1. for Health & Human Services Spring 2013Esri NewsIt feels like thorns scraping your eyes eachtime you blink. Repeated infections during your childhoodlead to scarring of the conjunctiva, or innermucous membrane of the upper eyelid. Youreyelashes turn inward and scratch the cornea.Slowly, painfully, you may go totally blind. The affliction is called trachoma, and itaffects the poorest of the poor—mostlywomen and children—especially in regionsthat have limited access to sanitation andwater. More people suffer from trachomain Africa than on any other continent. AndSaving Sight Beyond the End of the RoadArcGIS Helps Fight World’s Leading Cause of Preventable BlindnessBy Mike Schwartz, Esri Writerbecause this bacterial disease is transmittedvia close personal contact, it tends to occur inclusters—often affecting entire families andcommunities. Approximately 110 million people world-wide live in endemic areas and requiretreatment, with 210 million more living wheretrachoma is suspected of being endemic,according to the International TrachomaInitiative (ITI) at the Task Force for GlobalHealth based in Decatur, Georgia. “Affected people are said to be livingbeyond the end of the road,” said Dr. Danny The point features generated by the Esri software can be aggregated to the health district,turning the health district classification from “suspected endemic” to a prevalence value. Thisknowledge drives health interventions. Genemo Abdela is one of many surveyorsexamining almost 600,000 people in Ethiopia.The team is identifying areas where peopleare at risk from trachoma and hence wheretreatment programs are needed. (Credit:Dominic Nahr/Magnum/Sightsavers.)continued on page 4
2. Spring 2013Esri News for Health & Human Services is apublication of the Health & Human ServicesSolutions Group of Esri.To contact the Esri Desktop Order Center, call 1-800-447-9778within the United States or 909-793-2853, extension 1-1235,outside the United States.Visit the Esri website at esri.com.View Esri News for Health & Human Services online at esri.com/health or scan the code below with your smartphone.Advertise with UsE-mail email@example.com.Submit ContentTo submit articles for publication in Esri News for Health & HumanServices, contact Michael Schwartz at firstname.lastname@example.org.Manage Your SubscriptionTo update your mailing address or subscribe or unsubscribe toEsri publications, visit esri.com/publications.International customers should contact an Esri distributor tomanage their subscriptions.For a directory of distributors, visit esri.com/distributors.Circulation ServicesFor back issues, missed issues, and other circulation services,e-mail email@example.com; call 909-793-2853, extension 2778;or fax 909-798-0560.QR code generated on http://qrcode.littleidiot.be2 Esri News for Health & Human Services  Spring 2013ContentsThe information contained in this work is the exclusive property of Esri or its licensors. This work is protectedunder United States copyright law and other international copyright treaties and conventions. No part of thiswork may be reproduced or transmitted in any form or by any means, electronic or mechanical, includingphotocopying and recording, or by any information storage or retrieval system, except as expresslypermitted in writing by Esri. All requests should be sent to Attention: Contracts and Legal Services Manager,Esri, 380 New York Street, Redlands, CA 92373-8100 USA.The information contained in this work is subject to change without notice.The Geographic Advantage, Esri, the Esri globe logo, 3D Analyst, ArcAtlas, ArcCatalog, ArcData, ArcDoc,ArcEditor, ArcExplorer, ArcGIS, the ArcGIS logo, ArcGlobe, ArcIMS, ARC/INFO, ArcInfo, ArcLogistics, ArcMap,ArcNetwork, ArcNews, ArcObjects, ArcPad, ArcPress, ArcReader, ArcSDE, ArcSurvey, ArcToolbox, ArcTools,ArcUser, ArcView, ArcVoyager, ArcWatch, ArcWeb, ArcWorld, ArcXML, Business Analyst Online, BusinessMAP,CommunityInfo, EDN, Geography Network, GIS Day, MapData, MapObjects, Maplex, MapStudio,ModelBuilder, MOLE, NetEngine, RouteMAP, SDE, Sourcebook•America, StreetMap, Tapestry, @esri.com,esri.com, arcgis.com, geographynetwork.com, gis.com, and gisday.com are trademarks, service marks, orregistered marks of Esri in the United States, the European Community, or certain other jurisdictions.Other companies and products or services mentioned herein may be trademarks, service marks, orregistered marks of their respective mark owners.Copyright © 2013 Esri.All rights reserved.Printed in the United States of America.Cover 1 Saving Sight beyond the End of the RoadEsri News3 From My View6 Esri on the Road6 Christina’s Conference CornerCase Study 8 GIS Tracks Emerging Statewide Patient Care Patterns10 A New Probe for CSI?
