It is noteworthy that the interpolation tools in ESRI Arc-GIS 3D Analyst, Spatial Analyst, and Geostatistical Analyst extensions support kriging among other methods for the production of continuous surfaces from sampled points, while ESRI ArcGIS Tracking Analyst extension enables the visualisation and analysis of temporal data (including real-time data feeds) by defining events including time, location, and attribute information. (ArcGIS 3D Analyst also supports Triangulated Irregular Networks (TINs) and three-dimensional (3D) data visualisation giving users completely new perspectives about their data.
T114 22764-22875 Sentence denotes For example, adding 3D to attribute data such as population growth allows better viewing of trends and changes.
T115 22876-23015 Sentence denotes For detailed information about the complete range of ArcGIS Extensions, see http://www.esri.com/software/arcgis/arc gisxtensions/index.html
T116 23016-23172 Sentence denotes Many different test statistics are also available to test for spatial disease clustering, with different powers for detecting different kinds of clustering.
T117 23173-23452 Sentence denotes These tests include Besag-Newell's R, Cuzick and Edwards' k-Nearest Neighbours (k-NN), Moran's I, the spatial scan statistic (SatScan), Tango's Maximised Excess Events Test (MEET), Bonetti and Pagano's nonparametric M statistic, Swartz' entropy test, and Whittemore's test [19] .
T118 23453-23623 Sentence denotes Rogerson's spatial pattern surveillance technique is a surveillance method for detecting changes in spatial pattern in cases over time relative to the population-at-risk.
T119 23624-23752 Sentence denotes The location of new cases is monitored as they occur with the objective of detecting emerging clusters shortly after they occur.
T120 23753-23911 Sentence denotes The method represents a cumulative sum statistic and procedure for the monitoring of changes in spatial pattern for observations processed sequentially [20] .
T121 23912-24117 Sentence denotes For a comprehensive discussion of prospective statistical public health surveillance methods, the reader is urged to consult the recently published excellent review of the topic by Sonesson and Bock [21] .
T122 24118-24425 Sentence denotes The Amsterdam Police department uses spatial data mining technology from Sentient http://www.sentient.nl/ and MapInfo in a cutting edge crime analysis and prediction system, able to detect patterns in a wide range of data, including criminal records, weather measurements, and socio-demographic information.
T123 24426-24635 Sentence denotes This leads to better strategic insight, input for state and government policy and programmes, information for more effectively assigning finite resources and last but not least: more crimes being solved [22] .
T124 24636-24805 Sentence denotes The growing uses of remotely sensed imagery and satellite facilitated global positioning systems (GPS) are contributing to unprecedented surveillance of the environment.
T125 24806-25035 Sentence denotes High-resolution satellite imagery provides timely and detailed digital representations of existing landscapes and land covers, which can be spectrally classified and statistically correlated with disease host and vector habitats.
T126 25036-25164 Sentence denotes Remotely sensed data are being used both in historical and real-time modes to assess and model catastrophic health events [13] .
T127 25165-25449 Sentence denotes Automated change detection applied to a sequence of digital imagery from satellites or aerial photos for a small area of interest can be used to observe changes over time, such as the addition of housing developments, roads, and landfills and other changes in land use and land cover.
T128 25450-25597 Sentence denotes All these changes have implications in public health and are necessary to properly establish and revise community health priorities and plans [7] .
T129 25598-25765 Sentence denotes In the US, NASA's CHAART (Centre for Health Applications of Aerospace Related Technologies) facilitates the use of remote sensing technology in public health research.
T130 25766-25888 Sentence denotes Examples of projects carried at CHAART, as well as examples of GPS applications in health are described in [10] and [13] .
T131 25889-26136 Sentence denotes Xue et al define telegeoprocessing as a new discipline revolving around real-time spatial databases that are updated regularly by means of telecommunications systems in order to support problem solving and decisionmaking at any time and any place.
T132 26137-26222 Sentence denotes It involves the integration of remote sensing, GIS, GPS and telecommunications [23] .
T133 26223-26428 Sentence denotes Mobile phones and other digital devices are rapidly gaining location awareness and Web connectivity, promising new spatial technology applications that will yield vast amounts of spatial information [24] .
T134 26429-26549 Sentence denotes Examples of such applications include in-the-field data entry and access, and many useful location-based services [25] .
T135 26550-26870 Sentence denotes However, according to RSA Security Inc. http://www.rsasecu rity.com/, wireless and mobile telecommunications also pose the following security challenges: more connectivity resulting in more points of vulnerability; information is more easily intercepted; and devices, being more portable, are more easily lost or stolen.
T136 26871-27110 Sentence denotes Through multivariate spatial statistical modelling of disease processes, GIS enable the evaluation of potentially true disease outbreaks and a more effective allocation of sparse remedial resources towards their containment and prevention.
T137 27111-27327 Sentence denotes GIS also assist users in better understanding the potential harmful effects of environmental pollutants, e.g., toxic waste sites, and even in understanding the occurrence of pedestrian and other injuries, and crimes.
T138 27328-27486 Sentence denotes Today, environmental monitors measure air and water quality, solar irradiation, radon gas levels, and other exposures potentially deleterious to human health.
T139 27487-27635 Sentence denotes These measurements can be brought into GIS, spatially referenced and integrated analytically with other health predictor variables and outcome data.
T140 27636-27796 Sentence denotes In fact, any adverse (or positive) health-related phenomenon that can be defined spatially (atmospheric, aquatic or terrestrial) can lead to GIS analysis [13] .
T141 27797-28019 Sentence denotes The determination of effective response time zones for the provision of emergency care services is another application already benefiting from the unique capabilities of GIS in calculating travel time isochrones [13, 26] .
T142 28020-28264 Sentence denotes GIS can also help promote healthy behaviours by documenting where the populations are located that have the greatest need of improved information, then using GISenabled Internet sites as an outreach vehicle for community health education [27] .
T143 28265-28570 Sentence denotes For this reason, it is always encouraged to consider the public as one of the main beneficiaries of any national spatial health information infrastructure (see later), and they should be offered full access to data and information (subject to appropriate confidentiality and national security safeguards).
T144 28571-28804 Sentence denotes The Bradford Community Statistics Project http://www.communitys tats.org.uk/ provides a good example of public participation GIS projects, and aims at empowering residents to develop their own policy initiative and funding proposals.
T145 28805-29368 Sentence denotes Richards et al describe the advantages of GIS technology using some excellent public health example scenarios: a childhood lead poisoning prevention programme; mapping of motor vehicle injuries and fatalities in a community; and using data collected by marketing firms about consumer spending patterns and lifestyle segmentation profiles to identify the best target populations for prevention interventions, e.g., anti-smoking programmes, and to select the best media channel(s) and times of the day to communicate a particular message to a given population [7] .
T146 29369-29686 Sentence denotes Richards et al also describe a feasible scenario for geographically enabled electronic medical records wherein all electronic inpatient and outpatient medical records in a given community are regularly scanned to map asthma cases (in the example given) and compare current week maps with those for prior time periods.
T147 29687-29826 Sentence denotes In this way, any unusual case clusters or patterns in the community can be easily identified, e.g., an increase in asthma hospitalisations.
T148 29827-29916 Sentence denotes Such patterns can be further and more closely investigated and appropriate actions taken.
T149 29917-30075 Sentence denotes In the same asthma scenario described by Richards et al, most affected individuals in the hospital with the highest rate happened to work at the same factory.
T150 30076-30296 Sentence denotes Using GIS technology linked to a database about workplace chemical exposures, the potential exposures at the factory in question were reviewed and the agents associated with asthma-related hospital admissions identified.
T151 30297-30439 Sentence denotes An appropriate action was then initiated in the form of a request that an industrial hygienist visits the plant in question the same day [7] .
T152 30440-30753 Sentence denotes Gavin and her colleagues provide examples of how developing African countries are currently using geo-information to produce enhanced capacity for emergency response, more effective and efficient government operations, increased transparency of public decision-making and better addressing of social inequalities.
T153 30754-30976 Sentence denotes They mention a famine early warning system in Burkina Faso that uses climate, agricultural, and population data to provide timely, accurate projections of crop shortfalls, enabling the government to take corrective action.
T154 30977-31218 Sentence denotes They also describe how geo-information used in a poverty mapping initiative in South Africa was combined with information on sanitation and safe water supplies to create a strategy for containing a cholera outbreak in KwaZulu Natal province.
T155 31219-31358 Sentence denotes Data on illiteracy rates, dwelling types, and lack of basic services formed the basis for an effective, targeted health education campaign.
T156 31359-31461 Sentence denotes The resulting fatality rate for this outbreak, 0.22%, was among the world's lowest ever recorded [9] .
T157 31462-31763 Sentence denotes The World Health Organisation's HealthMapper application http://www.who.int/csr/mapping/tools/healthmap per/healthmapper/en/ and the Pan American Health Organisation's Sig-Epi (GIS in Epidemiology and Public Health -http://ais.paho.org/sigepi/ have already been described in our previous review [10] .
T158 31764-32013 Sentence denotes Real-time GIS applications in health and environmental surveillance, and in emergency and epidemics management are presented later in this paper (see section titled "Proactive, real-time, GIS-enabled health and environmental surveillance services").
T159 32014-32294 Sentence denotes Traditionally, two broad types of GIS applications can be distinguished which also reflect the two traditions in health geography (geography of disease and geography of healthcare systems), namely health outcomes and epidemiology applications and healthcare delivery applications.
T160 32295-32490 Sentence denotes There are also studies at the interface (overlap) between epidemiological and healthcare delivery applications, for example in relation to healthcare commissioning and needs assessment [10, 28] .
T161 32491-32767 Sentence denotes A number of studies have used GIS to study disease patterns (e.g., identify leukaemia clusters), spatio-temporal variations in health outcomes, and identify possible causes of mapped patterns (e.g., the relationship between cancer incidence and various environmental factors).
T162 32768-32869 Sentence denotes These generally involve the linkage of health information with environmental and socio-economic data.
T163 32870-33110 Sentence denotes GIS can also be used to target resources for disease prevention by highlighting areas with significantly high rates, and to predict which areas might be at future risk and which may benefit most from future local population screening [28] .
T164 33111-33548 Sentence denotes Examples of health outcomes and epidemiology applications using GIS include research carried in the UK at the West Midlands Cancer Intelligence Unit and the Small Area Health Statistics Unit (SAHSU) [10] , and also the work published by Dunn et al in which they have examined the association between asthma incidence and proximity to industrial sites in North East England and suggested relationships with prevailing wind patterns [29] .
T165 33549-33629 Sentence denotes Field et al describe an interesting application of GIS in modelling drug misuse.
T166 33630-33840 Sentence denotes Current methods for estimating the incidence, prevalence, and spread of drug misuse tend to be retrospective (delivering information about past events) and are not capable of forecasting spatio-temporal trends.
T167 33841-34007 Sentence denotes Field et al developed a GIS drug misuse system to create a dynamic model for forecasting and displaying spatio-temporal trends and linking environment with behaviour.
T168 34008-34184 Sentence denotes It includes a range of parameters to model drug misuse and its geographic spread across a population using UK data as a basis for developing a European-wide forecasting system.
T169 34185-34539 Sentence denotes Their approach provides the basis for examining more complex geographic diffusion scenarios such as the introduction of new practices by new users, the development of education and remedial initiatives, impacts of tourism and migration, cross-border contact, drug transportation, and increasing opportunities for economic and international contact [18] .
T170 34540-34732 Sentence denotes The World Health Organisation (WHO) Regional Office for Europe has also produced an Atlas of Health in Europe, a statistical atlas that presents key health figures for the WHO European Region.
T171 34733-34923 Sentence denotes It covers basic demographic data, mortality and morbidity, lifestyles and environmental indicators such as alcohol consumption and road traffic accidents, and types and levels of healthcare.
T172 34924-35122 Sentence denotes Most indicators are presented as a map to show overall regional variations, a bar chart to indicate country rankings, and a time chart to show trends over time in three main country groupings [30] .
T173 35123-35221 Sentence denotes The WHO's Atlas of Health in Europe offers static information about retrospective events and data.
T174 35222-35532 Sentence denotes Even if the WHO keeps publishing updated versions of this atlas, it will always lack (in its current form) the interactivity, realtime or near-real-time processing of current data, and the proactive features desirable in a true regional/community public health surveillance and spatial decision support system.
T175 35533-35661 Sentence denotes In Sweden, the development of spatial analysis has started with a focus on health determinants at community and regional levels.
T176 35662-35722 Sentence denotes GIS have been introduced for both presentation and analysis.
T177 35723-35945 Sentence denotes In March 2003, an atlas presenting health status and health determinants for all municipalities in Sweden was published on the NIPH (National Institute of Public Health) Web site http://www.fhi.se/ nyheter/data.asp?id=984.
T178 35946-36094 Sentence denotes It is planned for this atlas to be expanded and updated regularly with an increasing number of determinants, and to cover a larger time frame [31] .
T179 36095-36254 Sentence denotes Like the WHO's Atlas of Health in Europe, this Swedish atlas remains a collection of pre-drawn, static maps (still very valuable, but limited in many aspects).
T180 36255-36425 Sentence denotes A network of researchers and practitioners from various institutions in Sweden, is preparing for a training course, to be conducted in 2004, on spatial analysis research.
T181 36426-36483 Sentence denotes A textbook on spatial analysis in Sweden is also planned.
T182 36484-36587 Sentence denotes Cooperation on comparative analyses has been initiated with the University of Massachusetts (US) [31] .
T183 36588-36733 Sentence denotes These applications involve using GIS to plan healthcare delivery, study service need, accessibility and utilisation, and aid resource allocation.
T184 36734-37257 Sentence denotes For such applications to be truly integrated into the strategic decision-making process, they should incorporate task-appropriate statistical and modelling techniques, e.g., spatial interaction models (allowing proposed health services/centres to be added interactively to assess their impact), and location-allocation models in order to forecast and evaluate the implication of modifying the configuration of existing services (i.e., "what if" scenarios), and thus play a proactive role in the healthcare planning process.
T185 37258-37558 Sentence denotes GIS have been used in a number of studies to estimate the best/optimal location for a new clinic, hospital or GP surgery to minimise distances potential patients need to travel taking into account existing facilities, transport provision, hourly variations in traffic volumes, and population density.
T186 37559-37690 Sentence denotes A number of these studies using the networking capabilities of GIS have been concerned with the concept of potential accessibility.
T187 37691-37847 Sentence denotes Others, who have had access to spatially disaggregated data, have been concerned with (actual) revealed accessibility patterns of service utilisation [28] .
T188 37848-37963 Sentence denotes Another remarkable application involves the use of GIS to improve hospital bed availability and avoid access block.
T189 37964-38153 Sentence denotes Access block (hospital bed shortage) occurs when a patient in the emergency department (ED) requiring inpatient care is unable to gain access to an appropriate bed within a reasonable time.
T190 38154-38319 Sentence denotes It is measured by the percentage of all patients admitted, transferred to another hospital for admission, or dying in the ED whose total ED time exceeds eight hours.
T191 38320-38415 Sentence denotes Access block is the prime symptom of supply/demand mismatch in hospital bed stock in Australia.
T192 38416-38491 Sentence denotes This is also true in many other parts of the world today, including the UK.
T193 38492-38681 Sentence denotes Access block may result in ambulance bypass, increased ED waiting time and casualty queues, increased frequency of adverse events, increased patient complaints, and adverse media attention.
T194 38682-38896 Sentence denotes Ashby describes a number of ameliorating strategies to avoid access block that have been implemented by the Royal Brisbane Hospital in Queensland, Australia where he works as Executive Director of Medical Services.
T195 38897-39230 Sentence denotes Among these strategies is a method to improve hospital bed availability through precision bed management using integrated demand, utilisation and PAS (Patient Administration System) data, flow models and advanced GIS to map the geography of the hospital against variables such as patient numbers, staff numbers, and nurse dependency.
T196 39231-39586 Sentence denotes GIS are used in patient flow modelling to look firstly at opportunities for flow reversal of ED, outpatients and secondary level inpatients, and secondly to improve efficiency through optimum distribution of patients according to a number of variables including nurse dependency, projected length of stay, projected time of discharge and infection status.
T197 39587-39753 Sentence denotes GIS are proving superior to conventional patient activity systems in informing the organisation about bed management opportunities on an hour-by-hour basis [32, 33] .
T198 39754-40135 Sentence denotes It is noteworthy that Downey Regional Medical Centre (DRMC) in California, US, is currently using a large, multi-layered, GIS-enabled patient care and room management system that leverages digital floor plans, workflow analysis, and data visualisation for a better solution to how DRMC assigns patients to rooms, monitors the discharge process, and prepares rooms for new patients.
T199 40136-40325 Sentence denotes The system captures, logs, manages, and analyses a vast array of information about patients checking in, switching rooms, checking out, and moving from in-hospital to outpatient care [34] .
T200 40326-40507 Sentence denotes In a recent review paper, Higgs and Gould highlighted the gap between academic health-related applications of GIS and their everyday use within the UK National Health Service (NHS).
T201 40508-40627 Sentence denotes They argue for closer collaboration between GIS academics and NHS professionals to advance health-based GIS work [28] .
T202 40628-40823 Sentence denotes GIS have been used in the UK health sector for over a decade, but their greatest contribution so far has been in low-level operational tasks (see "surveys of levels of GIS use in the NHS" below).
T203 40824-40993 Sentence denotes There is little evidence that GIS are being formally considered or regularly used in strategic decision-making, e.g., major healthcare planning within the NHS [28, 35] .
T204 40994-41247 Sentence denotes The NHS Executive landmark report "Information for Health" published in 1998 sets out a strategy for improving the availability, reliability, management, analysis, and dissemination of digital data and information in the NHS over the coming years [36] .
T205 41248-41452 Sentence denotes As outlined in this key strategy document, data-rich records kept by GPs remain a relatively untapped resource particularly in the areas of local health surveillance, service audit and resource targeting.
T206 41453-41575 Sentence denotes Information for Health also calls for data sharing between NHS and non-NHS organisations in order to tackle health issues.
T207 41576-41739 Sentence denotes Linkages between, for example, poor health and unemployment, housing, crime, and education are major drivers for partnership approaches between such organisations.
T208 41740-41874 Sentence denotes The Acheson Report published in 1998 also recognised the need to adopt cross-governmental approaches to address health concerns [37] .
T209 41875-42529 Sentence denotes Considering all of this, and given the recent media attention to geographical variations in healthcare service provision, which often revolve around the so-called "postcode lottery" in treatment levels, the fact that a considerable majority of the datasets used in UK primary and secondary care are geo-referenced, and the recent increase in the number of articles (e.g., [10] ), books (e.g., [38] [39] [40] [41] ), and conferences (e.g., [42] ) about the potentials and use of GIS in health applications, it is surprising there has been no mention in Information for Health or other more recent follow-up documents (e.g., "Building the Information Core:
T210 42530-42656 Sentence denotes Implementing the NHS Plan" published in 2001 -[43]) of the role that spatial data and GIS could play in the new NHS [28, 35] .
T211 42657-43041 Sentence denotes The role of spatial information in the health sector in relation to, for example, local health improvement programmes or performance management is not identified in any of the core UK national strategy and policy documents, although the potential for using information from primary care systems to support needs assessment and resource targeting is one of the principal action points.
T212 43042-43223 Sentence denotes There is also no mention of the potential for GIS to support partnership approaches for providing and exchanging information on such issues at either national or local scales [35] .
T213 43224-43676 Sentence denotes The NHS Information Authority (NHSIA), established as a special Health Authority in 1999, states as one of its strategic objectives the need "to contribute to the implementation of Information for Health by establishing, maintaining, developing and supporting a national information infrastructure, national products, national standards, national services and working with the NHS and others to make effective use of these products and services" [44] .
T214 43677-43805 Sentence denotes Again it is astonishing that there is no explicit mention of the potential for geo-information and GIS in addressing these aims.
T215 43806-44027 Sentence denotes Neither are GIS included in any of the policy documents produced by the Information Policy Unit (IPU -http://www.doh.gov.uk/ipu/), which has overall responsibility for delivering the Information for Health strategy [28] .
T216 44028-44142 Sentence denotes However, this author was able to spot several local implementation documents on the Web mentioning the use of GIS.
T217 44143-44407 Sentence denotes One of these documents published on NHSIA Electronic Records Development and Implementation Programme (ERDIP) Web site mentions the use of GIS techniques, mapping to deprivation indices, and linkage to non-medical data in the context of electronic patient records.
T218 44408-44497 Sentence denotes It also refers to using GIS in matching of demand to location of surgery provision [45] .
T219 44498-44568 Sentence denotes Two other documents published on IPU Web site also cite GIS [46, 47] .
T220 44569-44832 Sentence denotes It is also noteworthy that a GIS special interest group has been set up in 2003 within the NHS Online Health Informatics Community Portal http://www.informat ics.nhs.uk/ to disseminate information and provide support to users of GIS within the UK health industry.
T221 44833-45013 Sentence denotes Geographically enabling the electronic patient record offers a powerful advantage in visualising unfolding epidemiological events and patterns hidden in aggregated patient records.
T222 45014-45485 Sentence denotes Unlike the UK national strategy documents and plans, the US National Health Information Infrastructure Strategy document (also known as "Information for Health") refers explicitly to GIS and real-time health and disease monitoring and states that "public health will need to include in its toolkit integrated data systems; high-quality community-level data; tools to identify significant health trends in real-time data streams; and geographic information systems" [48] .
T223 45486-45687 Sentence denotes GIS are also explicitly included in the National Electronic Disease Surveillance System (NEDSS) specifications and systems architecture of the US Centres for Disease Control and Prevention (CDC) [49] .
T224 45688-45778 Sentence denotes During the 1990s there were three significant surveys of the take-up of GIS in the UK NHS.
T225 45779-46019 Sentence denotes These studies pointed to sporadic levels of GIS use in mostly low-level, non-strategic tasks within the NHS, and have consistently flagged common sets of factors that are hindering the implementation and use of GIS within the NHS [28, 35] .
