Id |
Subject |
Object |
Predicate |
Lexical cue |
T1 |
411-556 |
Epistemic_statement |
denotes |
From a community health perspective, GIS could potentially act as powerful evidence-based practice tools for early problem detection and solving. |
T2 |
958-1067 |
Epistemic_statement |
denotes |
Yet despite all these potentials for GIS, they remain under-utilised in the UK National Health Service (NHS). |
T3 |
1068-1717 |
Epistemic_statement |
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. |
T4 |
1910-2059 |
Epistemic_statement |
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. |
T5 |
2964-3021 |
Epistemic_statement |
denotes |
Interactions within this triad can also change with time. |
T6 |
3022-3371 |
Epistemic_statement |
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] . |
T7 |
3971-4138 |
Epistemic_statement |
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. |
T8 |
4139-4357 |
Epistemic_statement |
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] . |
T9 |
4496-4633 |
Epistemic_statement |
denotes |
The same can be also said about government data in other countries, including data generated by the health sector in different countries. |
T10 |
4634-4830 |
Epistemic_statement |
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] . |
T11 |
4896-5005 |
Epistemic_statement |
denotes |
Use of spatial information opens up the possibility to increase efficiency in the public and private sectors. |
T12 |
6448-6792 |
Epistemic_statement |
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] . |
T13 |
6890-7201 |
Epistemic_statement |
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. |
T14 |
7202-7483 |
Epistemic_statement |
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] . |
T15 |
8241-8600 |
Epistemic_statement |
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. |
T16 |
8992-9075 |
Epistemic_statement |
denotes |
To conclude this introduction, we indicate how the rest of this paper is organised. |
T17 |
9686-10020 |
Epistemic_statement |
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. |
T18 |
10021-10266 |
Epistemic_statement |
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. |
T19 |
10724-10883 |
Epistemic_statement |
denotes |
Such applications currently involve limited SDI-like arrangements, and would certainly benefit from the development of mature SDIs in their respective regions. |
T20 |
10884-11106 |
Epistemic_statement |
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. |
T21 |
11690-11832 |
Epistemic_statement |
denotes |
These GIS methods should be coupled with proper spatio-temporal statistical methods to ensure valid analyses and robust conclusions [11, 12] . |
T22 |
11932-12450 |
Epistemic_statement |
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. |
T23 |
12594-12732 |
Epistemic_statement |
denotes |
The mathematical treatment of topographic or surface statistical values can be used as a filter against other variables or other surfaces. |
T24 |
12733-12934 |
Epistemic_statement |
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] . |
T25 |
12935-13337 |
Epistemic_statement |
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] . |
T26 |
13338-13551 |
Epistemic_statement |
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. |
T27 |
13552-13868 |
Epistemic_statement |
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] . |
T28 |
13869-14102 |
Epistemic_statement |
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] . |
T29 |
14225-14457 |
Epistemic_statement |
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. |
T30 |
14458-14660 |
Epistemic_statement |
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] . |
T31 |
14928-15063 |
Epistemic_statement |
denotes |
Different deprivation indices have different points of strength and weakness, and can yield different results in some studies [3, 15] . |
T32 |
15248-15322 |
Epistemic_statement |
denotes |
Choropleth maps are commonly used to depict the patterns of disease rates. |
T33 |
15323-15480 |
Epistemic_statement |
denotes |
Disease incidence and other spatio-temporal epidemiological events are portrayed on these maps as shaded polygons (each representing an administrative area). |
T34 |
15632-15748 |
Epistemic_statement |
denotes |
Visual communication of disease risk is over-simplified since all values appear evenly distributed within a polygon. |
T35 |
15749-16149 |
Epistemic_statement |
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 ). |
T36 |
16150-16266 |
Epistemic_statement |
denotes |
Other limitations of the choropleth design include the visual dominance of larger areas over smaller ones [14, 16] . |
T37 |
16267-16625 |
Epistemic_statement |
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] . |
T38 |
16626-16865 |
Epistemic_statement |
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). |
T39 |
16866-17534 |
Epistemic_statement |
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] . |
T40 |
17694-17865 |
Epistemic_statement |
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. |
T41 |
18480-18592 |
Epistemic_statement |
denotes |
A spatial filter can be applied to individual point data, as well as to data aggregated into small census areas. |
T42 |
18868-19041 |
Epistemic_statement |
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. |
T43 |
19116-19326 |
Epistemic_statement |
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. |
T44 |
19483-19562 |
Epistemic_statement |
denotes |
Kriging can be also used to produce continuous map surfaces from sample points. |
T45 |
20456-20631 |
Epistemic_statement |
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). |
T46 |
20814-21044 |
Epistemic_statement |
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. |
T47 |
21045-21151 |
Epistemic_statement |
denotes |
Kriging can also take into consideration associative covariates when producing the final smoothed surface. |
T48 |
21152-21307 |
Epistemic_statement |
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] . |
T49 |
21308-21380 |
Epistemic_statement |
denotes |
Trend surface analysis is another technique for producing smoothed maps. |
T50 |
21381-21533 |
Epistemic_statement |
denotes |
Trend surface maps are commonly used to report the spatial diffusion process of disease epidemics (the movement of epidemics across geographical space). |
T51 |
21534-21751 |
Epistemic_statement |
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). |
T52 |
21752-21879 |
Epistemic_statement |
denotes |
They also used animated sequences of trend surface maps to study the waves of diffusion of problematic drug misuse across time. |
T53 |
21880-22152 |
Epistemic_statement |
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] . |
T54 |
22587-22763 |
Epistemic_statement |
denotes |
(ArcGIS 3D Analyst also supports Triangulated Irregular Networks (TINs) and three-dimensional (3D) data visualisation giving users completely new perspectives about their data. |
T55 |
24426-24635 |
Epistemic_statement |
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] . |
T56 |
24806-25035 |
Epistemic_statement |
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. |
T57 |
26223-26428 |
Epistemic_statement |
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] . |
T58 |
26550-26870 |
Epistemic_statement |
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. |
T59 |
26871-27110 |
Epistemic_statement |
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. |
T60 |
27111-27327 |
Epistemic_statement |
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. |
T61 |
27328-27486 |
Epistemic_statement |
denotes |
Today, environmental monitors measure air and water quality, solar irradiation, radon gas levels, and other exposures potentially deleterious to human health. |