3. 3Spring 2013  esri.com/healthThey are everywhere and in every coun-try—smartphones. People are connectedand empowered in ways never previouslyimagined. When I go anywhere, I take out mysmartphone and input my current locationand end point address to get a route to mydestination. Almost instantly, I am suppliedwith not just one but several routes to choosefrom. Each has a total travel time, mileage,and often estimated times of arrival that factorin the traffic. Isn’t this the same on other paths we take inlife? Before committing to a particular courseof action, isn’t it wise to do our homework?Shouldn’t we learn as much as we can beforewe decide—whether traveling to a physicaldestination or deciding on a new home, a newjob, or where to go out for dinner? The biggerthe investment, the greater the risk of makinga poor decision. Like the smartphone, recent revolution-ary technological advances have enableddecision making in ways never before thoughtpossible. This includes personal and com-munity health. Research is exposing howthe communities we live in impact our ownpersonal health. Dr. Anthony Iton, senior vice presidentof Healthy Communities, the CaliforniaEndowment, states: “It is our ZIP code and notour DNA code that is the chief determinant ofour health.” At the Healthy Communities by DesignSummit at Loma Linda University, heldOctober 1 and 2, 2012, Iton and otherA Call for Smart Decisions inLean Economic TimesFrom My View . . .Christina Bivona-TellezEsri Health and Human Services Industry Solutions Managerspeakers challenged all of us to better under-stand that place matters. The summit broughttogether leaders who are charting differentcourses toward the embodiment of a healthycommunity, yet they agree that only by know-ing where existing challenges or obstacles arecan we begin to address them and become ahealthy community. As a whole, the population of the worldis aging, requiring more services across thecontinuum of care—from hospital intensivecare to community screenings for highblood pressure. What’s more, the significantgrowth of the senior population brings moredemands for services even as funding for sen-iors is being reduced. Simultaneously, babyboomers are demanding the best and mosttechnologically advanced care, which furtherdrives up costs. As we attempt to navigatethis new course for health care, we must notlose sight of the balance between deliveringefficient care and care that demonstratesquality outcomes. Economic pressures over the past five yearshave exposed how much more of the US grossdomestic product (GDP) is spent on health,but without corresponding quality of lifeindicators. All governments—local, regional,and national—are evaluating their budgetsin the realization that they must ratchetdown spending. Obvious targets for cutsinclude programs with the largest budgets.Health care and social services programsare being closely scrutinized, and limits arebeing set to keep funding at the same—orreduced—levels even as the demand isincreasing. Like selecting the routes to an agreed-upondestination, we in health and human servicesmust look at where we are and decide on thebest course of action to reach our goals. Wemust go beyond why we are seeing such asignificant increase in costs to determine thehow, where, and what-ifs. How can we more efficiently deliver careto those who need it most? Where wouldthat be? What if we do nothing—what is theimplication? For example, what if we decideto invest in a multiservice clinic in the part ofthe community where it’s needed—will it helpdecrease readmissions to the hospital? GISholds the key for health systems to under-stand the answers to these questions. We have unprecedented opportunities toprepare and determine a course to follow, butwill we be “smart” and take advantage of allthe information we have to truly understandwhere we are and where we need to be in thisnew age of innovation?Esri News