T226 46020-46321 Sentence denotes First, a study commissioned by the Association for Geographic Information, and carried out by Cummins and Rathwell (1991 -cited in [35] ) noted that GIS uptake was being hindered by the low level of awareness of the value of GIS in spatially representing population and health needs-based information.
T227 46322-46535 Sentence denotes This was attributed to a lack of spatial data-handling skills within the NHS and the failure to realise the value of geographical information, which was often being collected as part of existing operational tasks.
T228 46536-46706 Sentence denotes Cummins and Rathwell also found that there was little in the way of infrastructure to enable staff, training, resource management, and financial budgets to implement GIS.
T229 46707-46918 Sentence denotes The small size of many IT departments and high staff turnover, attributed to the higher wage levels of staff with spatial handling skills in the private sector, also hindered the effective implementation of GIS.
T230 46919-47300 Sentence denotes Gould (1992 -cited in [28, 35] ) found high levels of GIS awareness by Directors of Public Health and health authority information/IT officers in England and Wales, though respondents did not perceive any differences between GIS and computer assisted cartography software, and were not really using the software in anything more than simple mapping and low-level operational tasks.
T231 47301-47521 Sentence denotes Typically, maps were being included in the annual reports of the Directors of Public Health to illustrate the health priorities of individual health authorities, with very little emphasis on using GIS in strategic tasks.
T232 47522-47852 Sentence denotes Gould drew attention to a number of factors limiting the use of GIS for strategic tasks within the NHS, such as a low skills base in the handling of spatial information and the lack of functions for spatial analysis and spatial modelling in commercial packages (at that time; this is only marginally true in today's GIS packages).
T233 47853-47983 Sentence denotes These findings were replicated in a study conducted in the later part of the 1990s by Smith and Jarvis (1998 -cited in [28, 35] ).
T234 47984-48295 Sentence denotes Smith and Jarvis surveyed changes in the use of GIS within the NHS following the reforms of the early 1990s and found that GIS use has again tended to be uncoordinated and low-level in nature, because of a lack of policy directives concerning appropriate systems, as well as a general lack of high quality data.
T235 48296-48412 Sentence denotes Moreover, they noted a particular lack of collaboration between GIS academics and healthcare practitioners/managers.
T236 48413-48626 Sentence denotes Research undertaken in academia has certainly highlighted the benefits of spatial statistics and GIS approaches in mapping disease and in healthcare planning, but still needs to respond to NHS needs on the ground.
T237 48627-48730 Sentence denotes One area where GIS have debatably made less impact is that of measuring and monitoring NHS performance.
T238 48731-48956 Sentence denotes A number of dimensions could be measured such as improving the health of the general population, ensuring fair access to services, maintaining the effective delivery of appropriate care and analysing the outcomes of NHS care.
T239 48957-49102 Sentence denotes GIS have a potential role in evaluating performance and could be used to enable comparisons to be made between health authorities and NHS trusts.
T240 49103-49266 Sentence denotes GIS are being used by a relatively small number of authorities to assess the effectiveness and impact of health interventions and health education campaigns [28] .
T1 49267-49354 Sentence denotes More recently, Cooper (2000) surveyed thirteen health authorities in the West Midlands.
T2 49355-49686 Sentence denotes Two thirds of the surveyed health authorities stated that GIS was being underutilised and cited the main reasons as the high costs of digital geographical data and the lack of resources for training and work-time constraints for NHS personnel, because of the low priority given to GIS within the organisations by senior management.
T3 49687-49914 Sentence denotes Staff turnover, especially in organisations where only one member of staff is responsible for GIS work (this was the case in 30% of surveyed organisations), left such organisations vulnerable in terms of their GIS capabilities.
T4 49915-50158 Sentence denotes Cooper advocates the setting up of regional health GIS centres, integrated with the newly formed public health observatories to provide GIS support for local health services and to coordinate training programmes to improve the GIS skills base.
T5 50159-50349 Sentence denotes These regional services could be responsible for coordinating data collection at the regional level, and preventing any duplication of efforts in spatial data collection or processing [50] .
T6 50350-50442 Sentence denotes Public health observatories (PHOs), as proposed in the government White Paper "Saving Lives:
T7 50443-50639 Sentence denotes Our Healthier Nation" [51] , have been set up in each NHS region to draw information together from a range of sources with which to monitor health trends and to identify gaps in information [10] .
T8 50640-50774 Sentence denotes Looking at their objectives and published agenda, PHOs could have easily undertaken the tasks suggested by Cooper in [50] (see above).
T9 50775-51004 Sentence denotes However, after almost three years in existence now, it seems PHOs have failed to fulfil this task (or never thought of fulfilling it), though there are certainly some very good, but sporadic GIS activity within PHOs. (Figure 2 ).
T10 51005-51621 Sentence denotes Higgs et al research agenda for understanding the (under) utilisation of spatial data within the NHS (executed as an Economic and Social Research Council -ESRC-funded project in 2001) included the following tasks: (1) to update previous surveys of GIS utilisation in the NHS; (2) to review the types of GIS applications currently being used; (3) to explore the reasons for variations in the use and wider implementation of GIS, and also consider technical and organisational barriers that influence wider application; and (4) to examine the nature and extent of data exchanges within, and external to, the NHS [28] .
T11 51622-51677 Sentence denotes The results of this study were published in 2003 [35] .
T12 51678-51859 Sentence denotes The study involved a postal questionnaire survey of all health authorities and trusts in the UK, and follow-up semi-structured interviews with selected key respondents from the NHS.
T13 51860-52021 Sentence denotes Higgs et al found that 84% of health authorities and 29% of the health trusts that responded were using GIS in June-July 2001 (the time the study was conducted).
T14 52022-52151 Sentence denotes However, only 54% of health authorities and 56% of health trusts within this active subset reported having fully operational GIS.
T15 52152-52379 Sentence denotes Trusts using GIS include ambulance services NHS trusts that are using GIS in realtime emergency service despatching and control, and cancer intelligence units that are using GIS to examine spatial patterns of disease incidence.
T16 52380-52903 Sentence denotes Factors such as historical precedent, the presence of dedicated GIS-able individuals or teams, and the presence of an effective infrastructure of GIS advice, guidance, and support available to NHS organisations (e.g., in West Midlands and Trent -for some examples, see http://www.sheffield.nhs.uk/health data/gis.htm and http://gis.sheffield.ac.uk/) could explain the observed patterns of health organisations that are GIS users or nonusers, and those that show higher degrees of collaboration with local authorities [35] .
T17 52904-53036 Sentence denotes The production of maps was undertaken in 96% of the health authorities and 67% of the health trusts that reported using GIS in 2001.
T18 53037-53268 Sentence denotes The same active subset of health authorities and trusts was also found to be using GIS to undertake geographically based analysis (75% and 72%), data manipulation (46% and 51%), and analysis of statistical data (36% and 44%) [35] .
T19 53269-53724 Sentence denotes Health authorities were found to be making greater use of GIS for policy-related tasks, e.g., to produce health profiles of local populations, and in epidemiological research, assessing health needs for the purchase of health services, determining catchment areas for local services showing an interactive map of the incidence rates by PCG (Primary Care Group) of prostate cancer in the West Midlands Region over the five year aggregated period 1995-1999.
T20 53725-53861 Sentence denotes Rates have been directly standardised for age using the European Standard Population and are expressed as a rate per 100,000 population.
T21 53862-53979 Sentence denotes To show the variation across the West Midlands region, rates have been divided into quintiles and shaded accordingly.
T22 53980-54133 Sentence denotes Incidence data are provided by the West Midlands Cancer Intelligence Unit -http://www.wmpho.org.uk/wmciu. and planning the location of health facilities.
T23 54134-54245 Sentence denotes In health trusts, the dominant reported use of GIS was for targeting resources towards local population groups.
T24 54246-54372 Sentence denotes Using GIS in monitoring performance was undertaken in 30% of health authorities and 39% of health trusts in the active subset.
T25 54373-54448 Sentence denotes Internet and Intranet GIS were found to be still rare within the NHS [35] .
T26 54449-54797 Sentence denotes Higgs et al also attempted to measure the levels of joinedup working within NHS organisations and with external agencies (e.g., Police, local authorities, utilities, and other central government departments), which has the potential to address a wider range of cross departmental or governmental issues (e.g., health, poverty and social exclusion).
T27 54798-54880 Sentence denotes They found limited exchange of data between health trusts and other organisations.
T28 54881-55134 Sentence denotes By contrast, a more significant number of health authorities were reported exchanging data with external organisations, with significant collaboration with local authorities in over 30% of cases in the active subset (still not a very high figure) [35] .
T29 55135-55399 Sentence denotes Despite these uses of GIS in operational and policyrelated tasks, many respondents identified factors they perceived to be hindering the wider use of GIS within their organisation, and data exchange and collaboration with other organisations and local authorities.
T30 55400-55967 Sentence denotes These obstacles included work-time constraints, insufficient staff and financial resources to implement systems fully and undertake data exchange duties with other organisations (e.g., establishing networks and contacts), lack of skills and insufficient training or guidance, lack of digital data in appropriate formats and problems of ensuring data quality, data confidentiality issues, lack of demand from within some organisations to the use of GIS (directors are not aware of value of GIS rather than not committed to GIS), and lack of a clear GIS strategy [35] .
T31 55968-56131 Sentence denotes The lack of a clear organisational policy for exchanging data was among the most significant data exchange constraints identified by health authorities and trusts.
T32 56132-56446 Sentence denotes This was compounded by the currently ambiguous criteria to conform to data confidentiality requirements, and the lack of a service-level agreement with Ordnance Survey http://www.ordnancesurvey.co.uk/ or other providers like ESRI and MapInfo) for the purchase of base digital data for organisations within the NHS.
T33 56447-56566 Sentence denotes Another important problem reported was that of organisations not being aware of data held by other organisations [35] .
T34 56567-56938 Sentence denotes Higgs et al suggest raising awareness of the benefits of joined-up working arrangements, and introducing significant organisational and cultural changes to facilitate enabling contexts for enhanced collaborative use of GIS between NHS organisations and local authorities, in order to support the wider joined-up government agenda currently being promoted in the UK [35] .
T35 56939-57371 Sentence denotes It should be noted that Higgs et al carried their study and reported differences between health authorities and trusts in 2001 some time before the start of the current changes in the UK health system where Primary Care Trusts are now taking over many of the classical functions of health authorities and a smaller number of Strategic Health Authorities are taking an increasingly strategic role in performance management of trusts.
T36 57372-57550 Sentence denotes Higgs et al's survey could be used as a baseline with which to monitor the impacts of current and future organisational restructuring on the uses of GIS within the NHS [35, 53] .
T37 57551-57849 Sentence denotes In this section, we start by reviewing some of the recipes and recommendations provided by various specialist groups and researchers from around the world for a successful implementation of a national geo-information infrastructure that can also support real-time GIS applications in public health.
T38 57850-58069 Sentence denotes We then present a Canadian case study that emphasises the importance of data modelling and community/university collaboration among other elements involved in the development of community health geo-information systems.
T39 58070-58227 Sentence denotes The reader will notice that there are many recurring themes, and elements and ingredients which are common to all these recipes and the presented case study.
T40 58228-58406 Sentence denotes The section concludes with a detailed discussion of some of these elements and others that are crucial for properly building a national spatial health information infrastructure.
T41 58407-58686 Sentence denotes The International Conference on Spatial Information for Sustainable Development held in Nairobi, Kenya, in 2001 recognised that development and implementation of a National Spatial Data Infrastructure (NSDI) is a prerequisite for promoting sustainable development in any country.
T42 58687-58987 Sentence denotes The conference also recognised that although every NSDI is different due to a variety of cultural, social and economic factors unique within each country, there are a significant number of common elements that can be shared, and which countries should avoid re-inventing; these elements include [6] :
T43 58988-59072 Sentence denotes (1) Fostering a culture of data sharing that considers spatial information an asset:
T44 59073-59306 Sentence denotes A key success factor of NSDI implementation is the management of information (including spatial information) as an asset, e.g., only capture data that are needed and can be maintained, as in the case with finance and human resources.
T45 59307-59375 Sentence denotes A NSDI requires a culture of data sharing to exist within a country.
T46 59376-59476 Sentence denotes The benefits associated with data sharing should be researched to encourage wide participation [6] .
T47 59477-59524 Sentence denotes (2) Education, training, and capacity building:
T48 59525-59641 Sentence denotes The sharing of education and training resources and experiences by organisations is important for capacity building.
T49 59642-59939 Sentence denotes Universities should be encouraged to work with local organisations in the provision of Continuing Professional Development [6] . (Of interest in this context is UNIGIS International http://www.unigis.org/, a worldwide network of educational institutions offering distance-learning courses in GIS.)
T50 59940-59976 Sentence denotes (3) Addressing crucial legal issues:
T51 59977-60128 Sentence denotes Experience has shown that issues associated with national security, data privacy and associated liability are potential obstacles for NSDI initiatives.
T52 60129-60237 Sentence denotes Unambiguous legal frameworks to address these crucial legal issues must be established as early as possible.
T53 60238-60387 Sentence denotes Ordinary citizens must be considered one of the main NSDI beneficiaries and allowed access to NSDI information and services (where appropriate) [6] .
T54 60388-60477 Sentence denotes (4) Development of effective partnerships, and involvement of all stakeholders and users:
T55 60478-60598 Sentence denotes Mature NSDIs are complex solutions involving many stakeholders (including the health sector with all its organisations).
T56 60599-60780 Sentence denotes NSDIs are underpinned by effective partnerships and cooperation amongst a wide variety of multi-disciplinary stakeholders in the public and private sectors and end-user communities.
T57 60781-60872 Sentence denotes Appropriate business models must be agreed to support these partnerships at an early stage.
T58 60873-61052 Sentence denotes The success of a NSDI depends upon delivering products and services that are acceptable and desired by end users (within the government and the private sector, and also citizens).
T59 61053-61180 Sentence denotes It is essential that all users are involved when defining (user) requirements and testing the associated products and services.
T60 61181-61284 Sentence denotes NSDI policy must be flexible to address rapidly changing user needs and adapt to changing technologies.
T61 61285-61460 Sentence denotes NSDI Steering Groups (with end-user representation) should be formed to formulate appropriate policy and institutional frameworks and facilitate multi-stakeholder cooperation.
T62 61461-61578 Sentence denotes However, complete policy and institutional frameworks need not be in place before implementation of a NSDI can begin.
T63 61579-61752 Sentence denotes Roles and responsibilities among stakeholders must be clarified at an early stage, including the lead role -this should be an initial activity of a NSDI Steering Group [6] .
T64 61753-61977 Sentence denotes (5) Adopting common standards and data models: ISO http://www.iso.org/ and the Open GIS Consortium http:/ /www.opengis.org/ produce data and interoperability standards that should be adopted by NSDI stakeholders (see later).
T65 61978-62079 Sentence denotes To be able to integrate and share data we need to understand and resolve different semantics in data.
T66 62080-62364 Sentence denotes All NSDI datasets from different sources should adopt the same overarching philosophy and same/compatible data models to achieve multi-purpose data integration, both vertically and horizontally (within organisations, and across organisations and different administrative levels) [6] .
T67 62365-62439 Sentence denotes (6) A combined top-down and bottom-up incremental implementation approach:
T68 62440-62531 Sentence denotes It is recommended that a top down approach is combined with a pragmatic bottom up approach.
T69 62532-62722 Sentence denotes A mature NSDI can only be achieved through simpler and smaller solutions that start with realistic and clear short-term objectives, and grow incrementally through political and market needs.
T70 62723-62849 Sentence denotes Short-term bottom up projects will provide valuable experience that can feed into the formulation of NSDI policy and strategy.
T71 62850-63074 Sentence denotes By creating "proof of concept and benefits applications", these projects can be also used to gain and sustain political support, and convince further funding of NSDI [6] . (7) Do not just focus on data; develop applications:
T72 63075-63175 Sentence denotes Varied applications and services through a project-oriented approach will bring reality to the NSDI.
T73 63176-63304 Sentence denotes An overemphasis on data acquisition, without a market-linked application, will not provide any momentum for further development.
T74 63305-63422 Sentence denotes Visualisation, modelling and analysing activities will be the focus of value-added services in the coming years [6] .
T75 63423-63517 Sentence denotes EIS-AFRICA is a network for the cooperative management of environmental information in Africa.
T76 63518-63719 Sentence denotes It is a pan-African, non-profit, non-governmental organisation, registered in South Africa, and born out of the World Bank's Environmental Information Systems in Sub-Saharan Africa programme (EIS-SSA).
T77 63720-63870 Sentence denotes Building infrastructure for geo-information use is becoming as important to African countries as the building of roads and telecommunication networks.
T78 63871-64026 Sentence denotes As with the investment in other basic infrastructures, investing in a Spatial Data Infrastructure (SDI) underpins the provision of many essential services.
T79 64027-64139 Sentence denotes In a recent EIS-AFRICA position paper published in 2002, Gavin et al describe the following SDI components [9] :
T80 64140-64181 Sentence denotes (1) Up-to-date core digital geo-datasets:
T81 64182-64462 Sentence denotes A country's ability to use geo-information effectively depends on the existence and proper investment into the provision and maintenance of up-to-date core digital geo-datasets, e.g., locations of river networks, roads, land cover, administrative boundaries, and populated places.
T82 64463-64701 Sentence denotes The existence of these commonly used datasets facilitates the use of other geodata, such as demographic, socio-economic, epidemiological, environmental, and water quality data, which must be also available, accessible and up-to-date [9] .
T83 64702-64716 Sentence denotes (2) Standards:
T84 64717-64872 Sentence denotes Geodata must adhere to accepted standards to enable the unambiguous interpretation, integration, and comparison of related datasets from different sources.
T85 64873-65139 Sentence denotes Stakeholders should work together locally and with international bodies to develop/adopt standards for geodata collection and documentation [9] . (Adopting international standards will also ensure that future collaboration is possible at regional and global levels.)
T86 65140-65153 Sentence denotes (3) Metadata:
T87 65154-65258 Sentence denotes The accessibility of proper documentation (metadata) about existing geodata is also extremely important.
T88 65259-65307 Sentence denotes The mere existence of geodata is not sufficient.
T89 65308-65541 Sentence denotes Information about datasets is needed for the purposes of generating awareness of the data's existence among potential users, and for helping these users assess the reliability and/or relevance of available datasets for selected uses.
T90 65542-65765 Sentence denotes This in turn requires that data providers publicise their metadata to the public and targeted users in a suitable catalogue, directory or clearinghouse to enable searching and retrieving documentation on available datasets.
T91 65766-65820 Sentence denotes Metadata, too, should be standardised [9] (Figure 3 ).
T92 65821-65959 Sentence denotes (4) Policies and practices actively promoting the exchange and reuse of information, and greater public access to geodata are also needed.
T93 65960-66106 Sentence denotes Policies should start by removing barriers to access, e.g., excessive costs to use an information product or lack of clarity concerning copyright.
T94 66107-66235 Sentence denotes The absence of a policy concerning data access and sharing can often be as handicapping as the presence of an inhibiting policy.
T95 66236-66315 Sentence denotes Existing policies need to be revised and new poli- cies developed as necessary.
T96 66316-66508 Sentence denotes Broad-based national committees of data producers, users, and other stakeholders should be created to oversee the development of geoinformation policy and standards and ensure compliance [9] .
T97 66509-66551 Sentence denotes (5) Appropriate human and other resources:
T98 66552-66672 Sentence denotes Sufficient human and technical resources are required to collect, manipulate, interpret, and distribute geo-information.
T99 66673-66750 Sentence denotes Without appropriate human resources, geo-information will remain unexploited.
T100 66751-66829 Sentence denotes Sufficient financial resources must be available to invest in training people.
T101 66830-66928 Sentence denotes Retaining technical expertise should be also a priority within institutions using geo-information.
T102 66929-67077 Sentence denotes Adequate investments must be also made in technologies for digital data management and storage, and in improving communications infrastructure [9] .
T103 67078-67124 Sentence denotes (6) Coordination between various stakeholders:
T104 67125-67367 Sentence denotes The costeffective development of SDI requires the coordinated harnessing of resources and expertise in many different government agencies, the private sector, universities, nongovernmental organisations, and regional and international bodies.
T105 67368-67692 Sentence denotes Collaborative frameworks (partnerships) are required to prevent duplication of effort (which would occur if various institutions pursue singular, uncoordinated agendas), and ensure that all captured and generated data and information conform to common standards, so that they can be easily combined and effectively analysed.
T106 67693-67863 Sentence denotes Such frameworks should specify which organisations are gathering which kinds of information, how the information will be captured, and arrangements for data sharing [9] .
T107 67864-67886 Sentence denotes (7) Raising awareness:
T108 67887-67977 Sentence denotes Establishing a formal national programme can help heighten awareness and generate support.
T109 67978-68084 Sentence denotes Policymakers need to be engaged in the process through awareness training, briefings, and policy dialogue.
T110 68085-68243 Sentence denotes Organising conferences on geo-information, conducting studies on implementing SDI, and supporting professional development are all important ingredients [9] .
T111 68244-68489 Sentence denotes In a 140-page report commissioned by the World Health Organisation -Regional office for Africa (WHO-AFRO), Briggs proposes a programme of action to advance environmental health hazard mapping in Africa that includes the following elements [54] :
T112 68490-68509 Sentence denotes (1) Data modelling:
T113 68510-68676 Sentence denotes This involves developing and adapting health indicators according to specific local user needs [54] (see "Common semantics, data models and health indicators" below).
T114 68677-68709 Sentence denotes (2) Awareness-raising campaigns:
T115 68710-68880 Sentence denotes These should be based on real-world examples and demonstrations of environmental health hazard mapping, and aimed at key decision makers in concerned organisations [54] .
T116 68881-68915 Sentence denotes (3) Joint working in partnerships:
T117 68916-69258 Sentence denotes This involves adoption of a multi-sectoral approach to environmental health hazard mapping, encouragement and support for the sharing of experience and facilities, and support for training and long-term capacity-building, e.g., by building up expert/ national networks (partnerships) and organising workshops, seminars and study visits [54] .