T62 |
27487-27635 |
Epistemic_statement |
denotes |
These measurements can be brought into GIS, spatially referenced and integrated analytically with other health predictor variables and outcome data. |
T63 |
27636-27796 |
Epistemic_statement |
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] . |
T64 |
28020-28264 |
Epistemic_statement |
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] . |
T65 |
28265-28570 |
Epistemic_statement |
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). |
T66 |
29369-29686 |
Epistemic_statement |
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. |
T67 |
29827-29916 |
Epistemic_statement |
denotes |
Such patterns can be further and more closely investigated and appropriate actions taken. |
T68 |
30076-30296 |
Epistemic_statement |
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. |
T69 |
30440-30753 |
Epistemic_statement |
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. |
T70 |
30977-31218 |
Epistemic_statement |
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. |
T71 |
32014-32294 |
Epistemic_statement |
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. |
T72 |
32491-32767 |
Epistemic_statement |
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). |
T73 |
32870-33110 |
Epistemic_statement |
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] . |
T74 |
33111-33548 |
Epistemic_statement |
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] . |
T75 |
33630-33840 |
Epistemic_statement |
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. |
T76 |
34185-34539 |
Epistemic_statement |
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] . |
T77 |
35222-35532 |
Epistemic_statement |
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. |
T78 |
36095-36254 |
Epistemic_statement |
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). |
T79 |
37258-37558 |
Epistemic_statement |
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. |
T80 |
37848-37963 |
Epistemic_statement |
denotes |
Another remarkable application involves the use of GIS to improve hospital bed availability and avoid access block. |
T81 |
38492-38681 |
Epistemic_statement |
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. |
T82 |
39754-40135 |
Epistemic_statement |
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. |
T83 |
40326-40507 |
Epistemic_statement |
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). |
T84 |
40628-40823 |
Epistemic_statement |
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). |
T85 |
40824-40993 |
Epistemic_statement |
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] . |
T86 |
41576-41739 |
Epistemic_statement |
denotes |
Linkages between, for example, poor health and unemployment, housing, crime, and education are major drivers for partnership approaches between such organisations. |
T87 |
41740-41874 |
Epistemic_statement |
denotes |
The Acheson Report published in 1998 also recognised the need to adopt cross-governmental approaches to address health concerns [37] . |
T88 |
41875-42656 |
Epistemic_statement |
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: Implementing the NHS Plan" published in 2001 -[43]) of the role that spatial data and GIS could play in the new NHS [28, 35] . |
T89 |
42657-43041 |
Epistemic_statement |
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. |
T90 |
43042-43223 |
Epistemic_statement |
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] . |
T91 |
43224-43676 |
Epistemic_statement |
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] . |
T92 |
43677-43805 |
Epistemic_statement |
denotes |
Again it is astonishing that there is no explicit mention of the potential for geo-information and GIS in addressing these aims. |
T93 |
44028-44142 |
Epistemic_statement |
denotes |
However, this author was able to spot several local implementation documents on the Web mentioning the use of GIS. |
T94 |
44569-44832 |
Epistemic_statement |
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. |
T95 |
45014-45485 |
Epistemic_statement |
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] . |
T96 |
47301-47521 |
Epistemic_statement |
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. |
T97 |
47984-48295 |
Epistemic_statement |
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. |
T98 |
48731-48956 |
Epistemic_statement |
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. |
T99 |
48957-49102 |
Epistemic_statement |
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. |
T100 |
50159-50349 |
Epistemic_statement |
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] . |
T101 |
50350-50639 |
Epistemic_statement |
denotes |
Public health observatories (PHOs), as proposed in the government White Paper "Saving Lives: 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] . |
T102 |
50640-50774 |
Epistemic_statement |
denotes |
Looking at their objectives and published agenda, PHOs could have easily undertaken the tasks suggested by Cooper in [50] (see above). |
T103 |
50775-50991 |
Epistemic_statement |
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. |
T104 |
52022-52151 |
Epistemic_statement |
denotes |
However, only 54% of health authorities and 56% of health trusts within this active subset reported having fully operational GIS. |
T105 |
52380-52903 |
Epistemic_statement |
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] . |
T106 |
52904-53036 |
Epistemic_statement |
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. |
T107 |
54373-54448 |
Epistemic_statement |
denotes |
Internet and Intranet GIS were found to be still rare within the NHS [35] . |
T108 |
54449-54797 |
Epistemic_statement |
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). |
T109 |
55135-55399 |
Epistemic_statement |
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. |
T110 |
55968-56131 |
Epistemic_statement |
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. |
T111 |
56447-56566 |
Epistemic_statement |
denotes |
Another important problem reported was that of organisations not being aware of data held by other organisations [35] . |
T112 |
56567-56938 |
Epistemic_statement |
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] . |
T113 |
56939-57371 |
Epistemic_statement |
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. |
T114 |
57372-57550 |
Epistemic_statement |
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] . |
T115 |
57551-57849 |
Epistemic_statement |
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. |
T116 |
58228-58406 |
Epistemic_statement |
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. |
T117 |
58687-58987 |
Epistemic_statement |
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] : |
T118 |
58988-59306 |
Epistemic_statement |
denotes |
(1) Fostering a culture of data sharing that considers spatial information an asset: 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. |
T119 |
59376-59476 |
Epistemic_statement |
denotes |
The benefits associated with data sharing should be researched to encourage wide participation [6] . |
T120 |
59642-59770 |
Epistemic_statement |
denotes |
Universities should be encouraged to work with local organisations in the provision of Continuing Professional Development [6] . |
T121 |
59940-60128 |
Epistemic_statement |
denotes |
(3) Addressing crucial legal issues: Experience has shown that issues associated with national security, data privacy and associated liability are potential obstacles for NSDI initiatives. |
T122 |
60129-60237 |
Epistemic_statement |
denotes |
Unambiguous legal frameworks to address these crucial legal issues must be established as early as possible. |