4. 4 Esri News for Health & Human Services  Spring 2013Haddad, director of the ITI. “In some in-stances, you need to walk half a day to get tosome of these villages.”Neglected No LongerUntil recently, a better ability to identifyenclaves of so-called neglected tropicaldiseases—such as leprosy, river blindness,lymphatic filariasis (elephantiasis), Africansleeping sickness, and trachoma—has provedelusive. Fortunately, researchers combiningAndroid and Esri software have figured out aquick way to visually assess the prevalence oftrachoma in remote regions and to pinpointgaps in prevention and treatment services,said Haddad. A trachoma developmental study of thelatest data collection, transfer, and visualdisplay process using ArcGIS was launchedin mid-October 2012 in the Oromia regionof Ethiopia. It is part of a global surveyfunded by the UK government and led bythe international nongovernmental organiza-tion Sightsavers, which aims to examine asample of four million people across morethan 30 countries by March 2015 to identifywhere people are living at risk of contractingtrachoma and where treatment programs areneeded. In Ethiopia, several layers of smartphoneand Esri technology enabled the immediatetransfer of vast amounts of collected data todistant hardware and software platforms fordisplay, analysis, and sharing.Saving Sight beyond the End of the Road  continued from cover Esri products were chosen because of theirdynamic capabilities, said epidemiologist AlexPavluck, a senior manager of research informa-tion technology at International TrachomaInitiative. ArcGIS maps are not only useful asvisual tools but also offer real-time transferof data and automated updates that providemuch-needed efficiencies, Pavluck said. “One thing we wanted was the ability toproduce layered maps,” he said. “These arereally the key here—to show prevalence over-laid with areas currently receiving treatmentssuch as donated drugs.” The goal was to help realize an ambi-tious plan endorsed by the World HealthOrganization (WHO)—a dream, if you will, ofendemic countries with organized nationaltrachoma control programs—called GlobalElimination of Trachoma by the year 2020, orGET2020.“Affected people are saidto be living beyond theend of the road. In someinstances, you need towalk half a day to get tosome of these villages.”Dr. Danny Haddad, Director ofInternational Trachoma Initiative
5. 5Spring 2013  esri.com/health According to Haddad, the Esri technology-enhanced system wasbuilt on one already developed for a variety of neglected tropicaldiseases, including trachoma. It relied on Android devices, which madeit easy for field-workers to use. A robust reporting back end alloweddata to be sent via cellular network or Wi-Fi to a web-based systemat Task Force headquarters. It didn’t take long for this approach toachieve surprising results, transmitting data on lymphatic filariasis from18 countries. “Before we used the Android tools, we had piles of paper that hadto be manually entered after a survey,” recalled Haddad. Initial successencouraged public health workers in endemic countries to realize thata system such as this—but one that was even more capable—wasneeded to reach WHO’s ambitious GET2020. Global Atlas of Trachoma—developed in 2011 by the InternationalTrachoma Initiative with the support of partners such as the LondonSchool of Hygiene & Tropical Medicine, the Carter Center, and theBill & Melinda Gates Foundation—provided up-to-date regional mapsof trachoma’s geographic distribution. Health workers now couldreach more people with preventive hygiene; corrective surgery; andthe antibiotic azythromycin (Zithromax), donated by pharmaceuticalmanufacturer Pfizer Inc. Nevertheless, researchers discovered that the database supportingthe atlas identified more than 1,200 health districts that still lacked thedata needed to guide interventions. “We still didn’t have the entire picture,” said Rebecca Mann, geo-graphic information systems data manager at International TrachomaInitiative.Heart of the SystemThe latest Esri-enhanced system is designed to correct that. Here’show it works: Trained field-workers initially collect data on smart-phones and tablets using Android technology. “That’s the beauty of it,” said Mann. “The app can go on any devicerunning Android.” Then the devices quickly transfer data to a website on a serverhoused in Decatur where it is summarized, checked for errors, andmapped. Using a 3G connection, the data can be transmitted to theserver in real time. Next, the data moves to a central MySQL server