T118 69259-69386 Sentence denotes (4) An incremental approach aimed at making the best possible use of available data and expertise to address local needs [54] .
T119 69387-69490 Sentence denotes In a paper published in 1999 in Public Health Reports, Richards et al stress the following points [7] :
T120 69491-69628 Sentence denotes (1) There is a need for intelligent tools specifically designed for public health, and seamlessly integrated into routine workflows [7] .
T121 69629-69702 Sentence denotes (2) Training, its costs, and time needed for it should be all considered:
T122 69703-69810 Sentence denotes Training should cover epidemiological methods to ensure appropriate use of GIS technology in public health.
T123 69811-70036 Sentence denotes The cost of training programs offered by commercial GIS vendors and solution providers can be a financial burden, and GIS training programmes specifically designed for public health professionals are still relatively limited.
T124 70037-70157 Sentence denotes The time required for training can be also a challenge for organisations in which demands on personnel are already high.
T125 70158-70306 Sentence denotes Training materials should be offered in a variety of formats to facilitate distance learning (e.g., CD-ROMs and self-instruction Web-based courses).
T126 70307-70459 Sentence denotes Public health professional specialties/bodies need to recognise continuing education credit for individuals participating in GIS software training [7] .
T127 70460-70523 Sentence denotes (3) Current and accurate base data must be made available [7] .
T128 70524-70851 Sentence denotes (4) Software and data acquisition, maintenance and upgrade costs should be secured [7] . (In the case of the UK, reaching an agreement to enable the whole NHS for example to access Ordnance Survey (OS) geographic information would be economically much better than asking each NHS organisation to strike a separate deal with OS.
T129 70852-71261 Sentence denotes It is noteworthy that the business case outlining a proposed pilot agreement between OS and the NHS was approved by the NHSIA board in September 2003, and it now remains for the NHSIA and OS to determine the scope and funding of the pilot agreement, which is expected soon.) (5) Confidentiality issues must be addressed [7] (see "Individual privacy, national security, and data confidentiality issues" below).
T130 71262-71337 Sentence denotes (6) Standards must be adopted and partnerships promoted at all levels [7] .
T131 71338-71376 Sentence denotes (7) An incremental approach is needed:
T132 71377-71503 Sentence denotes Longer-term solutions usually require a series of small successes, carefully built upon in incremental fashion over time [7] .
T133 71504-71819 Sentence denotes In fact, much of the wider vision of a national public health spatial data infrastructure can be gradually and incrementally achieved through disparately funded and managed short-term projects, as long as we can ensure that these short-term projects make a useful and lasting contribution towards this wider vision.
T134 71820-71866 Sentence denotes In a recent ArcUser Online article, William F.
T135 71867-72147 Sentence denotes Davenhall, ESRI Health and Human Service Solutions Manager http:/ /www.esri.com/industries/health/index.html, describes an ambitious vision of a Community Health Surveillance System (CHSS -see later) spanning wide geographic areas, and mentions the following success factors [2] :
T136 72148-72211 Sentence denotes (1) Community data sharing must be systematic and regular [2] .
T137 72212-72318 Sentence denotes (2) Adopting data standards and sharing agreements will ensure a CHSS works effectively in real time [2] .
T138 72319-72566 Sentence denotes (3) Data have to be collected uniformly and include specifications for update frequency and allowed dissemination in different emergency and non-emergency situations, and for purposes other than those for which they were originally collected [2] .
T139 72567-72800 Sentence denotes (4) CHSS also requires robust, epidemiologically sound analytical software, well-trained staff, full system redundancy/fault tolerance, standardised database replication and off-site backups, among other ingredients for success [2] .
T140 72801-72996 Sentence denotes RODS, the Real-time Outbreak and Disease Surveillance system, is a computerised public health surveillance system for early detection of disease outbreaks, including those caused by bioterrorism.
T141 72997-73167 Sentence denotes RODS processes clinical encounter data from participating hospitals and sales data of over-the-counter (OTC) healthcare products from participating stores and pharmacies.
T142 73168-73427 Sentence denotes The system was used during the 2002 Winter Olympics and currently operates in two US states -Pennsylvania and Utah (more details about RODS are presented below under "Proactive, realtime, GIS-enabled health and environmental surveillance services") [55, 56] .
T143 73428-73495 Sentence denotes RODS researchers identified the following key elements for success:
T144 73496-73524 Sentence denotes (1) Data-sharing agreements:
T145 73525-73690 Sentence denotes These were executed in the case of RODS with every participating health system and OTC healthcare product retailer, and addressed confidentiality and other concerns.
T146 73691-73831 Sentence denotes Data sharing agreements should allow redistribution of data to any public health authority and permit data to be used in research [55, 56] .
T147 73832-73869 Sentence denotes (2) National data utilities/services:
T148 73870-74040 Sentence denotes Data sources that are amenable to a "national" approach should be formed into industry-based data utilities (services independent of any particular user interface) [56] .
T149 74041-74087 Sentence denotes (3) A deep understanding of data and industry:
T150 74088-74255 Sentence denotes Wagner et al found that a key element for success included the deep understanding of the OTC healthcare products industry provided to them by an industry expert [56] .
T151 74256-74290 Sentence denotes (4) Official/governmental support:
T152 74291-74505 Sentence denotes Equally key was a personal invitation, sent to the CEO of relevant corporations, for participation (sharing of otherwise proprietary data), authored by a highly respected government or public health official [56] .
T153 74506-74635 Sentence denotes (5) Development of an interdisciplinary team with expertise in medical informatics, computer science, law, and engineering [56] .
T154 74636-75109 Sentence denotes Morris and Henton list several key factors for progress and success of an environmental health surveillance system for Scotland (see "Large-scale environmental surveillance projects in the UK" below), including ensuring joint ownership of the project, successful partnerships and shared commitment among the disparate agencies that are involved in the project, adopting a phased approach, reaching a consensus on inputs and outputs, and having realistic expectations [57] .
T155 75110-75275 Sentence denotes In a recent study published in 2003 (see "Most recent published survey of levels of GIS use in the NHS" above), Higgs et al point to the following ingredients [35] :
T156 75276-75585 Sentence denotes (1) Establishing networks of GIS users from both the NHS and local authorities at local and higher levels to encourage more joined-up working, share expertise and experiences, as well as establish contacts and trust, and raise the awareness of the types of data that are held by different organisations [35] .
T157 75586-75608 Sentence denotes (2) Raising awareness:
T158 75609-76056 Sentence denotes A substantial proportion of respondents in Higgs et al's study from health authorities (90%) and trusts (74%) stated that a dedicated Web site giving advice on GIS matters for NHS organisations would be helpful in providing a forum or virtual network on the Web for the exchange of information and experiences, as well as in promoting and disseminating good practice examples of GIS use in healthcare, and identifying other suitable Web resources.
T159 76057-76198 Sentence denotes Successful examples of collaborative projects between NHS and local authorities that have involved the use of GIS should be also highlighted.
T160 76199-76414 Sentence denotes Other factors considered important in raising awareness include an annual GIS conference aimed at professionals from NHS organisations and local authorities, and the provision of seminars, workshops, and road shows.
T161 76415-76657 Sentence denotes According to Higgs et al, such "raising awareness" activities are vital given the need to build business cases for the development of GIS within NHS organisations and to show the capabilities and "business benefits" of GIS to directors [35] .
T162 76658-76876 Sentence denotes Croner points to several elements and tasks required to develop a nation's public health geospatial infrastructure and realise comprehensive Internet geospatial readiness in public health; these elements include [58] :
T163 76877-76955 Sentence denotes (1) Vision and leadership at the highest levels (e.g., departments of health):
T164 76956-77045 Sentence denotes This is necessary to ensure national public health geospatial mobilisation and readiness.
T165 77046-77227 Sentence denotes A suitable policy and funding must be established, including the provision of support to organisations lacking the resources to join in a common, coherent national initiative [58] .
T166 77228-77516 Sentence denotes (2) Assessing current state of geospatial readiness to respond to normal and emergency community health needs, and identifying beacon sites as resources for guidance and other forms of assistance to those agencies and departments not yet or in early formative stages of involvement [58] .
T167 77517-77580 Sentence denotes (3) Technology introduction; training and education programmes:
T168 77581-77656 Sentence denotes This implies the provision of necessary budgets for these activities [58] .
T169 77657-77791 Sentence denotes (4) Promoting collaboration with and between all sectors to share data, applications and expertise [58] (see "On partnerships" below).
T170 77792-77945 Sentence denotes (5) Moving to the Web and building all necessary critical connectivity/geospatial infrastructure that should not be independently recreated by all [58] .
T171 77946-78221 Sentence denotes (6) Geospatial readiness also requires that geospatial data holdings be identified, described and made Web-searchable in a standardised manner forming a truly uniform, integrated, navigable and shareable national inventory of existing public health geospatial data resources.
T172 78222-78632 Sentence denotes Best standards, rules, designs, and practices must be created/ agreed upon and published (covering spatial metadata, geocoding, accessibility for visually and manually impaired data users, and data access restrictions among other things) for uniform Internet-enabled GIS services, in which standards, definitions, and look-and-feel of the data and Web-based technology are the same throughout the nation [58] .
T173 78633-78815 Sentence denotes Community/university research collaboration is a relatively new research paradigm that has recently become a major strategic theme of health funding agencies in Canada and elsewhere.
T174 78816-78972 Sentence denotes Buckeridge and his colleagues present their experience in conducting a collaborative community/university respiratory health GIS research project in Canada.
T175 78973-79180 Sentence denotes Their experience is a good example of research into the kind of partnerships (community/academia) that are also required to realise the envisaged national spatial health information infrastructure in the UK.
T176 79181-79661 Sentence denotes Their specific project objectives were to: (1) develop and iteratively refine via active community/university collaboration a GIS for ready access to routinely collected health data (focusing on respiratory health), and to study logistical, conceptual and technical problems encountered during system development; and (2) to conduct a qualitative ethnographic study to document and analyse issues that can emerge in the process of community/university research collaboration [8] .
T177 79662-79747 Sentence denotes Buckeridge et al adopted user-centred and rapid prototyping/iterative design methods.
T178 79748-79815 Sentence denotes User feedback was gathered via questionnaires and discussions [8] .
T179 79816-80121 Sentence denotes In an initial step, university and community partners jointly developed a conceptual data model (or ontology) to facilitate data integration and enable participants from different backgrounds to share a common vocabulary and dialogue (see also "Common semantics, data models and health indicators" below).
T180 80122-80425 Sentence denotes The data model described by Buckeridge et al was based on a "determinants of health" model that explicitly acknowledges the influence of nonmedical determinants (e.g., income, occupation, and environment) on population health status, and qualitatively relates these determinants to health outcomes [8] .
T181 80426-80638 Sentence denotes Such models have been used successfully as the basis for other population health information system approaches, e.g., POPULIS (see "Caring for population demographics and socio-economic factors" below) [59, 60] .
T182 80639-80783 Sentence denotes The next steps involved identifying, evaluating, and acquiring potentially relevant datasets based on data needs identified from the data model.
T183 80784-80959 Sentence denotes Data describing determinants of respiratory health included census, cartographic files, land use, traffic volume, air monitoring and emissions, and consumer spending patterns.
T184 80960-81194 Sentence denotes Data describing outcomes of respiratory health included hospital separations (similar to Hospital Episode Statistics in England -see http://www.doh.gov.uk/hes/), ambulatory physician visits and procedures, and prescription drug sales.
T185 81195-81672 Sentence denotes Once data were acquired, they were integrated into the GIS using the developed data model and the spatial unit of the enumeration area, a Canadian census sampling area with a median population of 400 in the study area (Southeast Toronto) to relate datasets to one another (in this case the enumeration area acted as a common high resolution geographical unit for linkage -the data model facilitated data integration around the common geographical unit of the enumeration area).
T186 81673-81897 Sentence denotes The limited and inconsistent descriptions (metadata) of existing data were partially addressed by adopting a "standard" ad hoc metadata model within the system to represent available descriptions in an organised manner [8] .
T187 81898-82095 Sentence denotes Buckeridge et al highlighted some important issues they have encountered during the development of their system, and which are also generalizable to other community health information systems [8] :
T188 82096-82194 Sentence denotes (1) Early and continued involvement of users in system development is important, if not essential.
T189 82195-82383 Sentence denotes However, maintaining and coordinating consistent user involvement, especially across a number of organisations, is a difficult and resource-intensive task that should be well planned [8] .
T190 82384-82591 Sentence denotes (2) All relevant system stakeholders should be involved in the development of a data model or ontology to facilitate data selection and integration, and support a common understanding of data by people [8] .
T191 82592-82866 Sentence denotes (3) Challenges met while bringing disparate data together included lack of directories or catalogues for locating existing data, generally poor descriptions (metadata) for existing data, non-standard encoding of data, and concern over data "ownership" and/or privacy issues.
T192 82867-82952 Sentence denotes Web accessible directories of data would greatly facilitate identifying data sources.
T193 82953-83102 Sentence denotes In addition, action should be taken to improve data documentation (metadata), develop data standards, and enhance compliance with existing standards.
T194 83103-83250 Sentence denotes Many data holders did not have an established protocol for access to their data, or a clearly identified person with the authority to release data.
T195 83251-83410 Sentence denotes In the absence of these, data holders were reluctant to release data, and acquisition of some data required a considerable amount of negotiation and follow-up.
T196 83411-83537 Sentence denotes The difficulties encountered in acquiring data indicate that privacy concerns present a serious barrier to system development.
T197 83538-83673 Sentence denotes A wide range of stakeholders in society must collectively address the issues of privacy and stewardship of population health data [8] .
T198 83674-83875 Sentence denotes (4) The potential for data display to be misleading and for misinterpretation of data was addressed by providing users with descriptions (metadata) of datasets and constraining map types by data types.
T199 83876-84024 Sentence denotes Methods to allow only valid visualisation and analysis of data from a variety of sources across space and time must be developed and evaluated [8] .
T200 84025-84287 Sentence denotes (5) Problems from an interface design perspective included the need to constantly change the interface to accommodate a refined understanding of user needs and changes in the underlying data structure (because of the iterative nature of the development process).
T201 84288-84412 Sentence denotes Standard software engineering methods, such as design models and modular programming, helped to address these problems [8] .
T202 84413-84531 Sentence denotes (6) Users of community health information systems will nearly always have variable skills and organisational contexts.
T203 84532-84697 Sentence denotes The range of user skills and knowledge was partially addressed by developing a graphical user interface with multiple levels, each supporting a different user level.
T204 84698-84858 Sentence denotes Another approach would be to use artificial intelligence, as employed in decision support systems, to facilitate user control of information visualisation [8] .
T205 84859-84905 Sentence denotes (7) Community/university collaboration issues:
T206 84906-85067 Sentence denotes As organisations and individuals are brought together to form research partnerships, differences in their organisational/ institutional cultures become apparent.
T207 85068-85344 Sentence denotes Community partners tend to see potential conflicts between service provision and research demands, while university partners tend to see the collaboration as posing threats to research rigor, control over the research process and constraints on publication opportunities [8] .
T208 85345-85585 Sentence denotes Leadership style, vision, commitment to the idea of community/university collaboration, at least small amounts of "seed funding", and the willingness to learn from failures all appear to be significant features in successful collaborations.
T209 85586-85892 Sentence denotes Issues that shaped and influenced the collaborative process and partnership that developed during the course of Buckeridge et al's project revolved around three major themes: separate cultures (differences in expectations, values, outcomes, reward systems and work styles), time, and uncertainty/ambiguity.
T210 85893-85940 Sentence denotes These issues are neither positive nor negative.
T211 85941-86108 Sentence denotes Rather, they represent challenges which, depending on how they are met, have the potential to shape the collaborative process in either positive or negative ways [8] .
T212 86109-86210 Sentence denotes Sub-themes within the "separate cultures" category included issues around language, trust, and power.
T213 86211-86434 Sentence denotes Language differences (different knowledge backgrounds and ways of understanding the world) occurred as frequently between university partners from different academic disciplines as between university and community partners.
T214 86435-86633 Sentence denotes Trust developed gradually with time, as co-investigators came to recognise the strengths, commitment and knowledge of each other, and as the group worked to make joint decisions and solve conflicts.
T215 86634-86747 Sentence denotes Issues of power arose from differences in status, resources, skills, and personal commitment to the project [8] .
T216 86748-86941 Sentence denotes Time was a burden for individuals, but an asset to the collaborative project as a whole, as it supported the development of trust, mutual understanding and effective working relationships [8] .
T217 86942-87205 Sentence denotes Many co-investigators pointed out that the most difficult aspect of their collaboration was to learn to accept and work with the uncertainty and ambiguity about where the project was going as it developed and unfolded (despite clear project goals and objectives).
T218 87206-87405 Sentence denotes Nevertheless, uncertainty and ambiguity were found to be essential to the shared positive experience of exploration, debate, and reflection, and also created the space to ask critical questions [8] .
T219 87406-87517 Sentence denotes Community partners engaged in collaborative research with universities should see themselves as equal partners.
T220 87518-87706 Sentence denotes This could be achieved in part by making an organisational commitment to research (e.g., supporting staff involved in research and advocating with funding agencies for research resources).
T221 87707-88006 Sentence denotes On the other hand, universities should foster community/university research partnerships by developing university structures that support such collaboration, and inducing positive changes in the current academic culture, which places more value on individual rather than collaborative research [8] .
T222 88007-88185 Sentence denotes In the case study presented above, Buckeridge et al stressed the importance of community/university collaboration when developing a community health geo-information service [8] .
T223 88186-88596 Sentence denotes Public health also needs to be an integral part of a larger structural, multi-agency whole, where government and other relevant agencies at all levels are brought together to build, integrate, leverage through sharing and partnerships, and optimise spatial information, both vertically within and horizontally across organisations, for comprehensive routine as well as emergency planning and response services.
T224 88597-88933 Sentence denotes Intranet and Internet environments can help facilitating public health spatial data accessibility and integration at local, national and regional levels, and can support a physical and virtual "situation room" for both emergency and day-to-day management of operations for safeguarding the environment and protecting human health [58] .
T225 88934-89191 Sentence denotes A San Diego Association of Governments report titled "Guidelines for Data Development Partnership Success" is based on many years of GIS partnering experience and cites guidelines that may help other agencies develop successful partnership activities [61] .
T226 89192-89400 Sentence denotes A good example of successful partnerships is the online GIS service known as "Window to My Environment" (WME -http://www.epa.gov/enviro/wme/), which is offered by the US Environmental Protection Agency (EPA).
T227 89401-89573 Sentence denotes WME is designed to provide public accessibility to a wide range of federal, state, and local geospatial data about environmental conditions and features in any US location.
T228 89574-89678 Sentence denotes The data available in the WME application are distributed and reside at their respective agency servers.
T229 89679-89791 Sentence denotes Thus each participating agency manages its own data and its timeliness, which can be current and even real-time.
T230 89792-89840 Sentence denotes There is no limit on the number of WME partners.
T231 89841-89917 Sentence denotes Any agency can participate by adding its own data layer(s) to existing ones.
T232 89918-90013 Sentence denotes Participants can also create a reciprocal interface on their home server with WME connectivity.
T233 90014-90121 Sentence denotes Public health databases are not yet included in WME, but there are no specific barriers to inclusion [58] .
T234 90122-90249 Sentence denotes As information systems increase in complexity, models of the relationships between data elements become increasingly important.
T235 90250-90369 Sentence denotes Data models, more correctly called ontologies, explicitly define how concepts within data sources relate to each other.
T236 90370-90514 Sentence denotes They are conceptual models that facilitate integration of data by information systems and support a common understanding of data by people [8] .
T237 90515-90895 Sentence denotes To explain the importance of adopting common semantics when developing health geo-information services that span administrative boundaries, Richards et al provide the example of two neighbouring public health departments that are addressing a common infectious disease problem and would like to join their independently developed GIS maps into a common map for both jurisdictions.
T238 90896-91001 Sentence denotes Doing so requires consensus on a range of technical, GIS-related issues and public health-related issues.
T239 91002-91116 Sentence denotes The latter for example include case definitions, sources for case reports, and the time period for the study [7] .
T240 91117-91435 Sentence denotes In his report commissioned by WHO-AFRO, Briggs classifies environmental health hazards into eight categories: land/climate-related hazards, atmospheric hazards (outdoor air pollution), water-related hazards, food-borne hazards, vector-borne hazards, domestic hazards, occupational hazards, and infrastructural hazards.
T241 91436-91548 Sentence denotes Briggs' report stresses the importance of indicators as essential tools for environmental health hazard mapping.
T242 91549-91685 Sentence denotes Indicators provide the means of describing, monitoring, managing, and comparing hazards in terms that are relevant to information users.
T243 91686-91730 Sentence denotes Three types of indicator are proposed [54] :
T244 91731-91925 Sentence denotes (1) Hazard indicators: define the hazard in terms of its extent, magnitude, duration, frequency or probability of occurrence, without reference either to the exposed population or health effect;
T245 91926-92026 Sentence denotes (2) Risk indicators: describe the hazard in terms of the number or percentage of people exposed; and
T246 92027-92164 Sentence denotes (3) Health impact indicators: describe the hazard in terms of the actual health outcome, measured as either morbidity or mortality [54] .
T247 92165-92266 Sentence denotes Which type of indicator is most appropriate is likely to depend on the specific question being asked.
T248 92267-92454 Sentence denotes Natural hazards, for example, can be readily described by hazard indicators, while hazards like suicides and domestic violence are more easily described by health impact indicators [54] .
T249 92455-92532 Sentence denotes Unfortunately, there are no one-size-fits-all indicators that suit all users.
T250 92533-92752 Sentence denotes Indicators need to be customised according to specific and local user circumstances and needs, the specific hazard of interest, the type of question being asked, the scale of analysis, and data availability and quality.
T251 92753-93015 Sentence denotes For this reason, the emphasis in Briggs report was not on providing a core or generic set of environmental health hazard indicators, but on providing indicator profiles that show, for a sample of indicators, how they can be constructed/customised and used [54] .