T123 |
60388-60598 |
Epistemic_statement |
denotes |
(4) Development of effective partnerships, and involvement of all stakeholders and users: Mature NSDIs are complex solutions involving many stakeholders (including the health sector with all its organisations). |
T124 |
60781-60872 |
Epistemic_statement |
denotes |
Appropriate business models must be agreed to support these partnerships at an early stage. |
T125 |
61053-61180 |
Epistemic_statement |
denotes |
It is essential that all users are involved when defining (user) requirements and testing the associated products and services. |
T126 |
61285-61460 |
Epistemic_statement |
denotes |
NSDI Steering Groups (with end-user representation) should be formed to formulate appropriate policy and institutional frameworks and facilitate multi-stakeholder cooperation. |
T127 |
61461-61578 |
Epistemic_statement |
denotes |
However, complete policy and institutional frameworks need not be in place before implementation of a NSDI can begin. |
T128 |
61579-61752 |
Epistemic_statement |
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] . |
T129 |
61753-61977 |
Epistemic_statement |
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). |
T130 |
61978-62079 |
Epistemic_statement |
denotes |
To be able to integrate and share data we need to understand and resolve different semantics in data. |
T131 |
62080-62364 |
Epistemic_statement |
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] . |
T132 |
62365-62531 |
Epistemic_statement |
denotes |
(6) A combined top-down and bottom-up incremental implementation approach: It is recommended that a top down approach is combined with a pragmatic bottom up approach. |
T133 |
62532-62722 |
Epistemic_statement |
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. |
T134 |
62723-62849 |
Epistemic_statement |
denotes |
Short-term bottom up projects will provide valuable experience that can feed into the formulation of NSDI policy and strategy. |
T135 |
62850-63021 |
Epistemic_statement |
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] . |
T136 |
63022-63175 |
Epistemic_statement |
denotes |
(7) Do not just focus on data; develop applications: Varied applications and services through a project-oriented approach will bring reality to the NSDI. |
T137 |
63176-63304 |
Epistemic_statement |
denotes |
An overemphasis on data acquisition, without a market-linked application, will not provide any momentum for further development. |
T138 |
64873-65018 |
Epistemic_statement |
denotes |
Stakeholders should work together locally and with international bodies to develop/adopt standards for geodata collection and documentation [9] . |
T139 |
65019-65139 |
Epistemic_statement |
denotes |
(Adopting international standards will also ensure that future collaboration is possible at regional and global levels.) |
T140 |
65766-65820 |
Epistemic_statement |
denotes |
Metadata, too, should be standardised [9] (Figure 3 ). |
T141 |
65960-66106 |
Epistemic_statement |
denotes |
Policies should start by removing barriers to access, e.g., excessive costs to use an information product or lack of clarity concerning copyright. |
T142 |
66107-66235 |
Epistemic_statement |
denotes |
The absence of a policy concerning data access and sharing can often be as handicapping as the presence of an inhibiting policy. |
T143 |
66236-66315 |
Epistemic_statement |
denotes |
Existing policies need to be revised and new poli- cies developed as necessary. |
T144 |
66316-66508 |
Epistemic_statement |
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] . |
T145 |
66673-66750 |
Epistemic_statement |
denotes |
Without appropriate human resources, geo-information will remain unexploited. |
T146 |
66751-66829 |
Epistemic_statement |
denotes |
Sufficient financial resources must be available to invest in training people. |
T147 |
66830-66928 |
Epistemic_statement |
denotes |
Retaining technical expertise should be also a priority within institutions using geo-information. |
T148 |
67368-67692 |
Epistemic_statement |
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. |
T149 |
67693-67863 |
Epistemic_statement |
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] . |
T150 |
67864-67977 |
Epistemic_statement |
denotes |
(7) Raising awareness: Establishing a formal national programme can help heighten awareness and generate support. |
T151 |
67978-68084 |
Epistemic_statement |
denotes |
Policymakers need to be engaged in the process through awareness training, briefings, and policy dialogue. |
T152 |
68677-68880 |
Epistemic_statement |
denotes |
(2) Awareness-raising campaigns: 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] . |
T153 |
69629-69810 |
Epistemic_statement |
denotes |
(2) Training, its costs, and time needed for it should be all considered: Training should cover epidemiological methods to ensure appropriate use of GIS technology in public health. |
T154 |
69811-70036 |
Epistemic_statement |
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. |
T155 |
70037-70157 |
Epistemic_statement |
denotes |
The time required for training can be also a challenge for organisations in which demands on personnel are already high. |
T156 |
70158-70306 |
Epistemic_statement |
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). |
T157 |
70460-70523 |
Epistemic_statement |
denotes |
(3) Current and accurate base data must be made available [7] . |
T158 |
70524-70612 |
Epistemic_statement |
denotes |
(4) Software and data acquisition, maintenance and upgrade costs should be secured [7] . |
T159 |
70613-70851 |
Epistemic_statement |
denotes |
(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. |
T160 |
70852-71126 |
Epistemic_statement |
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.) |
T161 |
71262-71337 |
Epistemic_statement |
denotes |
(6) Standards must be adopted and partnerships promoted at all levels [7] . |
T162 |
71504-71819 |
Epistemic_statement |
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. |
T163 |
72212-72318 |
Epistemic_statement |
denotes |
(2) Adopting data standards and sharing agreements will ensure a CHSS works effectively in real time [2] . |
T164 |
73428-73495 |
Epistemic_statement |
denotes |
RODS researchers identified the following key elements for success: |
T165 |
73496-73690 |
Epistemic_statement |
denotes |
(1) Data-sharing agreements: These were executed in the case of RODS with every participating health system and OTC healthcare product retailer, and addressed confidentiality and other concerns. |
T166 |
73691-73831 |
Epistemic_statement |
denotes |
Data sharing agreements should allow redistribution of data to any public health authority and permit data to be used in research [55, 56] . |
T167 |
73832-74040 |
Epistemic_statement |
denotes |
(2) National data utilities/services: 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] . |
T168 |
75586-76056 |
Epistemic_statement |
denotes |
(2) Raising awareness: 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. |
T169 |
76057-76198 |
Epistemic_statement |
denotes |
Successful examples of collaborative projects between NHS and local authorities that have involved the use of GIS should be also highlighted. |
T170 |
77046-77227 |
Epistemic_statement |
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] . |
T171 |
77228-77516 |
Epistemic_statement |
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] . |
T172 |
77792-77945 |
Epistemic_statement |
denotes |
(5) Moving to the Web and building all necessary critical connectivity/geospatial infrastructure that should not be independently recreated by all [58] . |
T173 |
79181-79661 |
Epistemic_statement |