linked to an ArcGISmapping server. A Python script automatically converts tabular datainto feature points that link to ArcGIS map templates embedded in aproject website on arcgis.com. These points accumulate on the webmaps as data is collected, illustrating the distribution of surveyed clus-ters and ensuring that selected samples spatially represent the entiresurvey area. The server makes the data accessible worldwide so researchers andmanagers can review the accumulating information in real time, thenapprove it for wider dissemination such as within the trachoma atlas,said Danny Hatcher, an applications developer with Esri ProfessionalServices in Atlanta, Georgia. ArcGIS for Server pushes the data onto more detailed maps thatshow the entire survey area, providing visual displays that aid healthworkers in more quickly identifying areas and people needingtreatment. “It was nice that we didn’t have to reinvent the wheel,” said Hatcher,who set up the servers and wrote the Python script. “We could fit handin glove with ITI’s existing process and turn it into a map it could use.”Proof of Concept Mann recalled her excitement when the Ethiopian pilot projectbegan. Pavluck needed just half a day to train a team of local field-workers how to use the smartphones. “Because the system is so simple, it isn’t necessary to train a highlyspecialized team,” Mann said. When the field-workers in Ethiopia started collecting data, Mannand her colleagues in Decatur could actually see it flow from thephones to their server. “Python script converted the data into feature points, which I per-sonally added to the first mapping template,” she said. As more datacame in, the system automatically updated the website. The researchers plan to add features if the system runs smoothly.“As we get into the rhythm of things, I’m sure we’ll want to tweak oursystem,” Mann said. “But right now, we’re trying to keep it as simpleand straightforward as possible.” Haddad said researchers now are looking at other neglected tropicaldiseases and, thanks to ArcGIS, can more clearly see gaps in defensesagainst them. “This system is making a huge impact on how we runour programs,” he said. “It allows us to make much faster decisions onwhat we need to do.”For more information, contact RebeccaMann at firstname.lastname@example.org or visitwww.taskforce.org, www.trachoma.org,www.trachomaatlas.org, andwww.trachomacoalition.org. The teams responsible for surveying people in Ethiopia for trachomameet early in the morning before heading out to their assignedcommunities. Sixteen teams work to identify the disease in Ethiopia.(Credit: Dominic Nahr/Magnum/Sightsavers.)Esri News
6. 6 Esri News for Health & Human Services  Spring 2013Esri on the RoadEsri Health GIS ConferenceWhen: October 14–16, 2013Host: EsriWhere: Hyatt Regency, Cambridge,Massachusetts, USAWeb: esri.com/events/healthPlenary: David C. Goodman, MD, DartmouthUniversitySpeaker: Bruce D. Greenstein, Louisiana Secretaryof StateHighlights: • Be able to learn and discuss what others are doing with GIS in your industry. • See the latest updates on Esri technology. • Learn from members of the media how health is being impacted and portrayed in 2013. • Take a tour of Harvard University and see its GIS Operations Site and map libraryInquiries: E-mail email@example.com.Save the Date6 Esri News for Health & Human Services  Spring 2013World of Health ITMay 13–15, 2013Dublin, Irelandwww.wohit.orgHealth DatapaloozaJune 3–4, 2013Washington, DC, USAwww.hdiforum.orgEuropean Social Services ConferenceJune 17–19, 2013Dublin, Irelandwww.esn-eu.org/european-social-services-conference/index.htmEsri International User ConferenceJuly 8–12, 2013San Diego, California, USAesri.com/ucChristina Bivona-Tellez, Esri health and human services industry solutionsmanager, regularly participates in key conferences that will inevitably impacthealth care and human services not only in the United States but worldwide.Here are highlights, notes, and impressions of meetings she attended last fall: The Health Information Management Systems Society (HIMSS) meetingbrought together more than 1,900 attendees from 35 countries to learn theprevalent trends and vital issues affecting health care in hospitals