URISA GIS/Health Conf. -- "The Evolving Role of GIS in Hospital/Healthcare Emergency Managment" (short) -- Ric Skinner
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URISA GIS/Health Conf. -- "The Evolving Role of GIS in Hospital/Healthcare Emergency Managment" (short) -- Ric Skinner

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The Evolving Role of GIS in Hospital & Healthcare ...

The Evolving Role of GIS in Hospital & Healthcare
Emergency Management
Ric Skinner, GISP
The Stoneybrook Group LLC www.healthGISguy.com

I’ve been involved with the application of GIS in hospitals and healthcare for about 20
years. During this time I’ve experienced and observed GIS being applied in epidemiology,
health sciences, health resources, clinical/medical areas, health facilities management, market analysis, medical recruiting … and as I’ll discuss today … hospital and healthcare emergency management and disaster preparedness. The material for this talk comes from
research I’m doing for a book that will be published by CRC Press early next year on the
evolving role of GIS in hospital and healthcare emergency management.

This is the short version of my presentation as given at the conference June
6, 2009. A longer version will also be uploaded.

Ric Skinner, GISP
www.healthGISguy.com


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  • 1. The Evolving Role of GIS in Hospital & Healthcare Emergency Management The Stoneybrook Group LLC Ric Skinner, GISP I’ve been involved with the application of GIS in hospitals and healthcare for about 20 years. During this time I’ve experienced and observed GIS being applied in epidemiology, health sciences, health resources, clinical/medical areas, health facilities management, market analysis, medical recruiting … and as I’ll discuss today … hospital and healthcare emergency management and disaster preparedness. The material for this talk comes from research I’m doing for a book that will be published by CRC Press early next year on the evolving role of GIS in hospital and healthcare emergency management.
  • 2. Successful Reponse Starts with a Map Improving Geospatial Support for Disaster Management Committee on Planning for Catastrophe: A Blueprint for Improving Geospatial Data, Tools, and Infrastructure Mapping Science Committee Board on Earth Sciences and Resources Division on Earth and Life Studies www.nap.edu/catalog/11793.html Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The National Academy of Sciences concluded in their report that geospatial data and tools should be an essential part of every stage of emergency management, from planning through response and recovery to the mitigation of future events. This is certainly true in the hospital and healthcare domain.
  • 3. Critical Infrastructure and Key Resources Agriculture and Food Defense Industrial Base Energy Healthcare and Public Health National Monuments and Icons Banking and Finance Water Chemical Commercial Facilities Critical Manufacturing Dams Emergency Services Nuclear Reactors, Materials Waste Information Technology Communications Postal and Shipping Transportation Systems Government Facilities Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The Department of Homeland Security includes hospitals and healthcare facilities in the list of Critical Infrastrucure/Key Resources and emphasizes the important contribution that geospatial technology plays in protecting these assets in the Homeland Security Grant Program Supplemental Resource on Geospatial Guidance.
  • 4. The 80% Paradigm 80% of information needed for decision making has a location or spatial component (Yung et. al, 2008) More than 80% of all healthcare transactions are believed to have significant geographic relevancy (Davenhall, 2003) As much as 80% of information used during emergencies is 'spatial' information (EMSINA, 2004) Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Further justification is what I call the “80% Paradigm” It is commonly said that 80 percent of information needed for decision making has a location or spatial component More than 80 percent of all healthcare transactions are believed to have significant geographic relevancy. As much as 80 percent of information used during emergencies is 'spatial' information
  • 5. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Many books and articles have been published on the application of GIS in emergency management. A number of these have addressed GIS as a tool in the public health sector, and some articles can be found on GIS in hospital/healthcare emergency management. GIS is rapidly evolving and clearly has an important role in this area. This is because many of the emergency management challenges faced in hospitals and healthcare, such as resource inventory and allocation, situation awareness, decision support and locational intelligence, are the same that other business sectors experience. My talk today will provide some examples of how hospitals and healthcare facilities are benefiting from the use of GIS to improve their emergency management mandates and responsibilities. There won’t be time to cover all the examples I have found, however they will be included in the full length presentation that will be available in the conference proceedings. You’ll hear similar approaches and implementations of GIS are occurring from a variety of sources. I have a lot to cover so let’s get started. First you’ll see a title slide referencing the source of the example and then one or more illustrating slides. The slides and description are based on material provided by the source authors.
  • 6. Network GIS as a Tool for Healthcare Emergency Preparedness in Special Situations Petros Apotsos Independent Civil Engineering Consultant Greece Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI It is crucial for healthcare facilities to have a routing GIS in order to offer the best possible response to emergency calls and disaster situations. Based on scale and need, these systems can cover a city, a county or even a whole state or country. Given the specific characteristics of each area and based on integration level, scenarios can be developed in Healthcare Management so that the routing system takes these special situations into account. The use of a routing system for emergency units can decrease the response time to an emegrgency call
  • 7. All road networks should be modeled in the highest detail possible, so as to offer accurate routing data an Natural disaster cutting or impairing certain segments of the network. Evacuation or heavy traffic situations when parts of the network are gridlocked above predicted lev Situations when traffic direction limitations are compromised resulting in other parts of the networ
  • 8. Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) Charles Branas, University of Pennsylvania Marlen Kokaz, Cartographic Modeling Lab & Robert Cheetham, Avencia Corp. Philadelphia, PA Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The siting of trauma center hospitals is more complex than just maps of land area coverage showing ringed bands around each hospital. The speed and location of helicopters and ambulances, the number and location of trauma centers in a region, and the spatial relationships between these facilities need to be considered.