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] . |
T174 |
80426-80638 |
Epistemic_statement |
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] . |
T175 |
80639-80783 |
Epistemic_statement |
denotes |
The next steps involved identifying, evaluating, and acquiring potentially relevant datasets based on data needs identified from the data model. |
T176 |
81673-81897 |
Epistemic_statement |
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] . |
T177 |
82195-82383 |
Epistemic_statement |
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] . |
T178 |
82384-82591 |
Epistemic_statement |
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] . |
T179 |
82867-82952 |
Epistemic_statement |
denotes |
Web accessible directories of data would greatly facilitate identifying data sources. |
T180 |
82953-83102 |
Epistemic_statement |
denotes |
In addition, action should be taken to improve data documentation (metadata), develop data standards, and enhance compliance with existing standards. |
T181 |
83411-83537 |
Epistemic_statement |
denotes |
The difficulties encountered in acquiring data indicate that privacy concerns present a serious barrier to system development. |
T182 |
83538-83673 |
Epistemic_statement |
denotes |
A wide range of stakeholders in society must collectively address the issues of privacy and stewardship of population health data [8] . |
T183 |
83674-83875 |
Epistemic_statement |
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. |
T184 |
84413-84531 |
Epistemic_statement |
denotes |
(6) Users of community health information systems will nearly always have variable skills and organisational contexts. |
T185 |
84698-84858 |
Epistemic_statement |
denotes |
Another approach would be to use artificial intelligence, as employed in decision support systems, to facilitate user control of information visualisation [8] . |
T186 |
85068-85344 |
Epistemic_statement |
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] . |
T187 |
85345-85585 |
Epistemic_statement |
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. |
T188 |
85941-86108 |
Epistemic_statement |
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] . |
T189 |
86748-86941 |
Epistemic_statement |
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] . |
T190 |
87206-87405 |
Epistemic_statement |
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] . |
T191 |
87406-87517 |
Epistemic_statement |
denotes |
Community partners engaged in collaborative research with universities should see themselves as equal partners. |
T192 |
87518-87706 |
Epistemic_statement |
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). |
T193 |
87707-88006 |
Epistemic_statement |
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] . |
T194 |
88186-88596 |
Epistemic_statement |
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. |
T195 |
88597-88933 |
Epistemic_statement |
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] . |
T196 |
88934-89191 |
Epistemic_statement |
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] . |
T197 |
89679-89791 |
Epistemic_statement |
denotes |
Thus each participating agency manages its own data and its timeliness, which can be current and even real-time. |
T198 |
89841-89917 |
Epistemic_statement |
denotes |
Any agency can participate by adding its own data layer(s) to existing ones. |
T199 |
90014-90121 |
Epistemic_statement |
denotes |
Public health databases are not yet included in WME, but there are no specific barriers to inclusion [58] . |
T200 |
90122-90249 |
Epistemic_statement |
denotes |
As information systems increase in complexity, models of the relationships between data elements become increasingly important. |
T201 |
90250-90369 |
Epistemic_statement |
denotes |
Data models, more correctly called ontologies, explicitly define how concepts within data sources relate to each other. |
T202 |
90370-90514 |
Epistemic_statement |
denotes |
They are conceptual models that facilitate integration of data by information systems and support a common understanding of data by people [8] . |
T203 |
90515-90895 |
Epistemic_statement |
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. |
T204 |
91686-91730 |
Epistemic_statement |
denotes |
Three types of indicator are proposed [54] : |
T205 |
91731-91925 |
Epistemic_statement |
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; |
T206 |
91926-92026 |
Epistemic_statement |
denotes |
(2) Risk indicators: describe the hazard in terms of the number or percentage of people exposed; and |
T207 |
92027-92164 |
Epistemic_statement |
denotes |
(3) Health impact indicators: describe the hazard in terms of the actual health outcome, measured as either morbidity or mortality [54] . |
T208 |
92165-92266 |
Epistemic_statement |
denotes |
Which type of indicator is most appropriate is likely to depend on the specific question being asked. |
T209 |
92267-92454 |
Epistemic_statement |
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] . |
T210 |
92533-92752 |
Epistemic_statement |
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. |
T211 |
92753-93015 |
Epistemic_statement |
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] . |
T212 |
93784-93895 |
Epistemic_statement |
denotes |
The area across which the indicator can be used (scale of application or aggregation level) must be determined. |
T213 |
93896-94013 |
Epistemic_statement |
denotes |
Finally, the ways in which the indicator may be interpreted in relation to the hazard(s) it covers must be described. |
T214 |
94014-94287 |
Epistemic_statement |
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] . |
T215 |
94844-95017 |
Epistemic_statement |
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. |
T216 |
95018-95291 |
Epistemic_statement |
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. |
T217 |
95292-95518 |
Epistemic_statement |
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]. |
T218 |
96003-96439 |
Epistemic_statement |
denotes |
(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. |
T219 |
97091-97157 |
Epistemic_statement |
denotes |
The outcome will be a basic data model with three components [64]: |
T220 |
97158-97292 |
Epistemic_statement |
denotes |
(1) A conceptual object model of health application features, building relationships between health application geographies and users; |
T221 |
97293-97389 |
Epistemic_statement |
denotes |
(2) UML (Unified Modelling Language) code which is easily transformed into an ESRI geo-database. |
T222 |
97390-97997 |
Epistemic_statement |
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. |
T223 |
97998-98344 |
Epistemic_statement |
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). |
T224 |
98458-98744 |
Epistemic_statement |
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?" |
T225 |
98906-99033 |
Epistemic_statement |
denotes |
[59, 65] POPULIS reports on the health of a population, and the relationship between health and the use of healthcare services. |
T226 |
99608-99956 |
Epistemic_statement |
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] . |
T227 |
99957-100024 |
Epistemic_statement |
denotes |
However, POPULIS has missed a lot by not being a GISenabled system. |
T228 |
100391-100642 |
Epistemic_statement |
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. |
T229 |
100974-101147 |
Epistemic_statement |
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. |
T230 |
101148-101332 |
Epistemic_statement |
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? |
T231 |
101333-101499 |
Epistemic_statement |
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. |
T232 |
102693-102995 |
Epistemic_statement |
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. |