and healthsystems around the globe. At the plenary session, government and health careleaders from countries including Australia, New Zealand, Hong Kong, Singapore,and Taiwan discussed best practices, advances, and insights. In the opening keynote, Dr. Blackford Middleton of Harvard Medical Schooland Brigham and Women’s Hospital in Boston, Massachusetts, cited a study oninhalers; the study used GIS to map the location and time of inhaler use as wellas the release of emissions by a large industrial plant. Suddenly, a previouslyhidden correlation was revealed. The airborne emissions from the plant added dimensions to the analysis.Unless we try to understand the context of these conditions by mapping intime and place, Middleton said, we are missing key elements to knowing howbest to engineer significantly improved outcomes. He cited the latest Instituteof Medicine finding that the amount of new information becoming available farexceeds the capacity of the human brain to incorporate it—so technology suchas GIS must be employed to make sense of this vast sea of data.Christina’sConference CornerDates September 17–19, 2012Title HIMSS Asia PacificOrganizer HIMSSVenue Marina Bay Sands Expo and Convention Center, Singapore
7. 7Spring 2013  esri.com/healthDates October 1–2, 2012Title “Place Matters”: Healthy Communities by DesignOrganizer Loma Linda University School of Public HealthVenue Loma Linda University and Esri, Redlands, California In its third year, the 2012 Healthy Communities by Design Summitused geospatial technology to raise awareness of the relationshipbetween natural and man-made environments. Many presenters—in-cluding Michael Topmiller, a GIS data specialist with HealthLandscapeLLC, which makes an interactive web-based mapping tool for healthcare providers—came armed with amazing GIS maps that eloquentlyrevealed how health issues like obesity may stem from key contributingfactors such as low community walkability. Other presenters revealed maps displaying poor health outcomesand the impact of bad air quality. Participants exchanged ideas and discussed new community plan-ning approaches that leverage geospatial information to improve com-munity health. Two exceptional keynote addresses challenged each ofus to rethink our notion of community and how we need to press forpolicies that make sense. Dr. Richard Jackson, chairman of the Environmental SciencesDepartment at University of California, Los Angeles (UCLA), stressedthat environment is often ignored even though it has even greaterimpact on health than do social, economic, and educational factors.“In epidemiology, when everyone develops the same illness aboutthe same time, it is almost inevitably a common-source epidemicthat has its origin in the environment,” Jackson said, and the truthis revealed when data is mapped using powerful tools like GIS. Hecharged the group to work together to create places that promotehealth, a task that requires attention. A longtime consumer of Esri GISproducts since his days working at the Centers for Disease Controland Prevention (CDC) and Los Angeles Department of Public Health,Jackson touted the critical role of geospatial analysis in health promo-tion and prevention. Again, we and our health are all tied to place. On day two, Dr. Anthony Iton, senior vice president of HealthyCommunities at the California Endowment, observed that the healthstatus of disadvantaged populations is directly correlated with factorssuch as race, class, wealth, education, geography, and employment,challenging the group to recognize the impact of “health inequity.”Maps and accompanying photographs engaged the audience andunderscored the key points. “Our ZIP code is an even more powerfulhealth determinant than our DNA code,” Iton said.Esri NewsELLIOT LEARNING CENTERVALLEJO HIGH SCHOOLTENDER DAY CAREBetter Decisions Make Better CommunitiesEsri®Community Analyst provides you with all the data and tools you need toprioritize your critical policy projects. Access thousands of economic, health,business, and education data variables through instant reports and mapsso you can make informed decisions for your community.Start your free trial atesri.com/communityanalystCopyright © 2013 Esri. All rights reserved.