T252 93016-93286 Sentence denotes An indicator profile specifies the environmental health hazard(s) to which the indicator relates, the indicator's rationale and role, any alternative methods and definitions, any related indicator sets, sources of further information, and a listing of involved agencies.
T253 93287-93413 Sentence denotes Each indicator must be clearly defined alongside all underlying terms and concepts involved in describing and constructing it.
T254 93414-93575 Sentence denotes Data needed to construct an indicator must be identified and assessed regarding availability, quality, and characteristics in terms of the indicator in question.
T255 93576-93783 Sentence denotes The ways in which the indicator is computed (e.g., a mathematical formula) and units of measurements used in presenting it (e.g., percentage or number per thousand head of population) must be also specified.
T256 93784-93895 Sentence denotes The area across which the indicator can be used (scale of application or aggregation level) must be determined.
T257 93896-94013 Sentence denotes Finally, the ways in which the indicator may be interpreted in relation to the hazard(s) it covers must be described.
T258 94014-94576 Sentence denotes This includes determining what inferences can be made from apparent trends or patterns in the indicator, and any constraints on the interpretation of the indicator, due for example to data limitations or complexities in the relationships implied by the indicator [54, 62] . (2) What are the strengths and risks in our community that contribute to health? (quality of life; behavioural risk factors, e.g., substance abuse, lifestyle, and screening programmes; and environmental health indicators, e.g., air and water quality, workplace hazards, food safety, etc.)
T259 94577-94843 Sentence denotes (3) What is our health status? (social and mental health; maternal and child health; death, illness and injury; infectious disease; and sentinel events) CHSA also calls for establishing a system to monitor these indicators over time, e.g., to detect sentinel events.
T260 94844-95017 Sentence denotes The latter are cases of unnecessary disease, disability, or untimely death that could be avoided if appropriate and timely preventive services or medical care were provided.
T261 95018-95291 Sentence denotes These include vaccine-preventable illness, avoidable hospitalisations (those patients admitted to the hospital in advanced stages of disease which potentially could have been detected or treated earlier), late stage cancer diagnosis, and unexpected syndromes or infections.
T262 95292-95518 Sentence denotes Sentinel events may alert the community to health system problems such as inadequate vaccine coverage or lack of primary care and/or screening, a bioterrorist event, or the introduction of globally transmitted infections [63].
T263 95519-95822 Sentence denotes The CDC National Public Health Performance Standards Programme (NPHPSP -http://www.phppo.cdc.gov/ nphpsp/index.asp) is a more current partnership effort to improve the practice of public health, the performance of public health systems, and the infrastructure supporting public health actions in the US.
T264 95823-96439 Sentence denotes To achieve its goals, NPHPSP developed performance standards and matching assessment instruments for state and local public health systems, and for public health governing bodies. (NAC-CHO developed and tested the Local Public Health System Performance Assessment Instrument for NPHPSPhttp://www.phppo.cdc.gov/nphpsp/Documents/ Local_v_1_OMB_0920-0555.pdf) NPHPSP describes ten "Essential Public Health Services" that provide the fundamental framework for NPHPSP instruments by defining public health activities that should be undertaken in all communities http://www.phppo.cdc.gov/nphpsp/ 10EssentialPHServices.asp.
T265 96440-96593 Sentence denotes The Health Data Model (HDM) is a conceptually related collaborative project to develop a generic data model for health applications, using ESRI software.
T266 96594-96705 Sentence denotes ESRI staff and researchers at the University of California at Santa Barbara (UCSB) are leading this consortium.
T267 96706-96872 Sentence denotes The user members represent public health planning and research organisations, public health consulting firms, and GIS coordinators from medical centres around the US.
T268 96873-97090 Sentence denotes The current phase of this work has assigned top priority to service site selection, emergency response, facility emergency response, campus facility management, regional environmental health, and disease surveillance.
T269 97091-97157 Sentence denotes The outcome will be a basic data model with three components [64]:
T270 97158-97292 Sentence denotes (1) A conceptual object model of health application features, building relationships between health application geographies and users;
T271 97293-97389 Sentence denotes (2) UML (Unified Modelling Language) code which is easily transformed into an ESRI geo-database.
T272 97390-97997 Sentence denotes The average user can immediately begin to populate the geo-database rather than to design it, and the inherent commonality between users and sites adopting the resultant geo-database(s) should facilitate exchange of data; and In October 2003, this author contacted Dr. Mike Goodchild, HDM project leader, and asked him how does/will their conceptual object model relate/link to health indicators, e.g., those produced by NACCHO as part of their Community Health Status Assessment (CHSA) Toolbox, and those produced by WHO-AFRO as part of their consultation on environmental health hazard mapping for Africa.
T273 97998-98344 Sentence denotes Goodchild replied that he thinks they should include health indicators, and that they will start investigating NACCHO and WHO-AFRO's indicators to see if they can come up with a suitable way of including them in their HDM (Mike Goodchild, HDM project leader at the University of California at Santa Barbara, personal communication -October 2003).
T1 98345-98457 Sentence denotes More beds, more physicians and nurses, and more procedures do not always translate into better community health.
T2 98458-99033 Sentence denotes Departing from this premise, the Manitoba Centre for Health Policy (MCHP -http://www.umanitoba.ca/ centres/mchp/) has developed POPULIS, a POPULation health Information System, to answer questions like: "What factors -beyond access to medical care -determine the health of populations?" and "Would healthcare money have a greater impact on health if some were spent in other areas such as education, housing, nutrition, job creation and training?" [59, 65] POPULIS reports on the health of a population, and the relationship between health and the use of healthcare services.
T3 99034-99150 Sentence denotes It also relates these to socio-economic factors like education, unemployment, housing, and single parent households.
T4 99151-99253 Sentence denotes These factors are key components of the Socio-Economic Risk Index (SERI), a measure developed by MCHP.
T5 99254-99441 Sentence denotes The higher a region's score on this index, the higher the death rate is among its residents -death rate being a key and rather obvious indicator of a population's health status [59, 65] .
T6 99442-99607 Sentence denotes POPULIS has been conceived to help policy makers avoid a "knee-jerk" reaction to one set of negative indicators or to pressures generated by one-sided media stories.
T7 99608-99956 Sentence denotes It builds on data that are available but somewhat underused in today's healthcare systems, e.g., vital statistics, census, and healthcare service utilisation data, to provide healthcare decision makers with the continuously updated and localised detail essential for planning and managing a more effective and efficient healthcare system [59, 65] .
T8 99957-100024 Sentence denotes However, POPULIS has missed a lot by not being a GISenabled system.
T9 100025-100390 Sentence denotes The original POPULIS (based on Statistical Analysis System (SAS), a very popular statistical package) proved to be hard to maintain and not scalable, and a more recent publication by Roos in 1999 [65] has moved from describing POPULIS as a SAS front-end or software program to presenting it as a framework or approach of concepts, methods, procedures and databases.
T10 100391-100642 Sentence denotes GIS are excellent integrative, multidisciplinary knowledge management tools capable of linking and spatio-temporally analysing disparate, continuously changing datasets, and as such could have helped POPULIS achieve its vision in far much better ways.
T11 100643-100881 Sentence denotes Demographic shifts, e.g., the forecast rise in the number of elderly people in developed countries over the next decades, also have their impacts on healthcare services and expenditure, and must be carefully considered and modelled [66] .
T12 100882-100973 Sentence denotes Aggregating disparate data sources to a common geography has always been a strength of GIS.
T13 100974-101147 Sentence denotes The challenge of nationwide, regional and global coordinated efforts in case of natural or man-made disasters, however, calls for aggregating the aggregates on short notice.
T14 101148-101332 Sentence denotes For instance, if a disaster hits at the border of two cities or two EU countries, will their two information silos be able to work together, sharing and combining data instantaneously?
T15 101333-101499 Sentence denotes Today, many systems are based on closed or proprietary interfaces and formats, and are difficult to integrate with brands and platforms in use by other organisations.
T16 101500-101562 Sentence denotes Embracing open standards is the key to interoperability [67] .
T17 101563-101754 Sentence denotes Interoperability allows spatial data silos distributed anywhere on the Web to be searched, located, retrieved and compiled, either by a Web GIS service provider or at an individual's desktop.
T18 101755-101991 Sentence denotes The OpenGIS Consortium (OGChttp://www.opengis.org/) develops specifications to accommodate any operational differences and allow disparate Web GIS clients and desktop users to fully integrate Web accessible spatial data resources [58] .
T19 101992-102172 Sentence denotes OGC's ultimate goal is to enable the "spatial Web" with products that plug and play across different processing platforms, vendor brands, networks, and programming languages [67] .
T20 102173-102385 Sentence denotes Founded in 1994, OGC is an international industry consortium of 258 companies, government agencies and universities participating in a consensus process to develop publicly available geoprocessing specifications.
T21 102386-102456 Sentence denotes Geography Markup Language (GML) is the base language developed by OGC.
T22 102457-102596 Sentence denotes GML is becoming the world standard for eXtensible Markup Language (XML) encoding of geographic features and geoprocessing service requests.
T23 102597-102692 Sentence denotes The relevance of Web Services to spatial integration of disparate data sources is also obvious.
T24 102693-102995 Sentence denotes XML encoding of geodata, using GML and Web Services http:// www.opengis.org/initiatives/?iid=7 specifications and recommendations, makes it possible to display, overlay, and analyse geodata on any Web browser, even if the browser obtains views of different map layers from different remote map servers.
T25 102996-103350 Sentence denotes For example, layering Web Services from two politically/administratively separate but geographically contiguous cities or regions would allow the integration of their independent data silos to answer questions about an emergency involving both (provided that issues of common semantics, data models and case definitions have been resolved) [58, 67, 68] .
T26 103351-103495 Sentence denotes XML is also used for encoding spatial metadata (metadata are essential to aid the discovery of spatial data in a distributed environment) [58] .
T27 103496-103588 Sentence denotes Standards also exist for metadata (see "Existing SDIs and SDI initiatives worldwide" below).
T28 103589-103687 Sentence denotes One of the keys to GML deployment is a companion specification, the OGC Web Feature Service (WFS).
T29 103688-103808 Sentence denotes To get GML data, users query a Web server with an OGC Web Service Interface, collectively known as a Web Feature Server.
T30 103809-103959 Sentence denotes The OGC interface enables standardised access to a feature store and enables users to add, update or retrieve GML data locally or across the Internet.
T31 103960-104079 Sentence denotes Any data store can be used -users no longer need to care whether the underlying store is from ESRI, Oracle or IBM [69].
T32 104080-104217 Sentence denotes GML brings an alternative to expensive proprietary software, and an increasing number of companies have already joined the GML bandwagon.
T33 104218-104425 Sentence denotes Ordnance Survey (OS), the UK's national mapping agency, has adopted GML as the only geospatial data format for its MasterMap of Great Britain http://www.ordnancesurvey.co.uk/ oswebsite/products/osmastermap/.
T34 104426-104498 Sentence denotes OS MasterMap boasts about 400 million geographic features in GML format.
T35 104499-104681 Sentence denotes Each feature within OS MasterMap is assigned a unique 16-digit "topographic identifier" (TOID) that can be used by OS or its customers to reference any given feature in the database.
T36 104682-104893 Sentence denotes This makes it much easier for users to associate other information to the spatial feature, to refer unambiguously to a particular feature, and, therefore, to share spatial information with other users [24, 69] .
T37 104894-105005 Sentence denotes By separating presentation from content, powerful maps can be made that offer enhanced functionality for users.
T38 105006-105187 Sentence denotes GML contains map "content" only (e.g., where features are, their geometry, type and attributes), but it does not provide any information about how that map data should be displayed.
T39 105188-105337 Sentence denotes This is actually a benefit because different "stylesheets" can be applied to the geographic data to make it appear however the user wishes [70, 71] .
T40 105338-105521 Sentence denotes By combining a selected map stylesheet with a WFS query, users are presented with a fully interactive and editable vector map that can be viewed in any Web browser [69] ( Figure 4 ).
T41 105522-105618 Sentence denotes Another key feature of GML is its ability to be "self describing" through the use of XML schema.
T42 105619-105801 Sentence denotes Thanks to this feature, tools have been developed to model and load proprietary databases, e.g., Oracle Spatial databases, with geographic data supplied in GML formats [69] . making.
T43 105802-105980 Sentence denotes GML contains map "content" only (e.g., where features are, their geometry, type and attributes), but does not provide any information about how that map data should be displayed.
T44 105981-106096 Sentence denotes This allows different "stylesheets" to be applied to the geographic data to make it appear however the user wishes.
T45 106097-106673 Sentence denotes By combining a selected map stylesheet with a Web Feature Service (WFS) query, users are presented with a fully interactive and editable vector map that can be viewed in any Web browser. (Adapted from [70] .) reference systems (time information is essential in tracking applications like monitoring ambulance locations and in exploring the movement and growth of natural disasters), topology (the relationships between features, e.g., for use by routing applications popular in location-based services), gridded data, and default styles for feature and coverage visualisation.
T46 106674-106862 Sentence denotes The new release is modular, allowing users to pick out only the schemas or schema components that apply to their work, which simplifies and minimises the size of implementations [72, 73] .
T47 106863-106983 Sentence denotes However, it should be noted that GML and Web Services are only part of the solution to integration and interoperability.
T48 106984-107359 Sentence denotes Other health-related standards like HL7 (Health Level 7 -http://www.hl7.org/) and clinical coding schemes like SNOMED (Systematised Nomenclature of Medicine) -http://www.snomed.org/, LOINC (Logical Observation Identifiers Names and Codes -http:// www.loinc.org/, and ICD (International Classification of Diseases -http://www.cdc.gov/nchs/icd9.htm) are also equally important.
T49 107360-107882 Sentence denotes For example, RODS, the Real-time Outbreak and Disease Surveillance system, uses the HL7 message protocol to receive clinical encounter data from participating hospitals in real time [55] , while the US Department of Defense Global Emerging Infections System is basing its seven syndromic surveillance categories on groups of related ICD codes http:// www.geis.ha.osd.mil/GEIS/SurveillanceActivities/ ESSENCE/ICD9May02.xls (see also "Proactive, real-time, GIS-enabled health and environmental surveillance services" below).
T50 107883-108177 Sentence denotes Lowe also stresses the fact that technologies like XML and SOAP (Simple Object Access Protocol -involved in Web Services) are only part of the integration issue, and points to integrating geoprocessing and databases at other levels, and the related issues of optimisers and federated databases.
T51 108178-108241 Sentence denotes Industry professionals now manage very large spatial databases.
T52 108242-108404 Sentence denotes Often, client programs will pull a copy of the database spatial data into their own environment to process it instead of asking the database to do the processing.
T53 108405-108568 Sentence denotes If the client program request happens to involve a very large database table, the copy-and-exchange process may drag on endlessly or even fail because of overload.
T54 108569-108659 Sentence denotes This same potential problem awaits users of multiple feature-streaming map services [67] .
T55 108660-108899 Sentence denotes Alternatively, if the spatial processing remains within the database environment, an optimiser program common to all professional databases will internally organise a response to the query that returns results in the fastest possible time.
T56 108900-109152 Sentence denotes A query from the larger integrated system goes into the database and only the results come out, taking advantage of the database optimiser, reducing processing loads on the client that generated the question, and also reducing transmission loads [67] .
T57 109153-109242 Sentence denotes Each database vendor's optimiser works best within its own specific database environment.
T58 109243-109429 Sentence denotes A potential problem arises in case one wants to optimise the use of multiple databases when a query joins data from several different databases (from different vendors) at the same time.
T59 109430-109601 Sentence denotes In the same spirit as the Web Services model, agencies can keep their existing heterogeneous database technology, and use a federated database technology to unite the mix.
T60 109602-109774 Sentence denotes IBM, for example, offers a federated database technology that simulates views of any other database tables in IBM DB2 database, offering a master view of all data holdings.
T61 109775-109945 Sentence denotes Furthermore, the federated technology's optimiser is aware of the available processing resources in other databases and organises query responses appropriately [67, 74] .
T62 109946-110211 Sentence denotes Grid-based real-time distributed collaborative geoprocessing could also form the basis of a next-generation solution to data and computationally intensive geoprocessing applications that are extremely difficult to execute on conventional systems and networks [75] .
T63 110212-110355 Sentence denotes Grid computing allows non-collocated computers to work on and process data together, not just communicate and exchange data between each other.
T64 110356-110464 Sentence denotes It is already a reality with many ongoing projects (see for example http://mapcenter.in2p3.fr/ datagrid-s/).
T65 110465-110578 Sentence denotes Automated (even "on-the-fly") geocoding is one of the most essential spatial infrastructure-building tasks [58] .
T66 110579-110748 Sentence denotes Higgs and Richards mention how different geocoding methods (used to geo-reference UK postcodes) have different levels of accuracy, which could affect study results [3] .
T67 110749-110897 Sentence denotes Researchers need to determine if the level of error caused by a chosen method of geocoding may affect the results of their particular project [76] .
T68 110898-111370 Sentence denotes Also of relevance in this context are the North American Association of Central Cancer Registries GIS Handbook http://www.naaccr.org/Standards/GIS Handbook PDF 6-3-03.pdf, which discusses (in its second section) the importance of address geocoding for the spatial analysis of cancer data, and ProADDRESS, an ArcGIS extension that has been made available by ESRI UK for geocoding UK addresses and/or postcodes http://www.esriuk.com/ products/ProAddress_products.asp?pid=55.
T69 111371-111467 Sentence denotes Conflation is the ability to precisely geo-reference variant data layers compiled into one view.
T70 111468-111555 Sentence denotes This can be crucial in emergency situations such as terrorist and bioterrorist attacks.
T71 111556-111661 Sentence denotes The need currently exists for the development of automated conflation techniques transparent to the user.
T72 111662-111862 Sentence denotes Croner gives the example of New York City where lack of automated conflation methods following the fall 2001 World Trade Centre attack resulted in time-consuming problems for emergency response teams.
T73 111863-112046 Sentence denotes New York City is now building automated conflation capability by modifying all city planning spatial databases to include standardised "hooks" for matching and seamless linkage [58] .
T74 112047-112288 Sentence denotes For public health, a variety of rapid developing emergency-related events, including floods, fires, chemical spills and earthquakes, necessitate timely Web delivery of large spatial databases for responsive disaster intervention and control.
T75 112289-112373 Sentence denotes Bandwidth is not only a problem of developing countries, but developed ones as well.
T76 112374-112607 Sentence denotes Again, in the emergency response to the fall 2001 terrorist attack, lack of bandwidth in some areas of New York City resulted in delays in providing processed and urgently needed data for the Emergency Mapping and Data Centre (EMDC).
T77 112608-112785 Sentence denotes Because of low bandwidth Internet connections, large data files had to be written to CD-ROM and driven by state Police twice daily for delivery to the agencies that needed them.
T78 112786-112986 Sentence denotes Bandwidth is a key component of the transmission process of spatial data and is rapidly increasing in developed countries, promising improved spatial data transmission speeds in the near future [58] .
T79 112987-113262 Sentence denotes Richards et al call for GIS technology to be linked with community health planning tools through data entry forms and automated procedures (e.g., automated geocoding for vital statistics data) to help public health practitioners map and plan interventions at community level.
T80 113263-113417 Sentence denotes GIS software tools are needed that are specifically customdesigned for use in public health, especially by organisations with limited staff and resources.
T81 113418-113587 Sentence denotes Richards et al anticipate that GIS technology may one day become embedded and so deeply "buried" in public health practice to the extent that it is invisible to workers.
T82 113588-113686 Sentence denotes Future health GIS applications will "know" which data silos are needed and where they are located.
T83 113687-113900 Sentence denotes After loading the appropriate data and performing relevant analyses, they will offer alternative courses of action ranging from informing other people in the public health system to issuing health advisories [7] .
T84 113901-114009 Sentence denotes It is noteworthy that Epi Info Version 3 developed by the CDC in the US already fulfils part of this vision.
T85 114010-114196 Sentence denotes Epi Info Version 3 has been released as public domain software for Microsoft Windows, and is available free of charge on the Internet for anyone to download http://www.cdc.gov/epi info/.
T86 114197-114383 Sentence denotes The program has some GIS functionality allowing public health practitioners to import, utilise, and display map boundary files and data, but there is still room for further improvements.
T87 114384-114570 Sentence denotes The ultimate system will be one that is fault-tolerant and capable of analysing and presenting assembled data in ways that facilitate only appropriate interpretations of integrated data.
T88 114571-114879 Sentence denotes This can be achieved by using some form of user friendly, "intelligent", goal-oriented health GIS wizards (based on robust statistical methods where appropriate), so that only valid results and maps are produced, even when users attempt to select inappropriate settings or datasets for a particular analysis.
T89 114880-115019 Sentence denotes To maximise their utility, these wizards should also be fully integrated into everyday public health workflows and decision-making process.
T90 115020-115242 Sentence denotes Such seamless integration would let users focus and spend most of their time on what they want to achieve rather than on learning and overcoming the limitations of the tools they are supposed to use to achieve their goals.
T91 115243-115586 Sentence denotes In the US, Internet-based health GIS services must ensure Section 508 compliance with the Rehabilitation Act Amendments http://www.usdoj.gov/crt/508/ 508law.html and http://www.section508.gov/ to make complex graphical and mapping files accessible to visually impaired users [58] (see also http://www.esri.com/soft ware/section508/index.html).
T92 115587-115679 Sentence denotes The UK/EU equivalents of these accessibility requirements can be consulted online [77, 78] .
T93 115680-115927 Sentence denotes The Web interactive cancer mortality maps developed by the National Cancer Institute (NCI) and the National Institutes of Health (NIH) in the US are a good example of Section 508-compliant GIS services http://www3.can cer.gov/atlasplus/index.html.
T94 115928-116093 Sentence denotes These maps offer users choices about type of cancer, age, race, sex, geography (e.g., state or county), and selection of class intervals, colour shading and scaling.