T233 |
102996-103350 |
Epistemic_statement |
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] . |
T234 |
103351-103495 |
Epistemic_statement |
denotes |
XML is also used for encoding spatial metadata (metadata are essential to aid the discovery of spatial data in a distributed environment) [58] . |
T235 |
103960-104079 |
Epistemic_statement |
denotes |
Any data store can be used -users no longer need to care whether the underlying store is from ESRI, Oracle or IBM [69]. |
T236 |
104218-104425 |
Epistemic_statement |
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/. |
T237 |
104499-104681 |
Epistemic_statement |
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. |
T238 |
104682-104893 |
Epistemic_statement |
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] . |
T239 |
104894-105005 |
Epistemic_statement |
denotes |
By separating presentation from content, powerful maps can be made that offer enhanced functionality for users. |
T240 |
105006-105187 |
Epistemic_statement |
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. |
T241 |
105188-105337 |
Epistemic_statement |
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] . |
T242 |
105338-105521 |
Epistemic_statement |
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 ). |
T243 |
105802-105980 |
Epistemic_statement |
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. |
T244 |
105981-106096 |
Epistemic_statement |
denotes |
This allows different "stylesheets" to be applied to the geographic data to make it appear however the user wishes. |
T245 |
106097-106283 |
Epistemic_statement |
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. |
T246 |
106306-106673 |
Epistemic_statement |
denotes |
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. |
T247 |
106863-106983 |
Epistemic_statement |
denotes |
However, it should be noted that GML and Web Services are only part of the solution to integration and interoperability. |
T248 |
107883-108177 |
Epistemic_statement |
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. |
T249 |
108242-108404 |
Epistemic_statement |
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. |
T250 |
108405-108568 |
Epistemic_statement |
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. |
T251 |
108660-108899 |
Epistemic_statement |
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. |
T252 |
109243-109429 |
Epistemic_statement |
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. |
T253 |
109430-109601 |
Epistemic_statement |
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. |
T254 |
109946-110211 |
Epistemic_statement |
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] . |
T255 |
110579-110748 |
Epistemic_statement |
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] . |
T256 |
110749-110897 |
Epistemic_statement |
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] . |
T257 |
111468-111555 |
Epistemic_statement |
denotes |
This can be crucial in emergency situations such as terrorist and bioterrorist attacks. |
T258 |
112289-112373 |
Epistemic_statement |
denotes |
Bandwidth is not only a problem of developing countries, but developed ones as well. |
T259 |
112374-112607 |
Epistemic_statement |
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). |
T260 |
112786-112986 |
Epistemic_statement |
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] . |
T261 |
112987-113262 |
Epistemic_statement |
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. |
T262 |
113418-113587 |
Epistemic_statement |
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. |
T263 |
114571-114879 |
Epistemic_statement |
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. |
T264 |
114880-115019 |
Epistemic_statement |
denotes |
To maximise their utility, these wizards should also be fully integrated into everyday public health workflows and decision-making process. |
T265 |
115020-115242 |
Epistemic_statement |
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. |
T266 |
115243-115586 |
Epistemic_statement |
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). |
T267 |
115587-115679 |
Epistemic_statement |
denotes |
The UK/EU equivalents of these accessibility requirements can be consulted online [77, 78] . |
T268 |
115680-115927 |
Epistemic_statement |
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. |
T269 |
115928-116093 |
Epistemic_statement |
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. |
T270 |
116094-116314 |
Epistemic_statement |
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 ). |
T271 |
116423-116807 |
Epistemic_statement |
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). |
T272 |
116808-116970 |
Epistemic_statement |
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. |
T273 |
117171-117333 |
Epistemic_statement |
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. |
T274 |
117448-117596 |
Epistemic_statement |
denotes |
Kevin Coleman suggests several measures that can be taken for thwarting cyber terrorism; interested readers are urged to refer to his article [79] . |
T275 |
118374-118797 |
Epistemic_statement |
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] . |
T276 |
118798-118846 |
Epistemic_statement |
denotes |
Spatial data confidentiality is a complex issue. |
T277 |
118847-119030 |
Epistemic_statement |
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". |
T278 |
119031-119158 |
Epistemic_statement |
denotes |
A false identification may be just as damaging to an individual as a correct identification that is not kept confidential [7] . |
T279 |
119159-119365 |
Epistemic_statement |
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] . |
T280 |
119366-119538 |
Epistemic_statement |
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. |
T281 |
119851-119999 |
Epistemic_statement |
denotes |
Traditional ecological analysis based on choropleth mapping and the analysis of aggregate data for administrative areas has been heavily criticised. |
T282 |
120000-120491 |
Epistemic_statement |
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. |
T283 |
120492-120545 |
Epistemic_statement |
denotes |
Such concerns can only be addressed using micro-data. |
T284 |
120546-120735 |
Epistemic_statement |
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] . |
T285 |
120869-120962 |
Epistemic_statement |
denotes |
Moreover, using area centroids instead of exact locations can yield misleading results [12] . |
T286 |
120963-122208 |
Epistemic_statement |
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] . |
T287 |
122209-122339 |
Epistemic_statement |
denotes |
Fortunately, solutions exist that can preserve data confidentiality while still enabling fine-level analyses and reliable results. |
T288 |
122340-122944 |
Epistemic_statement |
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] . |
T289 |
122992-123152 |
Epistemic_statement |
denotes |
(1) Statistical and epidemiological methods: Armstrong et al describe different promising types of geographical masks to encode the geography of health records. |
T290 |
123153-123477 |
Epistemic_statement |
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] . |
T291 |
123478-123676 |
Epistemic_statement |
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. |
T292 |
124169-124401 |
Epistemic_statement |
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). |
T293 |
124473-124699 |
Epistemic_statement |
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. |
T294 |
124700-124910 |
Epistemic_statement |
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] . |
T295 |
125058-125219 |
Epistemic_statement |
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] . |
T296 |
125220-125331 |