8. 8 Esri News for Health & Human Services  Spring 2013Like other Medicare and Medicaid providers,Community Care of North Carolina (CCNC), acommunity-based, public-private partnership,has sought innovative solutions for control-ling costs and improving quality of care forthe 1.2 million beneficiaries it serves out ofthe state’s 1.6 million Medicaid recipients.CCNC needs to not only manage currentexpenses but also prepare for the estimated38.2 percent increase in North Carolina’sMedicaid population expected by 2019. Community Care of North Carolina hastaken a population management approachto providing services for the state’s mostvulnerable residents. Operating through14 local network partners, CCNC coordinatespatient care via so-called “medical homes,”saving taxpayers nearly $1.5 billion between2007 and 2009, according to one independentstudy. Managed by primary-care physicians,the medical home model provides accessible,continuous, coordinated, and comprehensivepatient-centered care with the active involve-ment of nonphysician medical personnel. Esri gave CCNC the edge it needed toachieve quality and efficiency by providinga powerful visual tool that allowed map-ping and analysis of emerging patient-carepatterns across the state and among CCNC’s14 network partners. CCNC turned to HealthLandscapeLLC—developer of UDS Mapper, MedSchool Mapper, and other web-based GISapplications—to build the North CarolinaCommunity Health Information Portal (NC-HIP). It was developed as an extension of theHealthLandscape platform, which uses Esri’sArcGIS 10.1 for Server, ArcGIS API for Flex,ColdFusion, and SQL Server. According to Annette DuBard, MD, MPH,director of quality, informatics, and evaluationfor CCNC, the organization has, since its in-ception 25 years ago, viewed GIS as a naturalnext step in using data to inform patient care. Although CCNC had a long and successfulhistory of engaging providers around data, itssystems were incomplete. Still missing wasGIS Tracks Emerging StatewidePatient Care PatternsNorth Carolina Improves Quality of Care for Medicare and Medicaid PatientsBy Mark Carrozza, MA, Health Informatics Developer, HealthLandscape LLCa way to visualize and understand emergingpatterns of care across the state and with thecompany’s network partners. Moreover, therewas no system in place for comparing CCNC’sinternal indicators against public healthindicators. GIS offered the hope that by putting clini-cal and claims data together with public data,CCNC could better understand what washappening at the community level, DuBardsaid. “We were seeing greater use of mappingand visual representations of data,” she said.“We became really interested in developing aGIS system to help us identify where opportu-nities for improvement exist.”Project HistoryIn 2010, one of CCNC’s network partners,Southern Piedmont Community Care Plan(now called Community Care of SouthernPiedmont), was named a Beacon Communityby the Office of the National Coordinator forHealth Information Technology (ONC). ONC awarded grant money to the federalBeacon Communities program over threeyears to build and strengthen health infor-mation technology (IT) infrastructure andexchange capabilities; make investments inIT that would result in measurable improve-ments in cost, quality, and population health;and develop innovative approaches tomeasure performance and improve patientcare. Community Care of Southern Piedmont,one of 17 Beacon Communities in the UnitedStates, was awarded a $15 million grant. Stakeholders within the Southern PiedmontBeacon Community (SPBC) saw the program Visualization Showing Age-Adjusted Cardiovascular Deaths per 1,000 Persons (2010) inNorth Carolina
9. Case Study9Spring 2013  esri.com/healthfunding as an opportunity to implement aGIS-based data dissemination system. Eachhad its own need: CCNC recognized thatvisually displaying clinical data collected viaelectronic health records on a GIS map couldsignificantly add to CCNC’s ability to drivequality improvement, public health partnerswanted more timely access to clinical data,and all stakeholders wanted a way to visualizepublic health indicators alongside clinicalhealth indicators.CCNC Network SitesNC-HIP is currently in the second of threephases and includes a public-facing site withcounty-level data as well as restricted sites foreach of the 14 networks. “Some data is restricted to internal CCNCnetwork staff, such as practice-level data oncosts and utilization and also risk-adjustedperformance measures,” said Sarah Lesesne,data analyst for CCNC and a coordinator ofthe rollout efforts. “For our networks, thesemeasures help display any potential geo-graphic trends in their practice data.” Lesesne has designed a comprehensiveprogram to ensure the tool is used widelyacross CCNC. “We have presented the portal to variousworkgroups: pediatrics workgroups, qual-ity improvement practice support groups,network quality improvement staff, networkand clinical directors, and others,” she said.“We’ve also identified ‘super users’ withineach of the networks. Their role is to bepoint person for the portal; facilitate regulartraining sessions; and bring users together toshare lessons learned and discuss how they’reusing the portal.”Public Health PartnersHealthLandscape incorporated the ability tocompare two indicators directly. This is par-ticularly important to public health profession-als, who want to be able to compare clinicalindicators against public health data. Side-by-side views enable users to lookat two indicators at once. The Comparisontool allows users to visualize the relation-ship between two indicators; they can see ahigh/high, high/low, low/high, and low/lowrepresentation of the data and can adjust thebreakpoints for comparison. The North Carolina Institute for PublicHealth, one of the SPBC partners, will betraining health department users in a moreformalized fashion, potentially offering certifi-cation in the tool.Initial Findings and Phase IIIAccording to DuBard, the portal is enablinganalysts to obtain a new view of metrics theyhave been following for some time. “It gives us the ability to see where wehave wide variation in our clinical carequality measures,” she said. “Often, there’sa 10 percent spread between the lowestand the highest quartiles. Showing the datageographically helps us hone in on whereimprovement opportunities exist.” Finally, said DuBard, GIS paints a broadpicture for all SPBC’s constituents. “It is morecompelling to see the data on a map, and itmakes it easier to talk about health factors ata community level. We can now take some ofthis data to more of a lay audience and focusit, saying, ‘This is an issue for our community.’It is helping us identify indicators that thecommunity can engage around,” she said. DuBard’s team, which is still makingenhancements to the portal, has two goals.