T95 116094-116314 Sentence denotes Charts and graphs associated with the maps translate graphical data into a comparison form accessible by screen readers and are thus compliant with Section 508 for those with visual or manual impairment [58] (Figure 5 ).
T96 116316-116422 Sentence denotes As the value of our information and computing infrastructure increases so to does the value of disruption.
T97 116423-116807 Sentence denotes Critical information infrastructures are potentially vulnerable to Screenshot of Section 508-compliant NCI cancer mortality maps and graphs Figure 5 Screenshot of Section 508-compliant NCI cancer mortality maps and graphs Screenshot of the customisable cancer mortality maps and graphs developed by the US National Cancer Institute (NCI -http://www3.cancer.gov/atlasplus/ index.html).
T98 116808-116970 Sentence denotes These maps (upper part of screenshot) and the associated charts and graphs (lower part of screenshot) are compliant with Section 508 of the US Rehabilitation Act.
T99 116971-117145 Sentence denotes This means they can be accessed by the blind or visually impaired through screen readers that read the text description file ([D] link) accompanying each map, graph or chart.
T100 117146-117170 Sentence denotes cyber terrorist attacks.
T101 117171-117333 Sentence denotes A cyber terrorist attack could be also used in support of a physical attack to cause further confusion and possible delays in proper response with greater losses.
T102 117334-117447 Sentence denotes Securing any spatial health information infrastructure we build against such attacks is thus extremely important.
T103 117448-117596 Sentence denotes Kevin Coleman suggests several measures that can be taken for thwarting cyber terrorism; interested readers are urged to refer to his article [79] .
T104 117597-117779 Sentence denotes This section discusses some of the more problematic issues associated with the implementation of a spatial health information infrastructure and real-time public health GIS services.
T105 117780-118025 Sentence denotes Individual privacy, national security, and data confidentiality issues, as well as a range of data/ analysis errors and problems are covered below, together with an array of solutions (currently available or under development) that address them.
T106 118026-118373 Sentence denotes In public health worldwide, any public identification of an individual's health status and residence, regardless of level of contagion or risk, is usually prohibited with very few exceptions, e.g., Megan's Law in the US, which allows the release of residential information on registered child sex offenders to the public by local government [58] .
T107 118374-118797 Sentence denotes SARS (Severe Acute Respiratory Syndrome) mapping in Hong Kong using disaggregate case data at individual building level in near real time was another noticeable exception to this well-established public health confidentiality rule, and also a unique and rare GIS opportunity that resulted in some very comprehensive public Internet mapping services (see "Real-time/near-real-time GIS for epidemics management" below) [80] .
T108 118798-118846 Sentence denotes Spatial data confidentiality is a complex issue.
T109 118847-119030 Sentence denotes Even if a single database may appear to have effective confidentiality safeguards, when several databases are linked within GIS, the "sum" may be less well protected than the "parts".
T110 119031-119158 Sentence denotes A false identification may be just as damaging to an individual as a correct identification that is not kept confidential [7] .
T111 119159-119365 Sentence denotes On the other hand, confidentiality constraints often preclude the release of disaggregate data about individuals, which limits the types and accuracy of the results of the analyses that could be done [81] .
T112 119366-119538 Sentence denotes Individual agencies holding micro-data (small population/individual health and environmental data) often impose restrictions on the level of geography that can be reported.
T113 119539-119850 Sentence denotes In the US, for example, the National Centre for Health Statistics (NCHS -http://www.cdc.gov/nchs/) requires that for all microdata that are released outside of NCHS, geographic identification must be deleted for all areas below the State level, which contain fewer than some predetermined number of inhabitants.
T114 119851-119999 Sentence denotes Traditional ecological analysis based on choropleth mapping and the analysis of aggregate data for administrative areas has been heavily criticised.
T115 120000-120491 Sentence denotes It is increasingly becoming clear in the field of public health that individual-level health information aggregated to pre-existing political or other administrative areas to protect individual privacy often destroys information needed for geographical analyses making it impossible to address many important public health concerns, e.g., accident risk of particular environments, hazards of living close to hazardous waste sites, exposure risk from lead associated with urban highways, etc.
T116 120492-120545 Sentence denotes Such concerns can only be addressed using micro-data.
T117 120546-120735 Sentence denotes The lack of spatially-disaggregate data on healthcare utilisation and clinical activity also limits the types and power of healthcare delivery studies that can be carried [13, 28, 82, 83] .
T118 120736-120868 Sentence denotes Using aggregated data instead of address-level data (when the latter is required) produces what Jacquez calls "spatial uncertainty".
T119 120869-120962 Sentence denotes Moreover, using area centroids instead of exact locations can yield misleading results [12] .
T120 120963-122208 Sentence denotes According to Armstrong et al, when data are spatially aggregated to large areas, the ability of researchers to detect disease clusters or to investigate suspected relationships between environmental exposures and disease events is affected in four ways: (1) absolute and relative locations within the geographical extent of each area are unobservable making it impossible to perform tests of clustering, except for those designed to operate specifically on data aggregated to areas; (2) the effect of the geographic scale of the aggregation with respect to the geographic scale of the clusters means that the aggregation level used in an analysis limits the size of clusters that could be detected; (3) the shape and placement of aggregation areas in relation to the realworld distribution of the disease or clusters under study, e.g., when a disease cluster straddles two or more aggregation areas, may result in ambiguous or negative results; and (4) accurate analyses are only possible when health data are spatially encoded to the boundaries of areas with common levels of environmental exposure, which is usually not the case since exposure assessment data are generally collected for different areas than health and demographic data [83] .
T121 122209-122339 Sentence denotes Fortunately, solutions exist that can preserve data confidentiality while still enabling fine-level analyses and reliable results.
T122 122340-122944 Sentence denotes These solutions involve (1) the use of statistical and epidemiological methods to mask the geographic location of data in a way that can still permit meaningful analysis, e.g., special types of spatial and temporal aggregation of data; (2) the creation of secure (networked) environments with limited and multiple levels of access (to confidential data) in which public health researchers can be carefully monitored to ensure protection of individual and household confidentiality; and (3) the development, publication and strict enforcement of appropriate, unambiguous policies and regulations [7, 58] .
T123 122945-122991 Sentence denotes The three solution groups are discussed below.
T124 122992-123036 Sentence denotes (1) Statistical and epidemiological methods:
T125 123037-123152 Sentence denotes Armstrong et al describe different promising types of geographical masks to encode the geography of health records.
T126 123153-123477 Sentence denotes These masks not only preserve the confidentiality of individual health records, but also preserve, to the maximum degree possible, the geographic properties of the data, thus permitting the investigation of questions that can be validly answered only with some (adequate) knowledge about the location of health events [83] .
T127 123478-123676 Sentence denotes The geographic coordinates of data collected at discrete locations can be subjected to a family of affine point transformations that move these locations deterministically to a new set of locations.
T128 123677-123926 Sentence denotes Another technique is random perturbation, in which each point is displaced (within the range of a constant maximum magnitude of displacement) by a randomly determined amount, and in a randomly determined direction, specific to its original location.
T129 123927-123976 Sentence denotes A third class of geographic masks is aggregation.
T130 123977-124054 Sentence denotes Areal aggregation involves enumerating the total that exists within a region.
T131 124055-124168 Sentence denotes Point aggregation uses a single, surrogate location to represent the location of several individual-level events.
T132 124169-124401 Sentence denotes In the latter case, regions could be represented by their geographic centroids, or surrogate locations could be computed that are optimised regarding some defined relationship to the original locations (location-allocation methods).
T133 124402-124472 Sentence denotes Other point aggregation methods include microaggregation and blurring.
T134 124473-124699 Sentence denotes It is also possible to aggregate for non-conterminous "regions" of interest like releasing health data for all areas within a given distance of a specified hazard, e.g., all children's accidents within 20 metres of stop signs.
T135 124700-124910 Sentence denotes Another possible approach to limiting disclosure is to remove all explicit geographic identifiers from the health record and replace them with contextual information of specific interest to the data user [83] .
T136 124911-125057 Sentence denotes The best approach will depend on the purpose of the data user as well as the degree of disclosure risk that the data custodian wishes to tolerate.
T137 125058-125219 Sentence denotes Preliminary research suggests that random perturbation of data, up to some limit, is superior to affine and aggregation masks for many analytical purposes [83] .
T138 125220-125331 Sentence denotes Areal aggregation is perhaps the most commonly adopted approach among those suggested by Armstrong et al [83] .
T139 125332-125438 Sentence denotes Health organisations are always looking for finer levels of boundary geography to aggregate their data to.
T140 125439-125578 Sentence denotes The US South Carolina Department of Health and Environmental Control (SCDHEC) used to aggregate spatial health information at county level.
T141 125579-125790 Sentence denotes While county-level data provide a wealth of information, information at this macro scale does not allow local health officials to adequately identify, analyse, and monitor health problems at the community level.
T142 125791-125973 Sentence denotes Laymon describes SCDHEC's more recent approach to managing geo-referenced vital health records by geocoding them, then aggregating them at census tract level instead of county level.
T143 125974-126210 Sentence denotes A US census tract is a small statistical subdivision of a county designed to be relatively homogenous with respect to demographics, socio-economic characteristics, and living conditions, and to contain between 2,500 and 8,000 residents.
T144 126211-126343 Sentence denotes SCDHEC chose census tracts because they contain useful socio-economic data that could be combined with the aggregated vital records.
T145 126344-126456 Sentence denotes Census tracts were also chosen because these geographic boundaries are updated once every decade (stable) [84] .
T146 126457-126693 Sentence denotes The resultant system, SCDHEC's Vital Health and Census Data Integration System, automates geocoding and aggregation of vital records data (births and deaths), while a Health Data Query System provides easy access to the aggregated data.
T147 126694-126915 Sentence denotes By joining aggregate vital records health data with existing socio-economic census data, the system provides a good tool for developing surveillance and intervention strategies while preserving residents' confidentiality.
T148 126916-127218 Sentence denotes The point data resulting from the geocoding process (before aggregation) is treated with all the confidentiality of paper certificate data, and stored for future use in very high-resolution studies [84] In England, Wales and Northern Ireland, Output Areas (OAs) have been introduced at the 2001 Census.
T149 127219-127285 Sentence denotes OAs form a new level of boundary geography for reporting purposes.
T150 127286-127526 Sentence denotes From April 2004 they will also be used as the finest level of reporting geography for Neighbourhood Statistics http://www.neighbourhood.statistics.gov.uk/, which includes crime, education, economic deprivation, work deprivation, and health.
T151 127527-127622 Sentence denotes Output Areas are built from postcodes, and have been designed for homogeneity and to be static.
T152 127623-127669 Sentence denotes Each OA contains approximately 125 households.
T153 127670-127831 Sentence denotes Due to their smaller size (compared to Enumeration Districts), OAs allow for a finer resolution of data analysis while still ensuring data confidentiality [85] .
T154 127832-127945 Sentence denotes Armstrong et al also mention another possible solution to data confidentiality problems based on software agents.
T155 127946-128010 Sentence denotes Software agents are emerging as an important computing paradigm.
T156 128011-128158 Sentence denotes If an agent were designed to support the analysis of public health data, users would not be required to have access to confidential health records.
T157 128159-128406 Sentence denotes Rather, they would submit a request to an intelligent analysis agent that would assess the request, and if found appropriate, would complete the analysis and return a result to the data user without exposing any individual-level health data [83] .
T158 128407-128591 Sentence denotes It is noteworthy that the Health System Resident Component (HSRC), part of RODS, the Real-time Outbreak and Disease Surveillance system (described below), is based on similar concepts.
T159 128592-128871 Sentence denotes HSRC is located within the firewall of a health system, and its purpose is to provide RODS with additional public health surveillance functions that would not be possible if it were located outside of the firewall due to restrictions on the release of identifiable clinical data.
T160 128872-129039 Sentence denotes It functions as a case detector in a distributed public health surveillance scheme linking laboratory and radiology data to increase the specificity of case detection.
T161 129040-129160 Sentence denotes HSRC removes identifiable information before transmitting any data to RODS (outside the health system's firewall) [55] .
T162 129161-129211 Sentence denotes (2) Secure networks and multiple levels of access:
T163 129212-129455 Sentence denotes Croner describes a solution to data confidentiality problems consisting of multiple levels of access to data classified according to its nature, ranging from confidential/protected data to public/open access data according to user credentials.
T164 129456-129570 Sentence denotes Access to confidential data can be accommodated for qualified users in secure Intranet or Internet settings [58] .
T165 129571-129744 Sentence denotes There are many specifications and standards involved in designing and implementing secure networks, e.g., BS 7799/ISO 17799 http://www.riskserver.co.uk/bs7799/ whatisit.htm.
T166 129745-130003 Sentence denotes EPAL, the Enterprise Privacy Authorisation Language http://www.zurich.ibm.com/security/enter prise-privacy/epal/, and XACML, the eXtensible Access Control Markup Language http://sunxacml.source forge.net/, are also very relevant developments in this context.
T167 130004-130175 Sentence denotes It is noteworthy that Digital Rights Manangement (DRM), conventionally used for protecting Internet music and films, is now available for other types of digital documents.
T168 130176-130477 Sentence denotes The latest Microsoft Windows Server 2003 Rights Management Services (RMS) technology offers the possibility to create multiple detail/data levels of data categorised according to sensitivity, and match them to multiple levels of access according to user credentials (see http:// www.microsoft.com/rm).
T169 130478-130593 Sentence denotes There are also other DRM solution providers today besides Microsoft, e.g., Macrovision http://www.macrovision.com/.
T170 130594-130792 Sentence denotes Davenhall introduces the concept of Private Secured Geography Networks (PSGN) built on geoservers, and capable of analysing geographic queries and distributing information with geographic relevance.
T171 130793-131072 Sentence denotes Each participating organisation in a community health surveillance system (CHSS -see below) can run its own PSGN and geoserver behind its firewall, and directly control information content and access by internal and external entities and maintain the confidentiality of its data.
T172 131073-131481 Sentence denotes While each participating organisation maintains its data securely, perhaps generating/holding different classes of data/levels of detail (e.g., anonymised vs. personal identifiable information) at a variety of security levels, all data can be automatically and quickly integrated when required, e.g., in the event of outbreak or epidemic, and released to only those who have proper access authorisation [2] .
T173 131482-131709 Sentence denotes The US NCI GIS for Health (GIS-H) developed as part of the Long Island Breast Cancer Study Project (LIBCSP) provides a good example of a successful implementation of multiple levels of data access according to user credentials.
T174 131710-131941 Sentence denotes A "Researchers" area of the LIBCSP Web site provides applications necessary for access and use of non-public resources that are subject to privacy and licensing restrictions http://www.healthgis-li.com/researchers/ researchers.htm.
T175 131942-132071 Sentence denotes On the other hand, data, information, maps and software that have been approved for public dissemination are available to anyone.
T176 132072-132413 Sentence denotes Similarly, the Washington State Health Department's online developmental Epidemiologic Query and Mapping System (EpiQMS -http://epiqms.doh.wa.gov/) incorporates three levels of security in order to accommodate citizens, public health and medical practitioners, and public health agency investigators access to state and regional health data.
T177 132414-132564 Sentence denotes This security model allows different levels of access to the data depending on the likelihood that an individual's privacy could be compromised [58] .
T178 132565-132609 Sentence denotes (3) Legislations, policies, and regulations:
T179 132610-132816 Sentence denotes It is also important for public health agencies to develop unambiguous, standardised confidentiality guidelines and security rules for their database holdings, and Web sharing and use of their spatial data.
T180 132817-133130 Sentence denotes Lack of sufficient or clear laws regarding privacy, and variations in protections of health data across different organisations and agencies may preclude or delay data sharing across regional lines and organisational boundaries, or involve unacceptable risks to the privacy of data that are transmitted [13, 58] .
T181 133131-133323 Sentence denotes Confidentiality guidelines and accessibility restrictions to the public and research community should be Web documented in searchable metadata that describe essential elements of the database.
T182 133324-133469 Sentence denotes Through metadata all public health agencies can inform others of their spatial data holdings and any limitations associated with their use [58] .
T183 133470-133718 Sentence denotes In the UK, the implications of recent legislation, such as the 1998 Data Protection Act [86] , which came into force in March 2000, on the use of geocoded patient information in medical research are somewhat unclear and need to be closely examined.
T184 133719-134010 Sentence denotes Potential changes in the provision of patient data to cancer registries such as the ethical requirement to obtain patient consent prior to information being passed to registries could, for example, have major implications for researchers examining spatial patterns in cancer incidence [28] .
T185 134011-134311 Sentence denotes On the positive side, Section 60 of the Health and Social Care Act 2001, which applies to England and Wales, allows the Secretary of State to make regulations enabling disclosure of information for specified purposes, without consent, but without breaching common law requirements of confidentiality.
T186 134312-134643 Sentence denotes This covers the processing of confidential patient information that relates to the present or past geographical locations of patients (including where necessary information from which patients may be identified) which is required for medical research into the locations at which disease or other medical conditions may occur [87] .
T187 134644-134759 Sentence denotes Directives and the related CEN/TC 251 (European Standardisation of Health Informatics) guidance document [88, 89] .
T188 134760-135044 Sentence denotes The UK General Medical Council, the Department of Health Information Policy Unit, the NHS Information Authority, and the Department for Constitutional Affairs also publish important documents covering confidentiality, data protection and data sharing issues [90] [91] [92] [93] [94] .
T189 135045-135459 Sentence denotes In the US, privacy rules in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its new DHHS (Department of Health and Human Serviceshttp://www.hhs.gov/ocr/hipaa/ privacy provisions contain extensive exemptions if the identification information is used for treatment, payment, research, or national priority activities that are carried out in the interest of public health and safety [58] .
T190 135460-135755 Sentence denotes On another level, following the September 2001 events in the US, many federal and local spatial databases, e.g., "critical infrastructure" spatial data, were assessed by their holding agencies as a potential liability to national security and withdrawn from the Internet or public dissemination.
T191 135756-136007 Sentence denotes The current concern is to find an appropriate balance between public access to spatial information and protection of information considered a priority for national security (this is another important aspect of data security and confidentiality) [58] .
T192 136008-136138 Sentence denotes GIS integration of complex data into visually easy-tounderstand pictures can sometimes be a setup for misunderstanding and misuse.
T193 136139-136284 Sentence denotes Richards et al call for sound epidemiological principles and methods to provide the foundation for the data analyses to be displayed on GIS maps.
T194 136285-136701 Sentence denotes To avoid drawing false conclusions from maps, GIS users need to understand and apply epidemiological principles and methods in formulating study questions, testing hypotheses about cause-and-effect relationships, and critically evaluating how the chosen dataset(s) and GIS method(s), data quality, confounding factors, and bias may influence the interpretation of results, and hence any decisions based on them [7] .
T195 136702-136782 Sentence denotes According to Monmonier, it is not just easy but also essential to lie with maps.
T196 136783-136940 Sentence denotes The cartographer's paradox is that to avoid hiding critical information in a fog of detail, the map must offer a selective, incomplete view of reality [95] .
T197 136941-137271 Sentence denotes Public health practitioners need to be alert for "lies" that can range from legitimate and appropriate suppression of some details selectively to help the user focus on what needs to be seen to more serious distortions in which the visual image suggests conclusions that would not be supported by careful epidemiological analysis.
T198 137272-137486 Sentence denotes For example, when some geographic units of analysis have small denominators, disease rates computed for these areas may appear extremely high if any cases have occurred in these areas (the "small numbers" problem).
T199 137487-137669 Sentence denotes When the rates for these geographic locations are displayed on a map, readers may incorrectly conclude that these are "hot spots", high priority locations for targeted interventions.
T200 137670-137821 Sentence denotes More appropriately, these areas should be labelled to indicate that rates are statistically unstable due to small numbers and therefore not shown [7] .
T201 137822-138365 Sentence denotes Along similar lines, in 1998, Jacquez defined the "gee whiz" effect as "the formulation of hypotheses to explain an apparent (visual) pattern whose existence has not been confirmed", and stressed the importance that appropriate and robust statistical methods be used to support the thematic data layers being displayed and analysed in order to avoid the consequences of visual bias in GIS processes, in which spatial patterns might seem to appear where none actually exists, and inferences might sometimes be made on invalid assumptions [12] .
T202 138366-138678 Sentence denotes In a personal e-mail communication with Dr. Geoffrey Jacquez five years after his original definition of the "gee whiz" effect, he affirmed that he still stands by the idea that pattern recognition (both spatial and spatio-temporal) requires objective approaches that transcend the subjectivity of the human eye.
T203 138679-138776 Sentence denotes According to Jacquez, these approaches play a role in both confirmatory and exploratory analyses.
T204 138777-138941 Sentence denotes He continues: "Especially within the exploratory framework, one must be able to discriminate true patterns from apparent patterns that could be explained by chance.
T205 138942-139151 Sentence denotes In the absence of such capability, both confirmatory and exploratory analyses spin their wheels because they lack an objective mechanism for identifying and quantifying relationships in the data." (Geoffrey M.
T206 139152-139399 Sentence denotes Jacquez, personal communication -July 2003) Jacquez also mentioned in his e-mail to this author that they have several initiatives underway in the development of surveillance systems at BioMedware http:// www.biomedware.com/, the company he leads.
T207 139400-139672 Sentence denotes One of these projects, NetSurv, will link diverse databases in real time, will support dynamic visualisation (linked windows and cartographic and statistical brushing), and will include surveillance and pattern recognition statistics for separating true signal from noise.
T208 139673-139844 Sentence denotes This will enable prospective analysis of incoming health data (the continuous monitoring of health data, combining historical data with new information as it is received).
T209 139845-140068 Sentence denotes The ultimate aim of the NetSurv project is to provide decision support and monitoring tools that will enhance existing disease surveillance systems and support timely analysis, policy formulation, and public health actions.
T210 140069-140289 Sentence denotes An early version of the architecture, but one that is linked only to static cancer mortality outcomes has been developed for the US NCI and may be downloaded from https://www.terraseer.com/atlas viewer.html ( Figure 6 ).
