Design Considerations for

Long Distance Public Health Information Exchange

Shanghai Municipal Center for Disease Control & Prevention

Liang Chen

1. Background

The California - China Environmental Health Training Program, first established in 2002, funded by the Fogarty International Center, National Institutes of Health, is a collaborative program between the Shanghai Municipal Center for Disease Control & Prevention (SCDC), and the California Department of Health Services (CDHS), Division of Environmental and Occupational Disease Control (DEODC) - Environmental Health Investigations Branch (EHIB). This program is designed to foster the development of environmental health research strategies, building on existing strengths of the Chinese environmental health community, that address the most profound environmental health issues -- strategies that are best suited to regional and national needs. It offers three training components: 1) U.S.-based training for selected scientists from SCDC; 2) conferences on environmental and occupational health issues, mainly China-based; and 3) enhancements to SCDC institutional capacity.

The U.S.-based training course is tailored to provide real-world experiences of immediate and direct benefit to the collaborating in-country agencies, is concentrated on pragmatic approaches to environmental health issues, and is designed to be completed within a 6 month period. In addition, the program is designed specifically to ensure that trainees not only receive the desired information and skills, but that those skills are conveyed to corresponding environmental health investigations within an increasingly complex social and political setting, multiple competing interests, and high levels of uncertainty, with the objective of addressing public

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health concerns in China. Ten trainees working in the areas of environmental health, occupational health

and poison control, food hygiene, chronic disease control and prevention, community health promotion, laboratory and public health emergency response of SCDC have participated in the program to date. During their stay in the U.S., they observed and participated in EHIB’s approach to conducting large-scale epidemiological studies and to assessing, planning, implementing and evaluating environmental health programs, took part in various kinds of project meetings and important conferences, participated in different stages of public health preparedness and response training or drill program, went to fields to practice investigations, took needed courses at university, visited the offices of the Centers for Disease Control and Prevention (CDC), the Environmental Protection Agency (EPA), the Poison Control Center (PCC), local health departments, hospitals and other related agencies. They also discussed complex problems at a meeting in China with experts from U.S., exchanged some information from different fields in China, and also had trips in communities to learn more about U.S.A. After the training courses, most of the trainees understood American society better, basic structure and missions of CDHS, EHIB, CDC, and other related agencies, general methods and techniques of treating public health problems, general ideas when facing a problem, Geographic Information Systems (GIS) use, data processing and analysis, community health promotion, public health preparedness and response, and also, improved English. The most important thing is now the trainees have used what they have learned for the future. Surely, some of the trainees have designed and implemented new projects, some have published papers, some have been assigned more important positions in new programs, and some have conducted training courses in their fields. The training benefits not only the trainees’ own job, but also those that they work with.

Two important international conferences sponsored by this program, the 3rd and the 4th International Academic Conference on Environmental & Occupational Medicine, were held successfully in Shanghai and Kunming, China. Topics covered a broad range of environmental and occupational health topics, such as public health, environmental and occupational health systems; health risk factors such as tobacco, organophosphate pesticides, lead, aluminum, dioxin and other chemicals, air, water pollution, physical and psychosocial work conditions, global climate, socio-cultural backgrounds and human health; asthma, cancer and acute injury; monitoring, surveillance, assessment, epidemiological, toxicological, biological and gene study; risk communication, education, intervention, and promotion; public health preparedness and response to chemical events or terrorism; primary occupational health service in developing countries, laboratory methods, techniques and safety; healthy cities; health strategies, policies and so on. Many experts from U.S., China, Canada, Italy, German, Australia, Singapore, India, Japan and Korea presented those topics, and two collections of conference theses have been published. More than 5oo professionals from different countries attended these two conferences. The conferences offered an opportunity for world wide scholars to exchange and share information, to meet informally, and to pursue issues of mutual interest to the

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government public health agencies. The conferences not only exchanged information between U.S. and China, but also shared information world wide.

In addition, the program has constructed a website to serve as both an aid to trainees and as a public overview to the project, and supported translating all abstracts of the Chinese Journal of Environmental and Occupational Medicine into English, impacted SCDC created protocols to redirect staff to deal with large acute outbreaks, helped organize a workshop to support proteomic studies of genetic and environmental influences on disease in China, and has been planning and assuming some collaborative projects, such as the China National Biological Specimen Bank.