“First, it’s important to obtain smaller-than-county views that map out disease prevalencedata, chronic disease outcomes, and hospitalutilization rates for smaller geographies—per-haps down to the census tract level,” saidDuBard. Then the team wants to both see the datastratified by subpopulations—race, gender,income—and be able to do comparativevisualizations to get a better view of healthcare disparities. “Ultimately,” said DuBard, “CCNC wants todevelop NC-HIP into a tool that gives doctors,public health workers, and policy makers arobust way to respond to the health needs ofthe community.”For more information,contact Mark Carrozzaat firstname.lastname@example.org. Above is a comparison view of age-adjusted percentage of adults withdiabetes and percentage of adults witha college degree. Dark blue shadingindicates geographies with high diabetesand high college-degree percentages; redindicates high diabetes, low college‑degreepercentages; light blue indicates low diabetes,high college-degree percentages; and yellowshows low diabetes and low college-degreepercentages.
10. 10 Esri News for Health & Human Services  Spring 2013Bone mapping at Ohio StateUniversity reveals the spatialrelationships of microscopicstructures and how bone was usedduring life. Researchers show thatArcGIS offers potential uses inforensic medicine, skeletal biology,and anthropology.Bone researcher David C. Rose straddles twoworlds. The Ohio State University (OSU) doctoralstudent in anthropology is also a captain inthe university’s Police Division, in which rolehe sometimes dealswith forensic inves-tigations involvinghuman remains. That exposure—and his focus onskeletal biology—gives Rose a uniquevantage point, whichprompted him tolaunch a project to determine whether pat-terns of change inside human bones couldreveal how they were used during life. Rose and coinvestigators Amanda M.Agnew, Timothy P. Gocha, Sam D. Stout, andJulie S. Field used Esri ArcGIS (through OhioState University’s Esri university site license)to identify and map features inside a humanmetatarsal, a long bone in the foot, creatingan entirely new way to study human skeletaland biological variation. Rose began the project to explore howbones grow quickly, adapting to the load thatis placed on them. “Patterns of tension andcompression show up in our internal bonestructure, and this software lets us look atthose patterns in a new way,” he said. The research is relevant for studying notonly internal human bone structure but alsothat of other species such as horses, said Rose.“We can use GIS to compare species and seehow animals differ from us.” Coresearcher Stout, professor of anthropol-ogy at Ohio State and Rose’s doctoral adviser,explained why the findings—first publishedonline in the June 14, 2012, edition ofA New Probe for CSI?ArcGIS Offers a Novel Way to Analyze Human BonesAmerican Journal of Physical Anthropology—are important: “Dave’s work allows us to visu-alize, analyze, and compare the distribution ofmicroscopic features that reflect the develop-ment and maintenance of bones. We can thenrelate this to skeletal health and disease, forexample, bone fragility in osteoporosis.” One other study—published by research-ers in Madrid in the June 2012 Journal ofStructural Biology—used GIS to map humanlong bone differentiation in shape, size, andtissue type during development from embryoto adult. But to the OSU research team’sknowledge, this is the first time anyone hasused ArcGIS software to map and analyze thespatial distribution of bone microstructure.Genesis of a New GIS ApplicationHow did Rose hit upon the notion of enlistingGIS in bone research? Early on, he knew that ArcGIS mappingsoftware could analyze nearly any kind of spatialdata, from crime statistics to flood models. Heeven used it to map line-of-sight views whiledeveloping security plans for events on campus. As it turned out, Rose had taken upper-level archaeology classes as part of his gradu-ate school curriculum. His instructor, JulieField, an assistant professor of anthropologyat Ohio State, had used GIS extensively inher fieldwork to map the location of objectsuncovered at excavation sites. Field emphasized the need to identify im-portant clusters of objects, such as householdor agricultural tools, that would indicate pat-terns of human activity, recalled Stout. “Basedon whatever scientific criteria you establish,ArcGIS software gives you a statistical meas-ure of whether the objects you’re looking atactually constitute a cluster,” he said. According to Stout, Field saw the potentialof using GIS as a research tool in measuringthe distribution, size, shape, and strain historyof bone microstructure. “You’re trying to describe how strong abone is for bending, tortion, and use,” Stoutsaid. “How much of a load can it experi-ence and how much at risk is a person for afracture? For example, this is useful data for The computer monitor on the right shows ArcGIS 10 running witha bone map displayed. The image on the left is a bone cross sectionunder magnification. (Photo courtesy of Dave Rose, pictured.)