Epistemic_statement |
denotes |
Areal aggregation is perhaps the most commonly adopted approach among those suggested by Armstrong et al [83] . |
T297 |
126211-126343 |
Epistemic_statement |
denotes |
SCDHEC chose census tracts because they contain useful socio-economic data that could be combined with the aggregated vital records. |
T298 |
127832-127945 |
Epistemic_statement |
denotes |
Armstrong et al also mention another possible solution to data confidentiality problems based on software agents. |
T299 |
128011-128158 |
Epistemic_statement |
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. |
T300 |
128159-128406 |
Epistemic_statement |
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] . |
T301 |
128592-128871 |
Epistemic_statement |
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. |
T302 |
129456-129570 |
Epistemic_statement |
denotes |
Access to confidential data can be accommodated for qualified users in secure Intranet or Internet settings [58] . |
T303 |
130176-130477 |
Epistemic_statement |
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). |
T304 |
130793-131072 |
Epistemic_statement |
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. |
T305 |
131073-131481 |
Epistemic_statement |
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] . |
T306 |
131942-132071 |
Epistemic_statement |
denotes |
On the other hand, data, information, maps and software that have been approved for public dissemination are available to anyone. |
T307 |
132414-132564 |
Epistemic_statement |
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] . |
T308 |
132817-133130 |
Epistemic_statement |
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] . |
T309 |
133131-133323 |
Epistemic_statement |
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. |
T310 |
133324-133469 |
Epistemic_statement |
denotes |
Through metadata all public health agencies can inform others of their spatial data holdings and any limitations associated with their use [58] . |
T311 |
133470-133718 |
Epistemic_statement |
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. |
T312 |
133719-134010 |
Epistemic_statement |
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] . |
T313 |
134312-134643 |
Epistemic_statement |
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] . |
T314 |
135460-135755 |
Epistemic_statement |
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. |
T315 |
135756-136007 |
Epistemic_statement |
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] . |
T316 |
136008-136138 |
Epistemic_statement |
denotes |
GIS integration of complex data into visually easy-tounderstand pictures can sometimes be a setup for misunderstanding and misuse. |
T317 |
136139-136284 |
Epistemic_statement |
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. |
T318 |
136285-136701 |
Epistemic_statement |
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] . |
T319 |
136702-136782 |
Epistemic_statement |
denotes |
According to Monmonier, it is not just easy but also essential to lie with maps. |
T320 |
136783-136940 |
Epistemic_statement |
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] . |
T321 |
136941-137271 |
Epistemic_statement |
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. |
T322 |
137272-137486 |
Epistemic_statement |
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). |
T323 |
137487-137669 |
Epistemic_statement |
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. |
T324 |
137670-137821 |
Epistemic_statement |
denotes |
More appropriately, these areas should be labelled to indicate that rates are statistically unstable due to small numbers and therefore not shown [7] . |
T325 |
137822-138365 |
Epistemic_statement |
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] . |
T326 |
138366-138678 |
Epistemic_statement |
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. |
T327 |
138777-138941 |
Epistemic_statement |
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. |
T328 |
138942-139138 |
Epistemic_statement |
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." |
T329 |
139400-139672 |
Epistemic_statement |
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. |
T330 |
139673-139844 |
Epistemic_statement |
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). |
T331 |
140069-140289 |
Epistemic_statement |
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 ). |
T332 |
141664-141810 |
Epistemic_statement |
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/. |
T333 |
141811-142093 |
Epistemic_statement |
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. |
T334 |
142094-142216 |
Epistemic_statement |
denotes |
However, early NetSurv pilot results showed that its Web-based interface was difficult, slow, and not user friendly [96] . |
T335 |
142217-142476 |
Epistemic_statement |
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). |
T336 |
142477-142645 |
Epistemic_statement |
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). |
T337 |
142646-143059 |
Epistemic_statement |
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). |
T338 |
143060-143090 |
Epistemic_statement |
denotes |
A balanced approach is needed. |
T339 |
143091-143427 |
Epistemic_statement |
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] . |
T340 |
143428-143621 |
Epistemic_statement |
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. |
T341 |
143622-143680 |
Epistemic_statement |
denotes |
We need to consider the daily activity spaces of patients. |
T342 |
143681-144041 |
Epistemic_statement |
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. |
T343 |
144042-144128 |
Epistemic_statement |
denotes |
The problem is particularly acute for diseases that have a long lag or latency period. |
T344 |
144250-144317 |
Epistemic_statement |
denotes |
Clearly, complete datasets of this nature are currently rare [97] . |
T345 |
144318-144596 |
Epistemic_statement |
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). |
T346 |
144856-145022 |
Epistemic_statement |
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] . |
T347 |
145023-145187 |
Epistemic_statement |
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] . |
T348 |
145188-145358 |
Epistemic_statement |
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. |
T349 |
145359-145551 |
Epistemic_statement |
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] . |
T350 |
146358-146573 |
Epistemic_statement |
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. |
T351 |
146617-146802 |
Epistemic_statement |
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] . |
T352 |
146893-147128 |
Epistemic_statement |
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. |
T353 |
147280-147393 |
Epistemic_statement |
denotes |
Paucity of biomedical facilities in rural areas usually means many health conditions there pass unreported [81] . |
T354 |
147394-147712 |
Epistemic_statement |
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. |
T355 |
147713-147998 |
Epistemic_statement |
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] . |
T356 |
147999-148213 |
Epistemic_statement |
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. |
T357 |
148344-148887 |
Epistemic_statement |
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] . |
T358 |
149517-149751 |
Epistemic_statement |
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. |
T359 |
149752-149891 |
Epistemic_statement |
denotes |
A geolibrary is distributed if its users, services, metadata, and information assets can be integrated among many distinct locations [98] . |
T360 |
149892-150042 |
Epistemic_statement |
denotes |
A distributed geolibrary would support collaborative work, such as multidisciplinary research by teams, and decision-making by groups of stakeholders. |