The program in its first stage has planted seeds and sown results in improving SCDC’s and ultimately China CDC’s effectiveness. Providing US-based training to SCDC managers allows them to return to Shanghai and share their knowledge with their own staff. Indexing Chinese journals will enable more exchange of information and will support improvements in Chinese scholarship. It’s really a great achievement of this great training program!

Although the program is going very well now, there are some limitations. The long distance between U.S. and China make communication difficult. The trainees often cannot keep in touch with experts from EHIB, at the same time, it is not easy for EHIB to follow the trainees, and both groups find it difficult to exchange information and share their new experience with outside partners. This is really a big problem that needs to be solved soon. In fact, when we have up-to-date public health news, we need to share it with others; to do a project plan, we need to get data and other ideas from the outside; when we encounter problems, we need to discuss them with experts; even when we want to improve our language skills, we need contact to people. In all these cases, what we need most is a convenient communication system. Increasing international contact will result in greater trust and more rapid warnings to international colleagues, leading to faster responses to emerging public health threats. So a convenient and economical long distance public health information platform should be developed soon.

2. Technologies and Methods of Information Exchange

2.1 TelephoneTelephone is still the most common and efficient communication device. Its

network extends worldwide, so people can reach nearly anyone on the planet. Although some telephone systems have functions to call and speak to two or more people at a time, they are not very costly and easy for training or meeting use.

2.2 TeleconferencingTeleconferencing-- the real-time exchange of information between people who

are not in the same physical space, is a telephone call between more than two

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participants. It is now very popular in the world. If people want to have teleconferencing, they usually need the support of a teleconferencing system. A teleconferencing system mainly consists of a conference bridge and many phones. It connects people through the conference bridge, which is essentially a server that acts like a telephone and can answer multiple calls simultaneously. Software plays a large role in the bridge's capabilities beyond simply connecting multiple callers.

Through teleconferencing, people can conduct meetings, customer briefs, training, demonstrations and workshops by phone instead of in-person.

Many phone conferencing systems require a login and personal identification number (PIN) to access the system. This helps protect confidential and proprietary information during the call.

Video phones can add a visual element to conference calls. Businesses often need to share other visual information.

A company can have its own bridge or can contract with a service provider for conference call hosting.

2.3 Satellite Video Conferencing A satellite video conference refers to events broadcast by satellite. This system

does not use telephone lines or cable systems, instead uses a satellite dish for two-way (upload and download) data communications. It usually consists of a transmitter and receiver dish antenna, two modems and coaxial cables between dish and modem. Now, Satellite communication systems are usually connected to the internet. They use Internet Protocol (IP) multicasting technology, which means up to 5,000 channels of communication can simultaneously be served by a single satellite. IP multicasting sends data from one point to many points at the same time by sending data in compressed format. So, it is an effective solution to communicate simultaneously with large groups in multiple locations locally, regionally, or nationally. It is especially a good choice for people living in rural areas who want broadband access to the Internet. Some providers let attendants interact with call-in questions, e-mail or fax during the conference.

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2.4 Web-based Information Utilities2.4.1 Web page & WebsiteA Web page is a simple text file that contains not only text, but also a set of

HTML tags that describe how the page should look when a browser displays it on the screen. HTML stands for Hyper Text Markup Language. A "markup language" is a computer language that describes how a page should be formatted. It can be used to change fonts, add colors, create headlines, links and embed graphics in the page. So, a web page can contain any type of information, and can include text, color, graphics, animation and sound.

A Web browser, like Netscape Navigator or Microsoft Internet Explorer, is a computer software application that can interpret the set of HTML tags within the page in order to display the page on screen as the page's creator intended it to be viewed, and can go to a Web server on the Internet to request a page, and pull the page through the network and into the user's machine. To get information from the internet, one must install a web browser in his/her computer and get an internet connection.

A website is a collection of web pages. It can consist of one page, or of tens of thousands of pages, depending on what kind of information and how much of them the site owner is trying to share with people on the internet.

If someone wants to share his/her information with others on the internet, he/she must design a website and create its web pages first, then select a web server, get a web address there, and upload the web pages there. A web server is a piece of computer software that can respond to a browser's request for a page, deliver the page to the web browser and save the customers' web pages through the internet. A web address is a unique computer/host location on the internet. People use it to access where a certain website locates. It is expressed either as a unique string of numbers or as its associated domain name, assigned by the web server provider. There are many web server providers in the world.