11. 11Spring 2013  esri.com/healthdesigning air bags in cars to minimize thechance of incurring skeletal fractures.”Small Bone Yields Big ResultsFor this study, which became his master’sthesis, Rose examined the cross section of ametatarsal from a deceased woman who hadgenerously given her body to the Division ofAnatomy’s body donation program. Using thisbone cross section, the researchers dem-onstrated how the software could be usedto show the loads on the foot caused by thewoman’s gait—that is, while walking. Rose recorded an extremely high-resolutionimage of the bone cross section under amicroscope. He used ArcGIS to map thelocation of key structures called osteons—thefundamental functional unit of compact bone. In this case, said Rose, the donor’s metatar-sal showed the predicted pattern of normalbone remodeling. It had concentrations ofparticular types of osteons along the top andbottom of the bone that could have beenformed by forces exerted as she walked. Rose acknowledged that his currenttechnique is invasive and cannot be used ona living person. “But in the future, ‘nano-CT’may examine a person’s bones to determinethe risk of fragility and fracture,” he said.Promising Technique NeedsRefinementBoth Rose and Stout caution that this studyprovides only a proof of concept and thatmany more types of bones would have to bestudied before GIS software could providemeaningful insight into bone biology. Nevertheless, foot bones are especiallyuseful in forensics due to the sometimes grue-some reality of unidentified remains: often,only the foot bones are intact, having beenprotected by shoes. “Other bones may bechewed up by animals, but a well-preservedfoot bone can be a very useful forensic ap-plication,” said Stout. Rose added that the reliable use of thistool for forensic applications calls for a betterunderstanding of spatial distribution. “Butthat’s still some years away,” he said. “This is anew area of research, and right now only onegroup is working on this, and that is ours.” At OSU, under Stout’s supervision, Roseis combining very basic concepts in GIS andskeletal biology. However, he foresees atremendous opportunity for advances at theintersection of the two disciplines. Rose added, “The real advantage to thismethod is that it offers a new scale for the studyof human physical variation, offering to shedlight on how we adapt to our surroundings.”For more information,contact David Rose,captain, Police Division,Ohio State University, atrose.81@osu-edu or bycalling 614-292-6367, orvisit researchnews.osu.edu. A Close-up of the Metatarsal Showing Marked Features of Interest in GIS (Photo courtesy of David C. Rose.)Case Study
12. PresortedStandardUS PostagePaidEsri380 New York StreetRedlands, California 92373-8100  usa134015  18.3M3/13spEsri International User ConferenceYou are GIS.You gain knowledge, share expertise, and help us understand our world.There’s a place where GIS goes beyond coordinates, breaks free of categories, and reaches pastanalysis. A place where products are launched, ideas are shared, and inspiration is set loose.Join us at the Esri UC. Register today at esri.com/uchealth.United we map!Esri International User ConferenceJuly 8–12, 2013 | San Diego Convention Center