Design Considerations for
Long Distance Public Health Information Exchange
Shanghai Municipal Center for Disease Control & Prevention
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
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
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
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
Telephone 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.
Teleconferencing-- the real-time exchange of information between people who
are not in the same physical space, is a telephone call between more than two
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.
2.4 Web-based Information Utilities
2.4.1 Web page & Website
A 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
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.
E-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
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 conferences
Audio 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.
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
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
2.4.6 Chat Room
A 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
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.
2.4.7 Web Conferencing
Having 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,
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
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
Transmit still pictures or video to other attendees via a webcam. (This
increases the required bandwidth and can sometimes slow the transfer of the
View information from the moderator's computer desktop using screen
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
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
messages Instant Flexibility Facility Security Message Cost 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
3. Consideration of the Information Exchange Platform
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.
The 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:
Provide information on the California - China Environmental Health Training
Program, its plan, trainees, mentors, activities and achievements.
Provide information on EHIB, SCDC, Fogarty International Center, National
Institutes of Health and other people and organizations related to the program.
3.1.3 News & Events
Provide news and events on environmental and occupational health, and or other
important public health related news and events.
Provide information on conference, meetings, activities and links to them.
3.1.5 International Conference
Provide conference information, agenda, presentations and others
Provide information on projects both of the EHIB and SCDC.
Provide epidemiology, statistics, methodology, etc, case study and other basic
3.1.8 Language Learning
Provide both English and Chinese learning methods, skills and others.
3.1.9 Community Health Education & Promotion
Provide basic information to educate publics.
3.1.10 Data Base
Provide laws, acts, regulation, testing criteria, analysis methods, Occupational
Exposure Limit (OEL), surveillance results, investigation reports, etc.
3.1.11 Discussion Group/BBS
A 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 Zone
Provide confidential information for registered people.
3.1.13 Web Links
Provide links to related websites.
Provide 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 & A
Provide useful questions and answers.
Provide files, presentations, software and so on.
Provide information on interesting cities, weather report, and others
Provide address, phone numbers, email, and others.
3.2 Group E-mail
EHIB 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 Conferencing
To 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.
VoIP has been used widely in the U.S. SCDC should soon set up a VoIP system
to meet the increasing demands of instant communication.
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,
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.