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2.4.2 E-mailE-mail has become an extremely popular communication tool. An e-mail message has always been nothing more than a simple text message --

a piece of text sent to a recipient. Although the ability to add attachments now makes

many e-mail messages quite long，even with attachments, however, e-mail messages

continue to be text messages.To receive and send e-mail, one must select an e-mail server and get an e-mail

account there first. Then are needs to install an e-mail client, such as Microsoft Outlook or others. E-mail client is a kind of software that shows user a list of all of the messages in the mailbox by displaying the message headers, lets user select a message header and read the body of the e-mail message, lets user create new messages and send them, and most e-mail clients now also let user send or receive attachments with the messages.

The real e-mail system consists of two different servers running on a server machine. One is called the SMTP server, where SMTP stands for Simple Mail Transfer Protocol. The SMTP server handles outgoing mail. The other is either a POP3 server or an IMAP server, both of which handle incoming mail. POP stands for Post Office Protocol, and IMAP stands for Internet Mail Access Protocol. A typical e-mail server looks like this:

2.4.3 Voice over Internet Protocol (VoIP)VoIP is a method for taking analog audio signals, like the kind you hear when

you talk on the phone, and turning them into digital data that can be transmitted over the Internet. VoIP can turn a standard Internet connection into a way to place free

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phone calls. The practical upshot of this is that by using some of the free VoIP software that is available to make Internet phone calls, you are bypassing the phone company (and its charges) entirely. So it decreases the cost of phone calls sharply.

There are three different "flavors" of VoIP service in common use today: ATA - The ATA is an analog-to-digital converter. It takes the analog signal from

your traditional phone and converts it into digital data for transmission over the Internet. Some providers have bundled ATAs free with their service. Users need only to plug the cable from the phone that would normally go in the wall socket into the ATA, and it has been ready to make VoIP calls. Some ATAs may ship additional software that is loaded onto the host computer to configure it.

IP Phones - These specialized phones look just like normal phones with a handset, cradle and buttons. But instead of having the standard RJ-11 phone connectors, IP phones have an RJ-45 Ethernet connector. IP phones connect directly to your router and have all the hardware and software necessary right onboard to handle the IP call. Wi-Fi phones allow subscribing callers to make VoIP calls from any Wi-Fi hot spot.

Computer-to-computer - This is certainly the easiest way to use VoIP. There is free or very low-cost software that can be used for this type of VoIP. The user needs the software, a microphone, speakers, a sound card and an Internet connection.

2.4.4 VoIP audio conferencesAudio conferencing using VoIP works very similarly to a traditional conference

call using analog telephones. In a conference call, callers connect to a conference bridge, a server that allows multiple people to talk to one another. VoIP audio conferences use the same principle -- callers connect to a conference bridge via their telephones or computers.

The main difference involves how the data moves from one point to another. Traditional telephones use circuit switching. For circuit-switched conferencing, the telephone system routes calls through a series of interconnected switches until it reaches the conference bridge. The conference bridge then connects multiple calls to one another. If all of the callers are located in the same office building, their calls connect to the bridge through the private branch exchange (PBX), which is a miniature phone network within the office. Either way, all the connections stay open as long as the call continues. Usually, only one person talks at a time, so only parts of the connection are actually in use at any given time.

VoIP networks do not use circuit switching. Instead, they use packet switching. While circuit switching keeps the connection open and constant, packet switching opens a brief connection -- just long enough to send a small chunk of data, called a packet, from one system to another. Instead of traveling from switch to switch, the data travels across the Internet, usually following the most efficient path.

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Conference calling capabilities are often built into VoIP networks or available as a service upgrade. If a business uses a VoIP network for its telephones, calls from outside of the company can still typically connect to the conference bridges. External lines may connect directly to the bridge server, or external calls may reach the server through the VoIP network.

2.4.5 Instant Messaging (IM) Instant messaging allows user to maintain a list of people that the user wishes to

interact with. User can send messages to any of the people in the list as long as that person is online. Sending a message opens up a small window where people can type, receive and see messages.