T211 140290-140448 Sentence denotes They also have Rogerson's spatial pattern surveillance method in their ClusterSeer software (see also "Testing for spatio-temporal disease clustering" above).
T212 140449-140614 Sentence denotes Help for the method, as well as for the entire Clus-terSeer software project is available online at https:// www.terraseer.com/csr/clusterseer_help.html (Geoffrey M.
T213 140615-140659 Sentence denotes Jacquez, personal communication -July 2003).
T214 140660-140747 Sentence denotes Three other software tools/visualisation projects are worth mentioning in this context.
T215 140748-140830 Sentence denotes The first of these tools is GeoDa http://agec221.agecon.uiuc.edu/csiss/geoda.html.
T216 140831-141030 Sentence denotes GeoDa was designed by Luc Anselin and co-workers at the University of Illinois at Urbana-Champaign to implement techniques for exploratory spatial data analysis on lattice data (points and polygons).
T217 141031-141220 Sentence denotes It is intended to provide a user friendly graphical interface to methods of descriptive spatial data analysis, such as spatial autocorrelation statistics and indicators of spatial outliers.
T218 141221-141305 Sentence denotes The second tool is GeoVISTA Studio http://www.geovistastudio.psu.edu/jsp/ index.jsp.
T219 141306-141480 Sentence denotes Developed at Pennsylvania State University Department of Geography, GeoVISTA Studio is a programming-free, open software development environment designed for geospatial data.
T220 141481-141663 Sentence denotes It allows users to quickly build applications for geocomputation and geographic visualisation, and is freely distributed over the Web at no cost to academic and non-commercial users.
T221 141664-141810 Sentence denotes The third project is Daniel Carr's micromap plots on the NCI/CDC State Cancer Profiles Web site http://statecancerpro files.cancer.gov/micromaps/.
T222 141811-142093 Sentence denotes In the future, it may become possible to incorporate BioMedware's disease trend monitoring techniques and novel visualisation approaches that are currently being developed within the NetSurv project (as well as tools like GeoDa) as analytic components in other surveillance systems.
T223 142094-142216 Sentence denotes However, early NetSurv pilot results showed that its Web-based interface was difficult, slow, and not user friendly [96] .
T224 142217-142476 Sentence denotes Though we definitely need rigorous, "objective approaches that transcend the subjectivity of the human eye", we also equally need easy and reliable tools suitable for use by non-expert statisticians (mainstream public health practitioners and informaticians).
T225 142477-142645 Sentence denotes Users, including policy makers, may be tempted to infer causation from correlation and to make inferences about individuals from population data (the ecologic fallacy).
T226 142646-143059 Sentence denotes While conclusions based on an analysis at the aggregate level are likely to be limited by aggregation bias and by the ecologic fallacy (failing to identify the true nature of cause-effect relationships at the level of the individual), conclusions based on analysis at the individual level may be also limited by the atomistic fallacy (failing to consider the broader context in which individual behaviour occurs).
T227 143060-143090 Sentence denotes A balanced approach is needed.
T228 143091-143427 Sentence denotes GIS technology could be used to link data for an individual (individual predictors) with contextual information and ecologic predictors aggregated at a variety of geographic (community) levels, enabling the preparation of multi-level spatial models to better evaluate and distinguish biological, contextual, and ecological effects [7] .
T229 143428-143621 Sentence denotes The potential discrepancy between the place of diagnosis and that of the exposure to environmental variables influencing the particular health outcome(s) in question must be taken into account.
T230 143622-143680 Sentence denotes We need to consider the daily activity spaces of patients.
T231 143681-144041 Sentence denotes Understanding the individual's time-space history can provide important (aetiological) information not only for the epidemiologist, but also for the clinician, and should be considered in order to address the effect of individuals' high mobility/activity space on any identified disease patterns, and to avoid erroneous aetiological hypotheses and conclusions.
T232 144042-144128 Sentence denotes The problem is particularly acute for diseases that have a long lag or latency period.
T233 144129-144249 Sentence denotes This requires the availability of disaggregated longitudinal databases containing the residential histories of patients.
T234 144250-144317 Sentence denotes Clearly, complete datasets of this nature are currently rare [97] .
T235 144318-144596 Sentence denotes Back in 1992, Openshaw (cited in [81] ) identified the following sources of GIS data error: errors in the positioning of objects, errors in the attributes associated with objects, and errors in modelling spatial variation (e.g., by assuming spatial homogeneity between objects).
T236 144597-144855 Sentence denotes Other GIS experts also include errors resulting from GIS operations on spatial data (transformation and interpolation), the effects of generalisation operations (aggregation), errors due to differences of a temporal nature, and representational errors [81] .
T237 144856-145022 Sentence denotes The scale level should be appropriate for the issues being investigated in an analysis, otherwise the results will not be meaningful and may be even misleading [11] .
T238 145023-145187 Sentence denotes Different diseases have patterns that are interesting at different spatial scales, and the optimum scale is the one that reveals the most interesting pattern [14] .
T239 145188-145358 Sentence denotes Moreover, because accuracy is scale-dependent, users should always determine if any resultant error at the currently selected scale is acceptable for a given application.
T240 145359-145551 Sentence denotes Users also need to be continually aware of the errors that could arise when map data compiled for different purposes, and frequently, at different scales are merged into one application [81] .
T241 145552-146181 Sentence denotes Oppong describes variations between different locations in data collection methods and standards, in the recorded items, particularly data on patient residence, and in Screenshot of TerraSeer's Cancer Atlas Viewer Figure 6 Screenshot of TerraSeer's Cancer Atlas Viewer Screenshot of TerraSeer's Cancer Atlas Viewer showing a US states diverging gradient map of Z-score standardised version of "R(ALL, ACC, BF, 7094)" numeric dataset, where R = the mortality rate per 100,000 person-years, age-adjusted to the 1970 US population, ALL = all ages combined, ACC = all cancers, BF = black female, and 7094 = the time period 1970-1994.
T242 146182-146357 Sentence denotes TerraSeer's Cancer Atlas Viewer allows users to visualise and interact with space-time data from the National Cancer Mortality Atlas http://www3.cancer.gov/atlasplus/new.html.
T243 146358-146616 Sentence denotes Users can view the data in the form of maps, animated (slideshow) maps, tables, scatterplots, boxplots, and/or histograms, and can also use the software to perform statistics to evaluate spatial pattern in the data. diagnostic standards and case definitions.
T244 146617-146802 Sentence denotes Such variations are often encountered in cancer research (to give an example), and can result in serious problems when pooling data from different locations for a common analysis [81] .
T245 146803-146892 Sentence denotes Oppong gives examples of GIS data problems in HIV/ AIDS research in developing countries.
T246 146893-147128 Sentence denotes National data reported to WHO is problematic because of differences between countries in adequacy of testing facilities and reporting practices, varying definitions of what constitutes a case of AIDS, and political distortions of data.
T247 147129-147279 Sentence denotes Besides, due to the location of biomedical facilities in urban areas, available data tend to over-represent these areas on the expense of rural areas.
T248 147280-147393 Sentence denotes Paucity of biomedical facilities in rural areas usually means many health conditions there pass unreported [81] .
T249 147394-147712 Sentence denotes Since it is impossible (in practice) to perform error-free spatial analysis, users must develop increased sensitivity to and awareness of the various types of data errors and uncertainty, as well as competency in techniques for recognising and reducing their negative impact on conclusions drawn from spatial analysis.
T250 147713-147998 Sentence denotes For example, the MARA (Mapping Malaria Risk in Africa -http:// www.mara.org.za/ project resorted to establishing a malaria risk atlas instead of an incidence atlas due to the lack of reliable data for determining the level of malaria incidence and mortality in African countries [81] .
T1 147999-148213 Sentence denotes Spatial data are strategically important to decision makers at all levels and thus should be an indispensable part of the basic infrastructure in the individual country, in line with roads, hospitals, schools, etc.
T2 148214-148343 Sentence denotes By infrastructure we mean the basic structures and facilities necessary for a country or an organisation to function efficiently.
T3 148344-148887 Sentence denotes An infrastructure has the following characteristics: (1) users are aware that "somebody" maintains the infrastructure, but do not regard this maintainer as an owner; (2) users expect it to always be available, even if there is a fee or other requirement for its use; (3) the delivery or provision of the service is largely standardised, and as a result of this, users take it for granted because of the ease of use; and (4) an infrastructure is expensive to develop and maintain, and the returns from the investment are usually long term [6] .
T4 148888-149019 Sentence denotes The vision and concepts behind a spatial information infrastructure are sometimes described in the literature under different hats.
T5 149020-149116 Sentence denotes Back in 1999, the US National Research Council published a document on distributed geolibraries.
T6 149117-149256 Sentence denotes A spatial information infrastructure and a distributed geolibrary share closely related concepts, and face a similar set of problems [98] .
T7 149257-149516 Sentence denotes Distributed geolibraries are modelled on the operations of a traditional library, updated to a digital networked world (e.g., the Web), and focused on the supply of information in response to a geographically defined need (using GIS and related technologies).
T8 149517-149751 Sentence denotes The contents of a distributed geolibrary are not limited to information normally associated with location maps or images of the Earth's surface, but also include any other information that can be associated with a geographic location.
T9 149752-149891 Sentence denotes A geolibrary is distributed if its users, services, metadata, and information assets can be integrated among many distinct locations [98] .
T10 149892-150042 Sentence denotes A distributed geolibrary would support collaborative work, such as multidisciplinary research by teams, and decision-making by groups of stakeholders.
T11 150043-150245 Sentence denotes It should be also possible to access a distributed geolibrary right in the field where information is needed most (especially in emergency management) using portable systems and wireless communications.
T12 150246-150396 Sentence denotes Moreover, specialised sensors may be brought to the field, supplying new data that will have to be integrated with existing data in the library [98] .
T13 150397-150522 Sentence denotes The success of a distributed geolibrary is largely dependent on the ability to integrate information available about a place.
T14 150523-150703 Sentence denotes This in turn depends on finding appropriate solutions to problems of indexing, visualisation, scaling, automated search and abstracting, formats and standards, and data conflation.
T15 150704-150863 Sentence denotes In addition, there are a variety of social and organisational issues, privacy concerns and intellectual property rights that also need to be catered for [98] .
T16 150864-151254 Sentence denotes To demonstrate how important the concept of geolibraries is, reference [98] provides some very realistic example scenarios (see http://www.nap.edu/html/geolibraries/ ch1.html), including one about a public health researcher who wants to analyse the complex associations of environment and disease in a particular urban area, and another one dealing with a chemical spill emergency response.
T17 151255-151425 Sentence denotes Information resources through distributed geolibraries could greatly assist rapid response to such emergencies and longer-term efforts aimed at prevention and mitigation.
T18 151426-151516 Sentence denotes Geo-referenced data form a significant part of the US National Information Infrastructure.
T19 151517-151898 Sentence denotes In 1994, former US President Clinton issued an Executive Order covering: (1) the establishment of an electronic national spatial data clearinghouse; (2) standardisation of metadata; (3) improvement of public access to spatial data; and (4) the requirement of federal agencies to use the clearinghouse to locate existing data before expending tax dollars to collect more data [13] .
T20 151899-152209 Sentence denotes In the same year (1994), the US Federal Geographic Data Committee (FGDC -http://www.fgdc.gov/) defined a National Spatial Data Infrastructure (NSDI) as "the technology, policies, standards, and human resources necessary to acquire, process, store, distribute, and improve utilisation of geospatial data" [99] .
T21 152210-152475 Sentence denotes FGDC, which has lead responsibility for the orderly deployment of the US NSDI, works to coordinate federal activities, in conjunction with state and local government and the private sector, regarding the collection, documentation, and dissemination of spatial data.
T22 152476-152654 Sentence denotes This interagency committee is responsible for coordinating the development of standards and partnerships for data description and exchange throughout the US government [13, 58] .
T23 152655-152807 Sentence denotes Today more than any time before, the US federal government is fully supporting the premise that digital spatial data constitute a federal capital asset.
T24 152808-153063 Sentence denotes The return on spatial investment can be highly cost effective through the onetime development of spatial data, and the subsequent sharing of that data among many users, at all levels of government and all sectors, over time ("build once, use many times").
T25 153064-153318 Sentence denotes One of the most recent NSDI-related US e-government initiatives, Geospatial One-Stop, is intended to revolutionise electronic government by providing a geographic component for use in all Internet-based government activities across all government levels.
T26 153319-153687 Sentence denotes This will enable immediate discovery and "one-stop" access to spatial metadata and data via a single Internet location/interface for different kinds of analyses and improved decision-making, and will eliminate the redundancies of costs associated with (duplicate efforts of) spatial data collection, conversion between formats, production and dissemination [58, 100] .
T27 153688-154042 Sentence denotes To achieve its vision, the Geospatial One-Stop initiative has launched Geodata.gov http://www.geodata.gov/, a Web-based portal for one-stop access to maps, data and other spatial services that will simplify the ability of all levels of government, private sector, academia and citizens to find spatial data and learn more about spatial projects underway.
T28 154043-154127 Sentence denotes The US health sector is rapidly becoming a responsive and integral part of the NSDI.
T29 154128-154266 Sentence denotes The Department of Health and Human Services (DHHS) is already a member of FGDC, which also has representatives from CDC and NIH [13, 58] .
T30 154267-154601 Sentence denotes Web-enabled public health GIS developments under the umbrella of NSDI are to be guided by OpenGIS Consortium Web interoperability and GML/XML spatial Web content standards, and FGDC-endorsed spatial metadata standards, e.g., the Content Standard for Digital Geospatial Metadata, FGDC-STD-001-1998, approved by FGDC in 1998 [58, 101] .
T31 154602-154858 Sentence denotes However, it is expected that all current national metadata specifications, e.g., the US FGDC-STD-001-1998 and the UK GIgateway Discovery Metadata Specifications (see below), will ultimately converge to ISO 19115/19139 in the near future [102] [103] [104] .
T32 154859-154991 Sentence denotes In the UK observation of the development of the US NSDI led in 1995 to what became the UK National Geospatial Data Framework (NGDF).
T33 154992-155150 Sentence denotes The askGIraffe Data Locator was then launched in July 2000, and has now become superseded by GIgateway http://www.gigateway.org/ moreinformation/history.html.
T34 155151-155234 Sentence denotes GIgateway is an information service providing access to spatial metadata in the UK.
T35 155235-155588 Sentence denotes At the heart of the service is the Data Locator http:// www.gigateway.org.uk/datalocator/default.html - Figure 7) , which is capable of carrying real-time searches across a number of distributed metadata-bases (held at their respective data providers' local sites that have registered with GIgateway), in addition to querying GIgateway's own catalogue.
T36 155589-155686 Sentence denotes A query of the Data Locator using the keyword "health" yielded 426 records (on 26 November 2003).
T37 155687-156041 Sentence denotes However, many of the returned metadata records had incomplete/empty fields, and no instant access over the Internet to the actual datasets they are describing, or to a license agreement/payment form to access these datasets, as one would expect from a comprehensive "onestop" Web-based clearinghouse (e-mail contact details are usually provided instead).
T38 156042-156248 Sentence denotes Moreover, the returned records did not include the latest Census 2001 Key Statistics for health areas in England and Wales http://www.statis tics.gov.uk/census2001/cn_61.asp, which was a notable deficiency.
T39 156249-156491 Sentence denotes GIgateway's metadata creation tool, a JAVAbased application called MetaGenie http://www.gigate way.org.uk/datalocator/metadatatool.html, enables the creation of geographic metadata compliant with GIgateway's Discovery Metadata Specifications.
T40 156492-156616 Sentence denotes MetaGenie will be rewritten to be fully compliant with the new international standards, ISO 19115/19139, in the near future.
T41 156617-156814 Sentence denotes GIgateway is funded by the UK Government and run by the UK Association for Geographic Information -AGI (Judith Jerome, GIgateway Information Services Manager, personal communication -October 2003).
T42 156815-157005 Sentence denotes The equivalent of the US FGDC NSDI in Europe is INSPIRE, the INfrastructure for SPatial InfoRmation in Europe, a recent initiative launched by the European Commission http://inspire.jrc.it/.
T43 157006-157162 Sentence denotes INSPIRE intends to trigger the creation of a European Spatial Data Infrastructure (ESDI) that delivers to the users integrated spatial information services.
T44 157163-157313 Sentence denotes INSPIRE is founded on the following principles: (1) data should be collected once and maintained at the level where this can be done most effectively;
T45 157314-157873 Sentence denotes (2) it must be possible to combine seamlessly spatial data from different sources across the EU and share it between many users and applications; (3) it must be possible for spatial data collected at one level of government to be shared between all levels of government; (4) spatial data needed for good governance should be available on conditions that are not restricting its extensive use; and (5) it should be easy to discover which spatial data are available, to evaluate their fitness for purpose and to know which conditions apply for their use [105] .
T46 157874-157969 Sentence denotes A common infrastructure for spatial information in Europe can only be realised in the long run.
T47 157970-158044 Sentence denotes Therefore, an extensible, step-by-step approach is being developed [105] .
T48 158045-158218 Sentence denotes It is noteworthy that the US NSDI development activities, which started nearly ten years ago, are not yet complete with some serious gaps still needing to be addressed [5] .
T49 158219-158380 Sentence denotes Figure 7 Screenshot of GIgateway Data Locator search form Screenshot of GIgateway Data Locator search form http:// www.gigateway.org.uk/datalocator/default.html.
T50 158381-158529 Sentence denotes GIgateway Data Locator is intended to help users find and use up-to-date and accurate geographic information on their area, from a range of sources.
T51 158530-158625 Sentence denotes It features six search methods that can be used any combination to retrieve the results needed.
T52 158626-158740 Sentence denotes One of these methods (6 -not shown) allows users to visually select a location using an interactive map of the UK.
T53 158741-159016 Sentence denotes These include the Canadian Geospatial Data Infrastructure (CGDI -http://www.geoconnections.org/CGDI.cfm/ fuseaction/home.welcome/gcs.cfm) and the Australian Spatial Data Infrastructure (ASDI -http://www.ga.gov.au/ nmd/asdi/ and http://www.anzlic.org.au/infrastruc ture.html).
T54 159017-159167 Sentence denotes The Australian Spatial Data Directory (ASDD -http://www.ga.gov.au/asdd/) provides search interfaces to discover spatial metadata throughout Australia.
T55 159168-159369 Sentence denotes On a global scale, a Global Spatial Data Infrastructure (GSDI -http://www.gsdi.org/) is being advanced through the leadership of many nations and organisations represented by a GSDI Steering Committee.
T56 159370-159516 Sentence denotes This multinational Steering Committee includes representatives from all continents, and all sectors -government, academia, and the private sector.
T57 159517-159627 Sentence denotes GSDI Web site provides the following definition: "GSDI supports ready global access to geographic information.
T58 159628-159975 Sentence denotes This is achieved through the coordinated actions of nations and organisations that promote awareness and implementation of complementary policies, common standards and effective mechanisms for the development and availability of interoperable digital geographic data and technologies to support decision making at all scales for multiple purposes.
T59 159976-160420 Sentence denotes These actions encompass the policies, organisational remits, data, technologies, standards, delivery mechanisms, and financial and human resources necessary to ensure that those working at the global and regional scale are not impeded in meeting their objectives." [106] A GSDI brochure published in 2002 stresses that SDIs provide a basis for spatial data discovery, evaluation, and application, and mentions the following SDI elements [107] :
T60 160421-160500 Sentence denotes (1) Geographic data: the actual digital geographic data and information [107] .
T61 160501-160601 Sentence denotes (2) Metadata: the data describing the data (content, quality, condition, and other characteristics).
T62 160602-160781 Sentence denotes They permit structured searches and comparison of data in different clearinghouses and give the user adequate information to find data and use it in an appropriate context [107] .
T63 160782-160872 Sentence denotes (3) Framework: includes base layers, which will probably differ from location to location.
T64 160873-161082 Sentence denotes It also includes mechanisms for identifying, describing, and sharing the data using features, attributes, and attribute values, as well as mechanisms for updating the data without complete recollection [107] .
T65 161083-161144 Sentence denotes (4) Services: to help discover and interact with data [107] .
T66 161145-161192 Sentence denotes (5) Clearinghouse: to actually obtain the data.
T67 161193-161371 Sentence denotes Clearinghouses support uniform, distributed search through a single user interface; they allow the user to obtain data directly, or they direct the user to another source [107] .
T68 161372-161504 Sentence denotes (6) Standards: created and accepted at local, national, and global levels [107] . (7) Partnerships: the glue that holds it together.
T69 161505-161624 Sentence denotes Partnerships reduce duplication and cost of collection and leverage local/national/global technology and skills [107] .
T70 161625-161871 Sentence denotes A free how-to book, "Developing Spatial Data Infrastructures: the SDI Cookbook", is also available for downloading from GSDI Web site in several languages; the English version is available from http://www.gsdi.org/pubs/cook book/cookbook0515.pdf.
T71 161872-162024 Sentence denotes The Cookbook gives geographic information providers and users the necessary background information to evaluate and implement existing components of SDI.
T72 162025-162211 Sentence denotes It includes recommended existing and emerging standards and specifications, as well as business case examples of best practice. (See also http:// www.gsdi.org/docs1997/97_ggdiwp2b.html.)
T73 162212-162470 Sentence denotes The vision and services presented in this section involve SDI-like structures and arrangements or rely on early "small-scale" SDI implementations, and would certainly benefit from the presence of mature SDIs covering the regions where these services operate.
T74 162471-162769 Sentence denotes The US CDC define public health surveillance as "the ongoing systematic collection, analysis, and interpretation of health data essential to planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know.
T75 162770-162870 Sentence denotes The final link in the surveillance chain is the application of these data to prevention and control.
T76 162871-163015 Sentence denotes A surveillance system includes a functional capacity for data collection, analysis, and dissemination linked to public health programmes." [108]
T77 163016-163131 Sentence denotes The systematic collection, analysis, and dissemination of health information are critical aspects of public health.
T78 163132-163187 Sentence denotes Surveillance is the problem-finding/monitoring process.