T361 |
150043-150245 |
Epistemic_statement |
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. |
T362 |
150246-150396 |
Epistemic_statement |
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] . |
T363 |
150704-150863 |
Epistemic_statement |
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] . |
T364 |
150864-151254 |
Epistemic_statement |
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. |
T365 |
151255-151425 |
Epistemic_statement |
denotes |
Information resources through distributed geolibraries could greatly assist rapid response to such emergencies and longer-term efforts aimed at prevention and mitigation. |
T366 |
152655-152807 |
Epistemic_statement |
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. |
T367 |
152808-153063 |
Epistemic_statement |
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"). |
T368 |
153319-153687 |
Epistemic_statement |
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] . |
T369 |
153688-154042 |
Epistemic_statement |
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. |
T370 |
154602-154858 |
Epistemic_statement |
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] . |
T371 |
155687-156041 |
Epistemic_statement |
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). |
T372 |
157163-157313 |
Epistemic_statement |
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; |
T373 |
157314-157873 |
Epistemic_statement |
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] . |
T374 |
157874-157969 |
Epistemic_statement |
denotes |
A common infrastructure for spatial information in Europe can only be realised in the long run. |
T375 |
158045-158218 |
Epistemic_statement |
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] . |
T376 |
158530-158625 |
Epistemic_statement |
denotes |
It features six search methods that can be used any combination to retrieve the results needed. |
T377 |
160782-160872 |
Epistemic_statement |
denotes |
(3) Framework: includes base layers, which will probably differ from location to location. |
T378 |
161625-161871 |
Epistemic_statement |
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. |
T379 |
162025-162152 |
Epistemic_statement |
denotes |
It includes recommended existing and emerging standards and specifications, as well as business case examples of best practice. |
T380 |
162212-162470 |
Epistemic_statement |
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. |
T381 |
162471-162769 |
Epistemic_statement |
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. |
T382 |
163188-163280 |
Epistemic_statement |
denotes |
This should ideally be linked to public health action, which is the problem-solving process. |
T383 |
163281-163565 |
Epistemic_statement |
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. |
T384 |
163831-164040 |
Epistemic_statement |
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. |
T385 |
164041-164309 |
Epistemic_statement |
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] . |
T386 |
164620-164828 |
Epistemic_statement |
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. |
T387 |
164829-164993 |
Epistemic_statement |
denotes |
Syndromic surveillance methods that can detect disease at an earlier stage are increasingly becoming an important research direction for public health surveillance. |
T388 |
164994-165267 |
Epistemic_statement |
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. |
T389 |
165268-165683 |
Epistemic_statement |
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] . |
T390 |
166380-166682 |
Epistemic_statement |
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. |
T391 |
166683-166902 |
Epistemic_statement |
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] . |
T392 |
167126-167463 |
Epistemic_statement |
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. |
T393 |
167464-167686 |
Epistemic_statement |
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). |
T394 |
169915-170146 |
Epistemic_statement |
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. |
T395 |
170147-170326 |
Epistemic_statement |
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. |
T396 |
170327-170693 |
Epistemic_statement |
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] . |
T397 |
170942-171296 |
Epistemic_statement |
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] . |
T398 |
171891-172196 |
Epistemic_statement |
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). |
T399 |
172197-172483 |
Epistemic_statement |
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. |
T400 |
173067-173304 |
Epistemic_statement |
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] . |
T401 |
173666-173857 |
Epistemic_statement |
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] . |
T402 |
174020-174304 |
Epistemic_statement |
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. |
T403 |
174602-174765 |
Epistemic_statement |
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. |
T404 |
174766-174884 |
Epistemic_statement |
denotes |
A CHSS should be able to automatically detect such spike and raise an alarm early enough to contain the outbreak [2] . |
T405 |
174938-175078 |
Epistemic_statement |
denotes |
Human intervention should not be required until preestablished critical levels -in the number and/or clustering of occurrences -are reached. |
T406 |
175193-175327 |
Epistemic_statement |
denotes |
However, the transition from episodic investigation to ongoing monitoring using GIS requires more robust data collection and analysis. |
T407 |
175696-175816 |
Epistemic_statement |
denotes |
To be reliable for the purposes of a CHSS, population-based data must also describe relatively small geographical areas. |
T408 |
177197-177415 |
Epistemic_statement |
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. |
T409 |
177416-177533 |
Epistemic_statement |
denotes |
For example, a surveillance system with daily batch transfer may delay by one day the detection of an outbreak [55] . |
T410 |
177534-177668 |
Epistemic_statement |
denotes |
Time intervals as small as hours can make a difference when a large cohort is exposed to rapidly progressing diseases such as anthrax. |
T411 |
177847-177962 |
Epistemic_statement |
denotes |
Preliminary studies suggest that sales of OTC healthcare products can be used for the early detection of outbreaks. |
T412 |
178809-178976 |
Epistemic_statement |
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. |
T413 |
179321-180444 |
Epistemic_statement |
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] . |
T414 |
180746-180831 |
Epistemic_statement |
denotes |
RODS also has a Web-based user interface that supports temporal and spatial analyses. |
T415 |
180832-180988 |
Epistemic_statement |
denotes |
RODS' password-protected, encrypted Web site allows users to review healthcare registration and sales of OTC healthcare products on epidemic plots and maps. |
T416 |
181884-182125 |
Epistemic_statement |
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. |
T417 |
182338-182538 |
Epistemic_statement |
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. |
T418 |
182539-182675 |
Epistemic_statement |
denotes |
Alternative data transformations are possible using differ-ent signal processing approaches focused on detecting more gradual increases. |
T419 |
182676-182853 |
Epistemic_statement |
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] . |
T420 |
182994-183122 |
Epistemic_statement |
denotes |
However, deployment of such systems requires skilled network engineers, Oracle database administrators, and interface engineers. |
T421 |
183123-183276 |
Epistemic_statement |