ICQ, a combination of letters that is shorthand for the phrase "I seek you," is the first IM tool, developed from a chat room in November 1996. For the great advantage of IM, many IM utilities have been developed in the world, such as AIM, MSN messenger, Skype messenger, UC, QQ and so on. The last two IM utilities are very popular in China. Almost all of these popular instant-messaging programs have free software, and they provide a variety of features:

Instant messages - Send notes back and forth with a friend who is online Chat - Create your own custom chat room with friends or co-workers Web links - Share links to your favorite Web sites Images - Look at an image stored on your friend's computer Sounds - Play sounds for your friends Files - Share files by sending them directly to your friends Talk - Use the Internet instead of a phone to actually talk with friends Streaming content - Real-time or near-real-time stock quotes and news

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IM programs usually use a software application, called a client, it needs to be installed on the user's computer. The client communicates with its server whenever the user is online and the client is running. Some client supports group chat, user can invite 2 to 9 friends to chat together. Now, some IM clients can communicate with other servers, for example, with the latest version of Yahoo messenger users can communicate with the latest version of MSN messenger users.

To use an IM tool, one needs to download and install a client, register a user ID from its server, run the client and logs in its server, and add friends in the list. Then one can communicate with those who are online, or leave messages to any of his/her friends.

2.4.6 Chat RoomA chat room is software that allows a group of people to type in messages that

are seen by everyone in the "room". It was developed in the early 1990s, and AOL (America Online) is considered the pioneer of this online community. It provides its users with the ability to talk in real-time with each other while they are online through the use of chat rooms and instant messages.

In recent years, many chat rooms have been developed and many communication functions have been added to the chat room. With these chat rooms, people can communicate with each other by text, image, audio, video, white board, display the video of speakers, transmit files and internet links, share applications and even have many people speak at same time. Most chat rooms can accommodate hundreds people.

When people register an IM, they get the authority to go into any of the IM server’s public chat rooms.

To get a private chat room that can accommodate more than 5 to 10 people, in most cases the user must register and pay for it.

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2.4.7 Web ConferencingHaving a conference on the internet requires support of a conference server. A

conference server is software running on sophisticated hardware delivering multimedia solutions to groups across IP-based networks (internets). It can send data from one sender to one receiver or to all participants, exchange visual information using webcams and streaming video and allow people to share whiteboard, documents online.

A web conference system requires three pieces of software working together; the conference server, the client, and a browser.

The conference server and the client usually combine tools already common to web pages and Internet communication. They bundle these tools into one interface to create an interactive meeting environment. These tools include:1) HTML, XML and ASP markup; 2) Java scripts; 3) Flash animation; 4) instant messaging; and 5) Streaming audio and video. It can merge with a user's existing e-mail, calendar, messaging and office productivity applications, or allow attendees to view the presentation in their regular web browser without installing any additional software.

The browser is used to open a security channel to the server during conference. User logs onto the conference server through his/her browser. Once the username and password are acknowledged by the server, the user's client application can access the conference.

A wide variety of web conferencing systems are available on the market. Some of them are entirely computer- and Internet-based, and others use the telephone system to distribute audio content. Depending on the software, people can:

View slide presentations from programs like PowerPoint. Draw or write on a common whiteboard by using their computer mice or

typing. Transmit still pictures or video to other attendees via a webcam. (This

increases the required bandwidth and can sometimes slow the transfer of the presentation.)

View information from the moderator's computer desktop using screen sharing.

Share documents, often even if attendees don't have the software that created them, using application sharing.

Ask and answer questions through audio chat (as an integrated part of the software) or by phone.

And some versions even allow an operator to remotely control the computer of another participant.

Web conferencing systems include options for security and encryption. Most require moderators and attendees to use a login name and password to access the conference. Some use SSL or TLS encryption to protect data. Some users host web conferences on internal servers so that the data stays behind the corporate firewall.

To use web conferencing, users can either purchase conferencing software and host their meetings themselves or use a hosting service. Hosting services provide the software and server space on which to conduct meetings. Either way, the company or

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the hosting service must have software to coordinate the meeting and ample server space and bandwidth to accommodate it.

2.5 Comparisons of the Utilities

messagesInstant

InteractionFlexibility Facility Security

Message

RecordingCost score

Telephone A Y N Y M C M 8

Teleconferencing AV Y N Y M C M 9

Satellite video conference AV Y N N H C H 8

Website TAVIF N Y N L Y L 11

Email TF N Y N M Y L 9

VoIP A Y N Y M C L 9

IM TAVIF Y Y N M Y L 13

IM chat room TAVIF Y Y N M Y M 13

Web video conferencing TAVIF Y Y N M/H Y H 12

T – Text; A – Audio; V – Video; I – Image; F – File; Y – Yes; N – No; M – Middle; H – High; L – Low; C -- Conditional

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3. Consideration of the Information Exchange Platform

Structure

A long distance public health information exchange platform between US and China needs to provide an easy way to communicate with many people from different locations instantly; a virtual place for meeting, training, learning and discussing; information needed for investigation, emergency response, laboratory testing, research and so on. Considering its flexibility, feasibility, and acceptability, this information exchange platform should be developed with 4 basic components: website, group email, VoIP and internet chat room.