T79 163188-163280 Sentence denotes This should ideally be linked to public health action, which is the problem-solving process.
T80 163281-163565 Sentence denotes Traditionally, surveillance was used for acute infectious diseases, but over the past decades there has been a significant expansion of surveillance into new areas of public health concern including injuries, environmental health, occupational safety and health, and chronic diseases.
T81 163566-163830 Sentence denotes One of the main problems of conventional public health disease surveillance, which relies on physician and laboratory reporting and manual off-line analysis of surveillance data, is that it is ill equipped for the timely detection of bioterrorist attacks [2, 55] .
T82 163831-164040 Sentence denotes It is unlikely that without an event or alert to raise his or her index of suspicion, a physician will attribute the early symptoms and signs of disease in a bioattack victim appropriately and report the case.
T83 164041-164309 Sentence denotes A key limitation of the current system is that the lone physician is blind to the cases his or her colleagues in a nearby hospital are seeing -knowledge that might lead the physician to consider uncommon diseases more strongly in his or her diagnostic reasoning [55] .
T84 164310-164619 Sentence denotes In fact, without a continuous (in real or near real time) and comprehensive health monitoring system covering a wide geographical scope, the public health community will never have much advanced warning of bioterrorist attacks to be able to abort them at an early stage, and limit their negative effects [2] .
T85 164620-164828 Sentence denotes The question remains, if we build such systems (some early examples already existsee below), what data should we monitor in real or near real time in order to be able to identify a covert bioterrorist attack.
T86 164829-164993 Sentence denotes Syndromic surveillance methods that can detect disease at an earlier stage are increasingly becoming an important research direction for public health surveillance.
T87 164994-165267 Sentence denotes Because the data used by syndromic surveillance systems cannot be used to establish a specific diagnosis in any particular individual, syndromic surveillance systems must be designed to detect signature patterns of disease in a population to achieve sufficient specificity.
T88 165268-165683 Sentence denotes For example, it would be irrational to use only the symptom of fever to attempt to establish a working diagnosis of inhalational anthrax in an individual, but it would be very sensible to consider anthrax release in a community if we were to observe a pattern of 1,000 individuals with fever distributed in a linear streak across an urban region consistent with the prevailing wind direction two days earlier [55] .
T89 165684-165957 Sentence denotes A recent review paper by Mandl et al provides a comprehensive review of syndromic surveillance systems, and is intended to serve as a guide for informaticians, public health managers, and practitioners who are currently planning deployment of such systems in their regions.
T90 165958-166154 Sentence denotes The paper also includes detailed discussions of the different outbreak detection methods that work with temporal and spatial data, as well as the metrics for measuring surveillance system quality.
T91 166155-166379 Sentence denotes An interesting point raised by Mandl and his colleagues is the need for truly unique person identifier, so that individuals are not double-counted as they move between healthcare institutions (sometimes during the same day).
T92 166380-166682 Sentence denotes Mandl et al also suggest using data already collected for other purposes whenever this is possible, since implementing new data collection processes can have prohibitive costs, and healthcare workers have repeatedly demonstrated poor compliance with additional data collection and administrative tasks.
T93 166683-167125 Sentence denotes They also recommend designing "dual use" systems and not only focusing on the detection of bioterrorism or very rare outbreaks in order to boost the sustainability and long-term funding viability of such systems [109] . (See also the pages titled "Syndromic Surveillance: an Applied Approach to Outbreak Detection" and published by the CDC's Division of Public Health Surveillance and Informatics -http://www.cdc.gov/epo/dphsi/syndromic.htm.)
T94 167126-167463 Sentence denotes The dream now is to develop a universal multivariate surveillance system that can collect, analyse and interpret health-related information worldwide using modern information infrastructures for the global prevention of a wide range of health problems, or at least the early detection of such problems in order to mitigate their effects.
T95 167464-167686 Sentence denotes GIS technologies and services that can function proactively in real time are extremely and critically important to realise this global public health surveillance vision (and indeed any smaller-scale surveillance services).
T96 167687-167864 Sentence denotes Such surveillance services also require a sound and comprehensive spatial health information infrastructure to be built and maintained in a coherent way at all operation levels.
T97 167865-167994 Sentence denotes Much of the information that underpins emergency preparedness, response, recovery, and mitigation is geospatial in nature [110] .
T98 167995-168573 Sentence denotes According to FGDC, "without the real-time ability to quickly visualise activity patterns, map locations, and understand the multi-layered geospatial context of emergency situations, US homeland security will not be achieved." (The same principle also applies to other countries.) Geographic information technologies, combined with appropriate sets of timely, accurate and shareable geospatial information, provide an invaluable tool for the prevention of, protection against, timely detection of, preparedness, response to, and recovery from natural and man-made disasters [5] .
T99 168574-168651 Sentence denotes These issues have now become more important after the September 2001 attacks.
T100 168652-168833 Sentence denotes Freier describes an organisational structure for emergency management operations using GIS based on the FEMA's approach (US Federal Emergency Management Agencyhttp://www.fema.org/).
T101 168834-168919 Sentence denotes This approach recognises four stages: planning, preparedness, response, and recovery.
T102 168920-169165 Sentence denotes Although Freier's paper is about using GIS to manage animal disease outbreaks and is thus primarily targeting animal health professionals, the GIS emergency management operations and methods it describes also apply largely to human health [11] .
T103 169166-169282 Sentence denotes FEMA's Mapping and Analysis Centre (MAC) runs an integrated, state-of-the-art enterprise GIS (E-GIS) for the Agency.
T104 169283-169561 Sentence denotes A GIS-based Consequence Assessment Tool Set (CATS), developed by SAIC (Science Applications International Corporation -http://cats.saic.com/ for FEMA and US Defense Threat Reduction Agency (DTRA), provides a powerful disaster prediction, analysis, planning, and response system.
T105 169562-169914 Sentence denotes MAC maintains an extensive array of datasets (more than 150 databases/map layers in CATS alone) to ensure their ability to provide their customers (federal and government agencies) with the information they need in the form of GIS maps, tables, and analyses for planning, preparedness, response, and mitigation in relation to disasters and emergencies.
T106 169915-170146 Sentence denotes MAC can produce GIS maps from important prediction model outputs, e.g., a hurricane wind model, a toxic plume model or an earthquake model, coupled with real-time data to provide estimates for projected damages in affected regions.
T107 170147-170326 Sentence denotes It can also generate maps from damage assessment data after a disaster has occurred to visualise actual damages by analysing collected aerial reconnaissance and ground truth data.
T108 170327-170693 Sentence denotes This can help emergency managers appreciate the spatial extent of damage, learn who was affected by the disaster and which resources were affected, and make timely, informed decision accordingly (e.g., a plume model can help determine those areas requiring evacuation; early informed interventions almost always result in mitigation of disaster effects) [111, 112] .
T109 170694-170941 Sentence denotes Johnson and Johnson provide a good, easy-to-read general introduction to GIS application areas, advantages and methods in public health and healthcare, with some emphasis on GIS uses in epidemiological surveillance and epidemics management [113] .
T110 170942-171296 Sentence denotes The WHO has developed a comprehensive Event Management System to manage critical information about outbreaks and to ensure accurate and timely communications between key international public health professionals, including WHO Regional Offices, Country Offices, collaborating centres and partners in the Global Outbreak Alert and Response Network [114] .
T111 171297-171534 Sentence denotes During outbreak response, the WHO uses a custom-made geographic mapping technology, which forms part of its existing system for outbreak alert and response, to assist in the location of cases and rapid analysis of an epidemic's dynamics.
T112 171535-171678 Sentence denotes The WHO also uses this epidemiological mapping technology to predict environmental and climatic conditions conducive for some outbreaks [115] .
T113 171679-171890 Sentence denotes The WHO aims to link the Event Management System to its Global Atlas of Infectious Diseases http://globalatlas.who.int/globalatlas/ interactivemap/rmm/ for real-time mapping and tracking of new outbreaks [114] .
T114 171891-172196 Sentence denotes Web-based maps allow for real-time or near-real-time map updates based on the latest datasets, for interactivity to be incorporated into the maps (desktop GIS-like functionality, e.g., drill-down and zooming), and for wider and more rapid dissemination of information (compared to other publishing media).
T115 172197-172483 Sentence denotes Some of the best examples of Web-based maps were produced during the latest SARS outbreak, which is considered the first major new infectious disease of the 21 st century and the Internet age that took full advantage of the opportunities for rapid spread along international air routes.
T116 172484-172516 Sentence denotes Kamel Unit 444) , Paris, France.
T117 172517-172935 Sentence denotes The reviewed maps employed a variety of techniques like choropleth rendering, graduated circles, graduated pie charts, buffering, thematic mapping, overlay analysis and animation to allow public health decision makers, travellers and local populations at risk to visually monitor and appreciate at a glance changes, trends and patterns buried in different online SARS datasets that were continuously varying with time.
T118 172936-173066 Sentence denotes Some of the mapping services presented provided very detailed information down to individual street/building level (in Hong Kong).
T119 173067-173304 Sentence denotes This kind of support is vital for improving global vigilance and awareness at all levels, and for making well-informed decisions when designing and following up epidemic control strategies or issuing and updating travel advisories [80] .
T120 173305-173665 Sentence denotes Davenhall defines a community health surveillance system (CHSS) as a network that constantly gathers, integrates, and analyses data on health indicators, occurrences, and transmissions of disease in a population; monitors the capabilities of the health system/level of health protection in that population; and spatially relates all this information using GIS.
T121 173666-173857 Sentence denotes This proactive, geographically based approach can deal more effectively with and provide early warnings of health threats and disease outbreaks, particularly those caused by bio-weapons [2] .
T122 173858-173953 Sentence denotes Davenhall distinguishes between a health surveillance system and a disease surveillance system.
T123 173954-174019 Sentence denotes The former features a lower threshold for action than the latter.
T124 174020-174304 Sentence denotes By the time someone is admitted to an acute care hospital with a communicable disease, that person may have been symptomatic for days or weeks and may have already been seen by healthcare professionals repeatedly, and would have already spread the disease to large numbers of persons.
T125 174305-174505 Sentence denotes For example, smallpox, which begins with a rash that becomes more painful and extensive, is often initially treated with an anti-inflammatory antihistamine drug such as Diphenhydramine HCL (Benadryl).
T126 174506-174601 Sentence denotes When this treatment proves ineffective, laboratory work is ordered and the diagnosis then made.
T127 174602-174765 Sentence denotes From a community health perspective, a spike in the number of prescriptions for Benadryl in one area could be used as an indicator of a possible smallpox outbreak.
T128 174766-174884 Sentence denotes A CHSS should be able to automatically detect such spike and raise an alarm early enough to contain the outbreak [2] .
T129 174885-174937 Sentence denotes CHSS will have a GIS-based incident tracking system.
T130 174938-175078 Sentence denotes Human intervention should not be required until preestablished critical levels -in the number and/or clustering of occurrences -are reached.
T131 175079-175192 Sentence denotes The rule-based CHSS will use data interpretations made by epidemiologists and other public health officials [2] .
T132 175193-175327 Sentence denotes However, the transition from episodic investigation to ongoing monitoring using GIS requires more robust data collection and analysis.
T133 175328-175443 Sentence denotes CHSS relies on a continuous stream of clinical data that are gathered automatically across geographical boundaries.
T134 175444-175695 Sentence denotes CHSS data include clinical data, such as symptoms, diagnostic results, and procedures (all coded using a suitable terminology or classification) and geographic information such as the locations of patients, medical personnel and assets, and outbreaks.
T135 175696-175816 Sentence denotes To be reliable for the purposes of a CHSS, population-based data must also describe relatively small geographical areas.
T136 175817-175989 Sentence denotes Data that reflect the level of "wellness" of a population in a geographic area are necessary to draw inferences about changes in health levels and exposure to disease [2] .
T137 175990-176168 Sentence denotes RODS is a NEDSS-compliant, GIS-enabled (using ESRI ArcIMS 4.0) public health surveillance system for early detection of disease outbreaks, including those caused by bioterrorism.
T138 176169-176310 Sentence denotes Hospitals send RODS data from clinical encounters over virtual private networks and leased lines in real time using the HL7 message protocol.
T139 176311-176568 Sentence denotes RODS automatically classifies the free-text registration chief complaint from the visit into one of seven syndrome categories (constitutional, respiratory, gastrointestinal, neurological, botulinic, rash, haemorrhagic, and other) using Bayesian classifiers.
T140 176569-176865 Sentence denotes It stores the data in a relational database, aggregates the data for analysis using data warehousing techniques, applies univariate and multivariate statistical detection algorithms to the data, and alerts users of when the algorithms identify anomalous patterns in the syndrome counts [49, 55] .
T141 176866-177018 Sentence denotes RODS processes sales of over-the-counter (OTC) healthcare products in a similar manner, but currently receives such data in batch mode on a daily basis.
T142 177019-177196 Sentence denotes It also groups sales data of OTC products into analytic product categories relevant to public health surveillance (e.g., bronchial remedies, diarrhoea remedies, etc.) [55, 56] .
T143 177197-177415 Sentence denotes Real-time (continuous stream) transfer of data is to be preferred to batch transfer of data, as the latter may delay detection of suspicious events by as long as the time interval (periodicity) between batch transfers.
T144 177416-177533 Sentence denotes For example, a surveillance system with daily batch transfer may delay by one day the detection of an outbreak [55] .
T145 177534-177668 Sentence denotes Time intervals as small as hours can make a difference when a large cohort is exposed to rapidly progressing diseases such as anthrax.
T146 177669-177846 Sentence denotes Furthermore, the challenge of merging similar data arriving from multiple sources with different time latencies is now a focus of attention in new surveillance approaches [56] .
T147 177847-177962 Sentence denotes Preliminary studies suggest that sales of OTC healthcare products can be used for the early detection of outbreaks.
T148 177963-178079 Sentence denotes People often engage in self-care with OTC medications such as cough syrups before seeking professional medical care.
T149 178080-178202 Sentence denotes RODS' National Retail Data Monitor (NRDM) receives data daily from 10,000 stores/pharmacies that sell healthcare products.
T150 178203-178391 Sentence denotes These stores belong to national chains that process sales data centrally and utilise Universal Product Bar Codes (UPC codes) and scanners to collect sales information at the cash register.
T151 178392-178566 Sentence denotes The high degree of retail sales data automation enables NRDM to collect information from thousands of store locations in near real time for use in public health surveillance.
T152 178567-178652 Sentence denotes Algorithms monitor the data automatically every day to detect unusual sales patterns.
T153 178653-178808 Sentence denotes The current niche for NRDM is early detection of a mass exposure of a large number of people through air, food, or water contamination (a cohort exposure).
T154 178809-178976 Sentence denotes Soon after such an exposure, the cohort will become symptomatic, and, depending on the symptoms, may begin self-treatment and then either recover or seek medical care.
T155 178977-179110 Sentence denotes If the cohort is large enough, sales of OTC healthcare products will increase significantly above the normal, background sales level.
T156 179111-179320 Sentence denotes The announced longerterm project plans include the expansion of monitoring to the level of selected prescription medications based on another standard coding system that is used in industry data systems [56] .
T157 179321-180444 Sentence denotes Wagner et al cite the following desiderata for systems like RODS' NRDM: (1) collection and analysis of data in as near as real time as possible; (2) completeness of sales data collection (>=70% is considered an adequate figure) for both early detection and sensitivity to smaller outbreaks; (3) availability of precise spatial information like individual store locations, or at least store Zip Codes to support adequate spatial analysis of sales data; (4) collection of supplemental data, e.g., about retailers' promotions or how day of the week affects local sales volumes; (5) a system for maintaining UPC code masters and mappings to analytic categories (as new product codes are assigned); (6) an effective link with the intended users of the system (public health authorities) to effect the desired actions (e.g., order quarantine); and (7) as most large urban population centres cross jurisdictional health boundaries, a centralised national approach is recommended to provide a complete picture of the health of contiguous regions and prevent any redundant data collection for overlapping nearby jurisdictions [56] .
T158 180445-180745 Sentence denotes Being linked to public health authorities and response also allows system developers to learn from prospective experience, to validate their data sources and algorithms in real-world settings, and to improve systems' ability to differentiate true infectious disease clusters from false alarms [109] .
T159 180746-180831 Sentence denotes RODS also has a Web-based user interface that supports temporal and spatial analyses.
T160 180832-180988 Sentence denotes RODS' password-protected, encrypted Web site allows users to review healthcare registration and sales of OTC healthcare products on epidemic plots and maps.
T161 180989-181130 Sentence denotes When a user logs in, RODS will check the user's profile and will display data only for his or her health department's jurisdiction [55, 56] .
T162 181131-181283 Sentence denotes Because populations and market share coverage for sales of OTC healthcare products differ between Zip Codes, plotting raw sales counts is uninformative.
T163 181284-181353 Sentence denotes NRDM maps represent a novel approach to presenting surveillance data.
T164 181354-181588 Sentence denotes They plot for each Zip Code -using the colours green, blue, yellow, orange, and red to indicate increasing levels of concern -how "unusual" sales were for the day in question relative to historical patterns of sales for that Zip Code.
T165 181589-181757 Sentence denotes In particular, the colours represent the number of standard deviations by which the observed sales of a product category in a Zip Code deviate from the expected counts.
T166 181758-181883 Sentence denotes In presenting the data in this fashion, the map serves as a device to focus the user's attention on the degree(s) of anomaly.
T167 181884-182125 Sentence denotes A user can quickly spot whether the map is predominantly green with a scattering of blue Zip Codes as would be expected, or whether there are confluent or linear patterns of blue, yellow, orange, or red indicating "unusual" sales activities.
T168 182126-182337 Sentence denotes The map monitor computes the number of standard deviations relative to a residual signal that has zero mean and constant variation after removal of weekly and longer trends in the data by wavelet transformation.
T169 182338-182538 Sentence denotes This procedure is intended to produce a "normalised" map that is very sensitive to sudden increases in product counts as would be the case in a medium-to large-scale air, food, or water contamination.
T170 182539-182675 Sentence denotes Alternative data transformations are possible using differ-ent signal processing approaches focused on detecting more gradual increases.
T171 182676-182853 Sentence denotes RODS researchers plan in the near future to screen the maps automatically with spatial scan statistics to identify those with anomalies suggesting a need for human review [56] .
T172 182854-182993 Sentence denotes Some of RODS software has been bundled into downloadable ready-to-use packages that are available from http://www.health.pitt.edu/rods/sw/.
T173 182994-183122 Sentence denotes However, deployment of such systems requires skilled network engineers, Oracle database administrators, and interface engineers.
T174 183123-183276 Sentence denotes An application service provider model for RODS (and similar services) seems more suited for those health organisations with no access to that skills set.
T175 183277-183358 Sentence denotes Such organisations can form coalitions to share the costs of such services [55] .
T176 183359-183574 Sentence denotes The relationship between physical environment and health is now accepted as complex, with environment acting not just directly but indirectly and in association with other influences to affect health and well-being.
T177 183575-183698 Sentence denotes Indicators of health-relevant environmental exposures are invariably also indicators of social justice/inequalities [116] .
T178 183699-183944 Sentence denotes The Environmental Health Surveillance System for Scotland (EHS3) is an ongoing project with funding from Scottish Neighbourhood Statistics that aims at providing for Scotland, the evidence base for better decision-making in environmental health.
T179 183945-184163 Sentence denotes EHS3, in its completed form, will be an ongoing multi-agency collaboration involving NHS Board Areas, local authorities, the Scottish Environment Protection Agency (SEPA), Water Authorities and other relevant agencies.
T180 184164-184407 Sentence denotes Its purpose will be to collect, hold and, as appropriate, analyse and interpret temporally and spatially tagged environmental and related health data throughout Scotland (e.g., attempt to correlate environmental exposures and health outcomes).
T181 184408-184516 Sentence denotes EHS3 will also disseminate this data, much of which is currently available but is under-utilised [57, 116] .
T182 184517-184688 Sentence denotes EHS3 developers need to determine what information is currently available to begin with, and also need to address the problems of incomplete health and environmental data.
T183 184689-184814 Sentence denotes EHS3 database will combine information obtained via ad hoc reporting of events, with a systematic active surveillance system.
T184 184815-184946 Sentence denotes It will include environmental parameters like air quality, water quality, radiation, noise, mobile phone masts, and landfill sites.
T185 184947-185204 Sentence denotes EHS3 will also incorporate health information from the SMR (Scottish Morbidity Record) hospital discharge data for a range of ICD 10 coded conditions, e.g., respiratory conditions, cerebrovascular disease, circulatory system disease, and malignant neoplasm.
T186 185205-185321 Sentence denotes Other EHS3 health data sources include CMR (Continuous Morbidity Recording) data, and data from death record fields.
T187 185322-185492 Sentence denotes The database thus created will be used to derive spatio-temporal trends in health and environmental exposure, which will be presented in tabular and geographical formats.
T188 185493-185737 Sentence denotes In conformity with surveillance principles, data gathering will be ongoing and regular outputs will be agreed which will inform policy and action (as an evidential basis for action) to promote improved environmental standards and public health.
T189 185738-185933 Sentence denotes With appropriate development, the system will also have potential as a predictive tool for managing environmentally occasioned (including weather-related) fluctuations in demand for NHS services.
T190 185934-186117 Sentence denotes A further important characteristic of EHS3 will be its dynamic character with an ability to change emphasis and enhance outputs in response to circumstances as they emerge [57, 116] .
T191 186118-186270 Sentence denotes Another environmental project, the London Air Quality Network (LAQN), was launched in 1993 to coordinate and improve air pollution monitoring in London.
T192 186271-186351 Sentence denotes By the end of 1999, twenty-nine London Boroughs were supplying data to the LAQN.
T193 186352-186539 Sentence denotes Increasingly, these data are being supplemented by measurements from local authorities surrounding London, thereby providing an overall perspective of air pollution in South East England.
T194 186540-186703 Sentence denotes The data are used to generate the daily updated London urban air pollution maps, which are published on LAQN Web site http://www.erg.kcl.ac.uk/london/asp/home.asp.