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. |
T422 |
183277-183358 |
Epistemic_statement |
denotes |
Such organisations can form coalitions to share the costs of such services [55] . |
T423 |
183359-183574 |
Epistemic_statement |
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. |
T424 |
184164-184407 |
Epistemic_statement |
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). |
T425 |
184517-184688 |
Epistemic_statement |
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. |
T426 |
185493-185737 |
Epistemic_statement |
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. |
T427 |
185738-185933 |
Epistemic_statement |
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. |
T428 |
186540-186703 |
Epistemic_statement |
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. |
T429 |
187110-187416 |
Epistemic_statement |
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] . |
T430 |
187557-187702 |
Epistemic_statement |
denotes |
From a community health perspective, GIS could potentially act as powerful evidence-based practice tools for early problem detection and solving. |
T431 |
188104-188415 |
Epistemic_statement |
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. |
T432 |
188537-188649 |
Epistemic_statement |
denotes |
A good starting point may be the CDC "Guide to Community Preventive Services" http://www.thecommunityguide.org/. |
T433 |
188650-189301 |
Epistemic_statement |
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. |
T434 |
189302-189415 |
Epistemic_statement |
denotes |
This could inform the development of successful GIS business plans for the health conditions under consideration. |
T435 |
189755-189979 |
Epistemic_statement |
denotes |
(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.) |
T436 |
190351-190766 |
Epistemic_statement |
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. |
T437 |
190767-191047 |
Epistemic_statement |
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. |
T438 |
191355-191543 |
Epistemic_statement |
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. |
T439 |
192044-192367 |
Epistemic_statement |
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. |
T440 |
192486-192705 |
Epistemic_statement |
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. |
T441 |
192883-193028 |
Epistemic_statement |
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. |
T442 |
193029-193210 |
Epistemic_statement |
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] . |
T443 |
193211-193309 |
Epistemic_statement |
denotes |
Perhaps the NHS should also take a closer look at the three sets of standards published by the US |
T444 |
193310-193526 |
Epistemic_statement |
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 |
T445 |
193527-194012 |
Epistemic_statement |
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) |
T446 |
194013-194378 |
Epistemic_statement |
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/. |
T447 |
194863-195174 |
Epistemic_statement |
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. |
T448 |
196016-196229 |
Epistemic_statement |
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. |
T449 |
196434-196821 |
Epistemic_statement |
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). |
T450 |
197244-197556 |
Epistemic_statement |
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. |
T451 |
197557-197774 |
Epistemic_statement |
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. |
T452 |
197847-197954 |
Epistemic_statement |
denotes |
Training should cover epidemiological methods to ensure appropriate use of GIS technology in public health. |
T453 |
197955-198241 |
Epistemic_statement |
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). |
T454 |
198242-198499 |
Epistemic_statement |
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. |
T455 |
198754-198983 |
Epistemic_statement |
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] . |
T456 |
198984-199114 |
Epistemic_statement |
denotes |
The best, current evidence derived from GIS research should be always embedded (and regularly updated) in all training programmes. |
T457 |
199115-199212 |
Epistemic_statement |
denotes |
This is one important way of linking the academia and research communities to realworld practice. |
T458 |
199330-199610 |
Epistemic_statement |
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. |
T459 |
199611-200217 |
Epistemic_statement |
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 |
T460 |
200218-200634 |
Epistemic_statement |
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 |
T461 |
200635-200918 |
Epistemic_statement |
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 |
T462 |
200919-201359 |
Epistemic_statement |
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 |
T463 |
201360-202374 |
Epistemic_statement |
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 |
T464 |
202375-202966 |
Epistemic_statement |
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 |
T465 |
202967-203514 |
Epistemic_statement |
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. |
T466 |
203675-203915 |
Epistemic_statement |
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. |
T467 |
203999-204123 |
Epistemic_statement |
denotes |
Today, solutions exist that can preserve data confidentiality while still enabling fine-level analyses and reliable results. |
T468 |
204124-204928 |
Epistemic_statement |
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. |
T469 |
205226-205479 |
Epistemic_statement |
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. |
T470 |
205659-206068 |
Epistemic_statement |
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. |
T471 |
206069-206310 |
Epistemic_statement |
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. |
T472 |
206311-206696 |
Epistemic_statement |
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. |
T473 |
206697-206847 |
Epistemic_statement |
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. |
T474 |
206848-207026 |
Epistemic_statement |
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. |
T475 |
207027-207343 |
Epistemic_statement |
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. |
T476 |
207344-207603 |
Epistemic_statement |
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). |
T477 |
207811-207978 |
Epistemic_statement |
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. |
T478 |
207979-208189 |
Epistemic_statement |
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. |
T479 |
208385-208569 |
Epistemic_statement |
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. |
T480 |
208809-208922 |
Epistemic_statement |
denotes |
It is recommended that a combined top-down and bottom-up incremental (phased) implementation approach be adopted. |
T481 |
209044-209391 |
Epistemic_statement |
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. |
T482 |
209392-209525 |
Epistemic_statement |
denotes |
Short-term bottom-up projects can feed valuable experience into the formulation and revision of the relevant policies and strategies. |
T483 |
209526-209735 |
Epistemic_statement |
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. |
T484 |
210679-210838 |
Epistemic_statement |
denotes |
Such applications currently involve limited SDI-like arrangements, and would certainly benefit from the development of mature SDIs in their respective regions. |
T485 |
210839-211177 |
Epistemic_statement |
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. |
T486 |
211178-211400 |
Epistemic_statement |
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). |
T487 |
211588-211886 |
Epistemic_statement |
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. |