3.1 WebsiteThe website should be designed and maintained by both EHIB and SCDC,

managed by EHIB. Surely, the editor of different items may come from EHIB, SCDC or even other agencies. It is better to develop this website from the http://www.cal-china.org/, and should cover the followings:

3.1.1 IntroductionProvide information on the California - China Environmental Health Training

Program, its plan, trainees, mentors, activities and achievements.3.1.2 OrganizationsProvide information on EHIB, SCDC, Fogarty International Center, National

Institutes of Health and other people and organizations related to the program.3.1.3 News & EventsProvide news and events on environmental and occupational health, and or other

important public health related news and events.3.1.4 AnnouncementsProvide information on conference, meetings, activities and links to them.3.1.5 International ConferenceProvide conference information, agenda, presentations and others3.1.6 ProjectsProvide information on projects both of the EHIB and SCDC.3.1.7 ReviewingProvide epidemiology, statistics, methodology, etc, case study and other basic

knowledge. 3.1.8 Language LearningProvide both English and Chinese learning methods, skills and others.3.1.9 Community Health Education & PromotionProvide basic information to educate publics.

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3.1.10 Data BaseProvide laws, acts, regulation, testing criteria, analysis methods, Occupational

Exposure Limit (OEL), surveillance results, investigation reports, etc.3.1.11 Discussion Group/BBSA discussion group is a many to many form of communication. It lets visitors

post discussion topics and then reply and discuss their answers.3.1.12 Member ZoneProvide confidential information for registered people.3.1.13 Web LinksProvide links to related websites.3.1.14 URLProvide visitors the lists of related web address. Because some websites are

dynamic, which means that people may not be able to access them by links directly, some websites don’t allow other websites create links to them.

3.1.15 Q & AProvide useful questions and answers.3.1.16 DownloadsProvide files, presentations, software and so on.3.1.17 OthersProvide information on interesting cities, weather report, and others3.1.18 ContactProvide address, phone numbers, email, and others.

3.2 Group E-mailEHIB should set up a California - China Environmental Health Training

Program related group email system. Let registered people share more information about each other at the same time.

3.3 Web ConferencingTo try, it is better to select the UC Internet Chat Room as a virtual place to

communicate by text, audio or video between US and China. SCDC should register and manage it. In the future, SCDC should set up a web conferencing system for more usage on diseases control and prevention.

3.4 VoIPVoIP has been used widely in the U.S. SCDC should soon set up a VoIP system

to meet the increasing demands of instant communication.

4. Conclusion

The California - China Environmental Health Training Program has not only increased trainees’ knowledge and skills, enhanced the SCDC’s institutional capacity, but also influenced other professionals, impacted other health agencies in China,

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even in other countries. We are eager to develop a public health information exchange platform. This

will reduce the distance and communication challenges. The platform will enable information to reach where it needs to go efficiency.

There are many communication utilities to choose from. A website can accommodate every kind of data and provide almost unlimited information, and it can also receive feedback from its visitors. It is a very good medium for information; Web conferencing and Internet chat rooms can provide people a virtual communication environment. The instant transmission function of audio, video, text and file bring people together from different places world wide. These are no doubt the best conversation tools. Although email can only carry limited information once, nothing can replace its position yet; The VoIP has a very good facility, capability and economical characteristics for communication. They are all our top choices as important components of our information exchange platform. With them, we can easily exchange information anywhere in the world.

An integrated multiple communication system may bring us many benefits. SCDC needs to set up both a VoIP system and a web conferencing system to meet the great increasing demands of communication within and outside of the agency.

5. References

http://www.cal-china.org/http://communication.howstuffworks.com/teleconferencing.htmhttp://www.tech-faq.com/teleconferencing.shtmlhttp://www.ultracall.co.jp/eng/confe/http://ced.ncsu.edu/2/videoconference/admin/webconf.htmhttp://www.megameeting.com/

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