T195 186704-186927 Sentence denotes The core LAQN activities are funded, operated and managed by the Environmental Research Group (ERG) at King's College London, with support and funds from the Department of Environment, Food and Rural Affairs (DEFRA) [117] .
T196 186928-187109 Sentence denotes For all environmental health projects like those presented above, the importance of data quality, currency, completeness and fitness to the purpose at hand cannot be overemphasised.
T197 187110-187416 Sentence denotes Accurate and statistically representative locational information along with standardised quality-controlled measurements of environmental exposures, over time, are essential if one is to perform robust spatial statistical analyses of suspected associations between the environment and human diseases [13] .
T198 187417-187556 Sentence denotes GIS offer a very rich toolbox of methods and technologies that goes far beyond the mere production of simple maps (or digital cartography).
T199 187557-187702 Sentence denotes From a community health perspective, GIS could potentially act as powerful evidence-based practice tools for early problem detection and solving.
T200 187703-188103 Sentence denotes When properly used, GIS can: inform and educate (professionals and the public); empower decision-making at all levels; help in planning and tweaking clinically and cost-effective actions, in predicting outcomes before making any financial commitments and ascribing priorities in a climate of finite resources; change practices; and continually monitor and analyse changes, as well as sentinel events.
T201 188104-188415 Sentence denotes However, although multiple novel spatial statistical and GIS methods are potentially available, we still need to unambiguously determine which method(s) specifically should be used by practitioners for each specific health condition of interest, and whether the proposed methods are cost-effective and scalable.
T202 188416-188536 Sentence denotes A critical review is needed of the evidence for GIS for specific preventable, mitigable and treatable health conditions.
T203 188537-188649 Sentence denotes A good starting point may be the CDC "Guide to Community Preventive Services" http://www.thecommunityguide.org/.
T204 188650-189301 Sentence denotes Topics identified in this guide (e.g., alcohol abuse, cancer, diabetes, mental health, motor vehicle occupant injury, oral health, physical activity, sexual behaviour, social environment, tobacco product use, vaccine preventable diseases, violence) could be addressed one by one by conducting a focused review of GIS literature on each topic, and then categorising the "nature of the scientific evidence" documenting whether GIS add any value to our understanding and management of the reviewed topic and/or the evidence that it would be feasible and cost-effective for the respective public health programmes tackling the reviewed topic to adopt GIS.
T205 189302-189415 Sentence denotes This could inform the development of successful GIS business plans for the health conditions under consideration.
T206 189416-189633 Sentence denotes A good example that comes to mind in this context is the 73-page "GIS for cancer" handbook titled "Using Geographic Information Systems Technology in the Collection, Analysis, and Presentation of Cancer Registry Data:
T207 189634-189979 Sentence denotes A Handbook of Basic Practices" that was published by the North American Association of Central Cancer Registries [118] . (However, as is the case with any country-specific GIS research and publications, care should be exercised when extending findings and recommendations to other countries with different health and healthcare system settings.)
T208 189980-190350 Sentence denotes In reviewing GIS literature for the above mentioned purposes, this author appreciates the fact that the set of definitions and criteria for reviewing evidence as used in the CDC Community Guide is not directly usable for reviewing currently available GIS literature due to the nature of the latter; a modified set of definitions and criteria first needs to be developed.
T209 190351-190766 Sentence denotes Also organising focus groups that bring together programme administrators, practitioners and the public is required to complement the expected gaps and deficiencies in current GIS literature, and to define the key questions that decision makers would want to be able to answer with GIS for any health condition under review, and think explicitly about what data and methods should be used to answer those questions.
T210 190767-191047 Sentence denotes Traditionally, two broad types of GIS applications can be distinguished which also reflect the two traditions in health geography (geography of disease and geography of healthcare systems), namely health outcomes and epidemiology applications and healthcare delivery applications.
T211 191048-191168 Sentence denotes The use of GIS for improving hospital bed availability is among the most notable applications under the latter category.
T212 191169-191354 Sentence denotes There are also studies at the interface (overlap) between epidemiological and healthcare delivery applications, for example in relation to healthcare commissioning and needs assessment.
T213 191355-191543 Sentence denotes However, despite all these potentials for GIS, they remain very much under-utilised in the UK NHS in mostly lowlevel, non-strategic tasks and in a largely fragmented and uncoordinated way.
T214 191544-191713 Sentence denotes Spatial data and GIS are still not mentioned in any main UK health information strategy or policy document (the US seems to be somewhat ahead of the UK in this respect).
T215 191714-191933 Sentence denotes Table 1 summarises the main factors hindering the wider use of GIS within NHS organisations, and precluding adequate spatial data exchange and collaboration between the NHS and other organisations and local authorities.
T216 191934-192043 Sentence denotes Researchers have come to the conclusion that more networking is needed of people, skills, expertise and data.
T217 192044-192367 Sentence denotes This can be achieved by establishing networks of GIS users from both the NHS and local authorities at local and higher levels to encourage more joined-up working, share expertise and experiences, as well as establish contacts and trust, and raise the awareness of the types of data that are held by different organisations.
T218 192368-192485 Sentence denotes A dedicated Web site acting as forum or virtual network on the Web is one way to realise these networks of GIS users.
T219 192486-192705 Sentence denotes However, this author thinks that a common coherent UK initiative is urgently needed to build a comprehensive national, multi-agency spatio-temporal health information infrastructure functioning proactively in real time.
T220 192706-192882 Sentence denotes The NHS should start by carefully defining the purpose(s) of a nation-wide, coherent GIS implementation across its organisations, and by developing a clear "GIS business plan".
T221 192883-193028 Sentence denotes For each health condition amenable to GIS processing within the NHS, the desired information output and ways of using it must be also determined.
T222 193029-193210 Sentence denotes Tomlison's methodology is targeted at people who have been charged with launching or implementing GIS for their organisation, and is thus strongly recommended in this regard [119] .
T223 193211-193308 Sentence denotes Perhaps the NHS should also take a closer look at the three sets of standards published by the US
T224 193310-193526 Sentence denotes • Work-time constraints, and insufficient staff and financial resources to implement systems fully and to undertake data exchange duties with other organisations • Lack of skills and insufficient training or guidance
T225 193527-194012 Sentence denotes • Lack of digital data in appropriate formats • Problems ensuring data quality • Data confidentiality issues and the currently ambiguous criteria to conform to data confidentiality requirements • Lack of a service-level agreement with Ordnance Survey (or other providers) for NHS organisations to be able to access base digital data • Organisations not being aware of data held by other organisations (lack of a comprehensive and up-to-date central metadata catalogue or clearinghouse)
T226 194013-194378 Sentence denotes • Limited awareness of the benefits of geo-information and joined-up working arrangements • Lack of demand from within some organisations to the use of GIS (directors not being aware of value of GIS rather than not being committed to GIS) • Lack of a clear GIS strategy and of a clear organisational policy for exchanging data series http://www.dartmouthatlas.org/.
T227 194379-194751 Sentence denotes The PCSA database contains nationwide data of interest to US health policymakers at all jurisdictional levels as well as researchers about US primary healthcare resources, populations, utilisation, and associated outcomes compiled and presented in newly developed units of analysis, the Primary Care Service Areas (PCSAs), and related to other geopolitical regions [123] .
T228 194752-194862 Sentence denotes Our experience with the health and healthcare applications of GIS has markedly increased over the last decade.
T229 194863-195174 Sentence denotes However, GIS have been usually applied to time-limited, single, isolated aetiological research or surveillance issues processing mainly retrospective data rather than to ongoing, broad efforts and wide-scale applications processing real-time or near-real-time data for health planning, promotion and protection.
T230 195175-195281 Sentence denotes Moreover, in the early 1990s much attention was focused on GIS as a basis for spatial information systems.
T231 195282-195508 Sentence denotes But soon it became clear that the pure technical approach had to be replaced by a more holistic approach comprising organisational, political and technical matters at the different local, national, regional, and global levels.
T232 195509-195577 Sentence denotes The concept of "Spatial Data Infrastructure" (SDI) became a reality.
T233 195578-195679 Sentence denotes SDI principles originated in two US National Research Council reports in the early 1990s [124, 125] .
T234 195680-195810 Sentence denotes SDIs first developed outside the health sector, and then belatedly health began to discover their importance in many applications.
T235 195811-196015 Sentence denotes SDIs contain the people and institutions that make, maintain, and make accessible, the foundation data layers that permit the custodians of other data layers to attach their data to the foundation layers.
T236 196016-196229 Sentence denotes It must be stressed that the contents of a national health spatial data infrastructure are not just any georeferenced health data but, in addition, the foundation spatial data to which health data can be attached.
T237 196230-196433 Sentence denotes The foundation layers for a health spatial data and information infrastructure are best exemplified in the US by PCSAs and Hospital Service Area data layers provided by the Dartmouth Project (see above).
T238 196434-196821 Sentence denotes In a personal e-mail communication with Professor Gerard Rushton, he argues PCSAs and Hospital Service Area data layers are spatial data foundation layers because other US health data often collected and maintained locally, are more valuable after they have been linked to these layers (Gerard Rushton, Department of Geography, University of Iowa, personal communication -December 2003).
T239 196822-197013 Sentence denotes In a workshop paper presented in 2001, Professor David Rhind counts about 40 countries developing their national SDIs and highlights the problems that have been faced and the lessons learned.
T240 197014-197243 Sentence denotes The latter include ensuring the involvement of the private sector as a central SDI player from the outset, having a realistic vision, securing political leadership and support, and coordinating between the many SDI players [126].
T241 197244-197556 Sentence denotes Table 2 presents a summary of the recipes and main recommendations provided by various specialist groups and researchers from around the world for a successful implementation of a national/regional/global spatial data and information infrastructure that can also support real-time GIS public health applications.
T242 197557-197774 Sentence denotes Raising awareness activities and campaigns are much needed and should put strong emphasis on real-world, practical GIS scenarios and examples to reach out to policy and strategy makers in the health and other sectors.
T1 197775-197846 Sentence denotes Training is also one of the most important elements listed in Table 2 .
T2 197847-197954 Sentence denotes Training should cover epidemiological methods to ensure appropriate use of GIS technology in public health.
T3 197955-198241 Sentence denotes Public health professional specialties/bodies need to recognise continuing education credit for individuals who participate in GIS software training (perhaps the recently established NHSU, the corporate university for the NHS -http://www.nhsu.nhs.uk/, could play a role in this regard).
T4 198242-198499 Sentence denotes Some excellent Web-based training material and courses are already available free of charge, but there is still an urgent need for many more training modules to be developed and most importantly to be thoughtfully and coherently integrated in sensible ways.
T5 198500-198753 Sentence denotes Existing material includes Rushton It is not uncommon for GIS research to include very practical and useful gems, but these often remain confined to the closed circles of researchers and hidden from the larger communities of GIS professionals and users.
T6 198754-198983 Sentence denotes A good example of such gems that should be exposed and disseminated are Boscoe and Pickle's recently published guidelines for choosing geographic units for choropleth rate maps in the context of public health applications [127] .
T7 198984-199114 Sentence denotes The best, current evidence derived from GIS research should be always embedded (and regularly updated) in all training programmes.
T8 199115-199212 Sentence denotes This is one important way of linking the academia and research communities to realworld practice.
T9 199213-199222 Sentence denotes Table 2 :
T10 199223-199329 Sentence denotes Requirements for a successful implementation of a national/regional/global geo-information infrastructure.
T11 199330-199610 Sentence denotes Summary of the recipes and main recommendations provided by various specialist groups and researchers from around the world for a successful implementation of a national/regional/global geo-information infrastructure that can also support real-time GIS public health applications.
T12 199611-200217 Sentence denotes Developing geospatial culture and awareness/changing people and organisations • Vision and leadership at the highest levels (e.g., departments of health) • Official/governmental support • Fostering a culture of data sharing and joined-up working at all levels (local to global) that considers spatial information an asset • Raising awareness activities and campaigns; reaching out to policy and strategy makers in the health and other sectors • Policies and practices actively promoting the exchange and reuse of geo-information, and greater public access to it • Education, training, and capacity building
T13 200218-200634 Sentence denotes • Appropriate human, financial and technical resources • Providing support to organisations lacking the necessary resources to join in common, coherent national/regional/global initiatives • Adequate information telecommunications technology infrastructures and bandwidth • Moving to the Web and building all necessary critical connectivity/geospatial infrastructure that should not be independently recreated by all
T14 200635-200918 Sentence denotes • Developing unambiguous legal frameworks and policies, as well as suitable technical solutions to address the crucial issues of individual privacy, national security, and data confidentiality • Adequate protection measures of networked geo-information assets against cyber terrorism
T15 200919-201359 Sentence denotes • Up-to-date and accurate core digital geo-datasets • National data utilities/services (industry standard services that are independent of any particular user interface) • Standardised metadata in centralised catalogues or clearinghouses • Adopting common standards to address integration and interoperability issues (GML and other technologies; health-related standards) • Automated geocoding • Automated conflation of geospatial databases
T16 201360-202374 Sentence denotes • Do not just focus on data; develop applications • Adopting common semantics, data models (ontologies) and health indicators; the latter should also cover population demographics and socio-economic factors • A deep understanding of data and industry; reaching a consensus on the inputs and outputs in different health and healthcare applications • Developing increased sensitivity to and awareness of data problems and errors, as well as competency in techniques for recognising and reducing their negative impact on conclusions drawn from spatial analysis • Appropriate and robust statistical and epidemiological methods must be used to avoid the consequences of visual bias and various data problems in GIS processes • Seamless integration into routine workflows of intelligent software tools that are easy-to-use by mainstream public health practitioners, and which allow only valid visualisations and analyses of data from a variety of sources across space and time • User interface accessibility requirements
T17 202375-202966 Sentence denotes • Development of effective partnerships (including community/academia collaboration), and involvement of and coordination between all stakeholders and users • Community data sharing must be systematic, uniform and regular, and governed by adequate data-sharing agreements • Building interdisciplinary teams with expertise in public health and epidemiology, medical informatics, medical statistics, health economics, computer science, law, and engineering • Other important points: joint ownership of projects by their respective stakeholders; shared commitment; having realistic expectations
T18 202967-203514 Sentence denotes • A combined top-down and bottom-up incremental implementation approach • Assessing current state of geospatial readiness to respond to normal and emergency community health needs, and identifying beacon sites as examples to follow • Fault tolerance at all levels (hardware and software) • Full systems redundancy, and standardised database replication measures and off-site backups (these are also important aspects of data security) Sufficient financial resources must be available to invest in training people and retaining technical expertise.
T19 203515-203674 Sentence denotes Adequate investments must be also made in technologies for digital data management and storage, and in improving communications and networking infrastructures.
T20 203675-203915 Sentence denotes Reliable intranet and Internet environments with adequate bandwidth can support a physical and virtual "situation room" for both emergency and day-to-day management of operations for safeguarding the environment and protecting human health.
T21 203916-203998 Sentence denotes The tricky issues of data security and confidentiality must be properly addressed.
T22 203999-204123 Sentence denotes Today, solutions exist that can preserve data confidentiality while still enabling fine-level analyses and reliable results.
T23 204124-204928 Sentence denotes These solutions involve: (1) the use of statistical and epidemiological methods to mask the geographic location of data in a way that can still permit meaningful analysis, e.g., special types of spatial and temporal aggregation of data; (2) the development and use of software agents and health system resident components that can process an analysis request and return a result to the data user without exposing any individual-level health data; (3) the creation of secure networked environments with limited and multiple levels of access (to confidential data) in which public health researchers can be carefully monitored to ensure protection of individual and household confidentiality; and (4) the development, publication and strict enforcement of appropriate, unambiguous policies and regulations.
T24 204929-205225 Sentence denotes Best standards, specifications, rules, designs, and practices (covering spatial metadata, geocoding, accessibility for visually and manually impaired data users, and data access restrictions among other things) must be created/ agreed upon and published for uniform Internet-enabled GIS services.
T25 205226-205479 Sentence denotes All relevant infrastructure and systems stakeholders should be involved in the development of appropriate data models (or ontologies) for their various applications to facilitate data selection and integration, and ensure a common understanding of data.
T26 205480-205658 Sentence denotes This author also predicts even more exciting developments in the coming months and years with the rapid advances in geospatial Semantic Web research and technologies [128, 129] .
T27 205659-206068 Sentence denotes Data/analysis problems and errors are not uncommon and include scale issues, the "small numbers" problem, issues of the atomistic and ecologic fallacies, changing activity spaces of mapped subjects, and the frequent variations between different locations in data collection methods and standards, in the recorded items, particularly data on patient residence, and in diagnostic standards and case definitions.
T28 206069-206310 Sentence denotes Users must develop increased sensitivity to and awareness of the various types of data errors and uncertainty, as well as competency in techniques for recognising and reducing their negative impact on conclusions drawn from spatial analysis.
T29 206311-206696 Sentence denotes There is also a need for intelligent tools specifically designed for public health, and seamlessly weaved into everyday public health workflows and decision-making processes to enable users to focus and spend the larger part of their work time on what they want to achieve rather than on learning and overcoming the limitations of tools they are supposed to use to achieve their goals.
T30 206697-206847 Sentence denotes The tools must be able to convey meaningful, bottom-line conclusions that can support the decision maker rather than just outputting bunches of facts.
T31 206848-207026 Sentence denotes The ideal tools also need to be fault-tolerant and capable of analysing and presenting assembled data in ways that facilitate only appropriate interpretations of integrated data.
T32 207027-207343 Sentence denotes This can be achieved by using some form of user friendly, "intelligent", goal-oriented health GIS wizards (based on robust statistical and epidemiological methods where appropriate), so that only valid results and maps are produced, even when users attempt to select inappropriate settings for a particular analysis.
T33 207344-207603 Sentence denotes The tools are also best designed and built to work in modular and nested fashions, so that they may be reused, linked and combined in different ways as needed to serve different scenarios and compound situations with little or no modifications (of the tools).
T34 207604-207810 Sentence denotes Along similar lines, Professor Stan Openshaw thinks that GIS need to adopt and link to technologies that go beyond data collection, management and ownership, standards, simple mapping, and trivial analysis.
T35 207811-207978 Sentence denotes According to Openshaw, the ideal spatial analysis methods should be safe and user friendly for use by people with no higher degrees in statistical or spatial sciences.
T36 207979-208189 Sentence denotes The methods should also respond to user needs on the ground, be highly automated, explicitly handle spatial data imprecision, and produce self-evident results that can be mapped and communicated to non-experts.
T37 208190-208329 Sentence denotes Openshaw's proposed typology of methods includes among others "pattern spotters and testers" and "relationship seekers and provers" [130] .
T38 208330-208384 Sentence denotes Community data sharing must be systematic and regular.
T39 208385-208569 Sentence denotes Data-sharing agreements are needed that address confidentiality and other concerns, allow redistribution of data to any public health authority, and permit data to be used in research.
T40 208570-208808 Sentence denotes Data have to be collected uniformly and include specifications for update frequency and allowed dissemination in different emergency and non-emergency situations, and for purposes other than those for which they were originally collected.
T41 208809-208922 Sentence denotes It is recommended that a combined top-down and bottom-up incremental (phased) implementation approach be adopted.
T42 208923-209043 Sentence denotes Longerterm solutions usually require a series of small successes, carefully built upon in incremental fashion over time.
T43 209044-209391 Sentence denotes In fact, much of the wider vision of a national/regional/global public health spatial data and information infrastructure can be gradually and incrementally achieved through disparately funded and managed short-term projects, as long as we can ensure that these short-term projects make a useful and lasting contribution towards this wider vision.
T44 209392-209525 Sentence denotes Short-term bottom-up projects can feed valuable experience into the formulation and revision of the relevant policies and strategies.
T45 209526-209735 Sentence denotes Moreover, by creating "proof of concept and benefits applications", these projects can be also used to gain and continue political support for the wider vision, and secure further funding towards achieving it.
T46 209736-210240 Sentence denotes We also quickly reviewed existing SDIs and SDI initiatives at different levels of development worldwide, including the US National Spatial Data Infrastructure (NSDI) and the related Geospatial One-Stop initiative with its Webbased service, Geodata.gov; the UK GIgateway; INSPIRE, the INfrastructure for SPatial InfoRmation in Europe, which intends to trigger the creation of a European Spatial Data Infrastructure (ESDI); other national SDIs; and the Global Spatial Data Infrastructure (GSDI) activities.
T47 210241-210369 Sentence denotes Finally, we discussed public health surveillance and syndromic surveillance methods (especially in the context of bioterrorism).
T48 210370-210678 Sentence denotes We reviewed the use of real-time/near-realtime GIS for emergency and epidemics management, with examples from the 2003 SARS outbreak, and somewhat detailed reviews of the Real-time Outbreak and Disease Surveillance system (RODS) from the US and two largescale environmental surveillance projects from the UK.
T49 210679-210838 Sentence denotes Such applications currently involve limited SDI-like arrangements, and would certainly benefit from the development of mature SDIs in their respective regions.
T50 210839-211177 Sentence denotes The dream remains to develop a universal multivariate surveillance system that can collect, analyse and interpret health-related information worldwide using modern information infrastructures for the global prevention of a wide range of health problems, or at least the early detection of such problems in order to mitigate their effects.
T51 211178-211400 Sentence denotes GIS technologies and services that can function proactively in real time are extremely and critically important to realise this global public health surveillance vision (and indeed any smaller-scale surveillance services).
T52 211401-211587 Sentence denotes Such surveillance services also require a sound and comprehensive spatial health data and information infrastructure to be built and maintained in a coherent way at all operation levels.
T53 211588-211886 Sentence denotes As the reader might have noticed, there are many requirements, e.g., standards and security, and ingredients of success in common to both the nation-wide implementation of integrated electronic health and social care records and the building of a national spatial health information infrastructure.
T54 211887-211940 Sentence denotes Both development directions are closely interrelated.
T55 211941-212135 Sentence denotes In fact, properly implemented electronic health and social care records are always required (in aggregated form) as a key data source within a national spatial health information infrastructure.