  • 9. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH) is a mathematical optimization model that uses population and access to existing trauma centers based on geographic relationships to ambulances and helicopters to simulate the effects of newly sited trauma centers. TRAMAH is supported by an interactive website that uses GIS technology to enable visitors to identify the locations of current hospitals and trauma centers and their accessibility via ambulance or helicopter.
  • 10. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI This slide shows the modeled 60 minute response time by ambulance or helicopter to trauma centers in Oregon.
  • 11. Disaster Preparedness and Response for Vulnerable Populations: Essential Role of GIS for Emergency Medical Services during the San Diego County 2007 Firestorm Isabel Corcos, Holly Shipp, Alan Smith, & Leslie Upledger-Ray, County of San Diego, Health and Human Services Agency, Public Health Services Agency, Emergency Medical Services San Diego, CA In 2007, a massive wildfire “firestorm” destroyed nearly 400,000 acres of San Diego County, and more than 500,000 individuals were evacuated from fire-threatened areas.
  • 12. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The San Diego Department Operations Center coordinated the evacuation of medically fragile individuals from residential health care facilities and 2 acute care hospitals using GIS to pre-plan the evacuation of threatened facilities. 12
  • 13. EMS directed 2100 medical evacuations in one day Evacuation with minimal impact on 2 acute care hospitals patients 1 psychiatric hospital Moved them only once 12 skilled nursing facilities With 3 days of medications With their medical records With staff from the sending facility Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI GIS-trained epidemiologists drew perimeters around rapidly changing fire zones, evacuation zones, and predicted fire paths in order to locate nursing homes, group homes, care centers and other medical facilities within the affected areas. All patients evacuated from a medical facility were tracked through the DOC. 13
  • 14. Integrating GIS into Emergency Medical Services Peter Dworsky MONOC Monmouth-Ocean Hospital Service Corp. Neptune, NJ Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI In the recent ditching of US Airways flight 1549 in the Hudson River, over 50 BLS Ambulances, 6 paramedic Units, 3 medevac helicopters, 10 specialized Mass Casualty Response Trucks and trailers along with more than 200 EMS providers were dispatched to multiple staging areas throughout the region. All of the assets were tracked at the local level and some not at all. Technology was not leveraged and some units were lost as they were repositioned. Hospitals typically do not have the ability to see the incident other than what is on TV.
  • 15. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI By integrating EMS into Healthcare GIS systems, EM agencies and hospitals will be able to make better use of their resources and activate disaster plans based on real time data. This is a screen shot from a dispatch console of a system showing color coded primary response zones.
  • 16. Introducing GIS to Hospital Emergency Management Decision-makers Joseph G. Ferko III DO, MS EMS Innovations, Inc. Pasadena, MD Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The disaster operations environment is changing for the hospital/healthcare emergency manager and GIS is seeing an increasingly more important role.
  • 17. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI In many Mass Casualty Incidents the hospital emergency manager no longer works in the hospital. The hospital is now moving to the scene or surging to the outdoors.
  • 18. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI GIS is being used for the mapping of injury and illness locations for WMD and pandemic. Considerations include locating patients and locations for staging medical care. GIS is also being used for the determination of staffing, pre-positioning of supplies and transportation issues.
  • 19. Natural Disasters and the Role of GIS in Assessing Need Omar Ha-Redeye Univ. of Western Ontario & Bryan Heal The Armichand Group Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI In the past 10 years, topographic maps generated by GIS have become as indispensable to humanitarian healthcare providers as surgical kits and purified water. Under intense pressure to act quickly, aid agencies and governments increasingly use GIS maps as a foundation for major decisions from aid planning to where to build a field hospital.
  • 20. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI In some countries the traditional practice of talking to people and gathering on the ground intelligence is still important. However, GIS compliments sound field epidemiology principles conducting a post disaster needs assessment. 20
  • 21. Integrating GIS into county based emergency management, HVA, and disaster planning on Florida's East Coast James C Kendig Health First Inc. Rockledge, FL Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI GIS was used to formulate the county's and hospital based Hazard Vulnerability Assessment (HVA) which was ultimately used to help develop the approved emergency management plan and drill scenarios supported by the HVA.
  • 22. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Do you think location might be important factor for this Florida hospital? And do your therefore think that GIS might be an important tool in the hospital’s Hazard Vulnerability Assessment?
  • 23. 1900-2005 Atlantic Hurricanes and hurricanes passing within 75 miles of Cape Canaveral Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI GIS is used in joint-partnership programs participation with ESF8 (health & medical facilities) during disasters, and the development of a hospital evacuation tool that has matured from a fax based approach to a web based system. Clearly, GIS can be an important tool in regional approaches to mutual aid.
  • 24. Boston Marathon Patient Tracking Johanna Meyer AECOM Boston, MA & Dana Ohannessian Mass DPH Boston, MA Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI GIS use in emergency management for events like the Boston Marathon offers the ability to track events and people.
  • 25. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI From the lead runners to the injured, the events along a 26 mile route are recorded and reviewed to allow the dispatch of assistance. ESF-8 (Health & Medical Facilities) tracks each injury from evaluation to hospital admissions along the route at multiple locations. This real time tracking also monitors the emergency room capacity as ambulances are dispatched.
  • 26. GIS and Regional Mass Casualty Incident Planning: The Role of GIS in Identifying Regional Risks and Assets Jonathon Mohr Philadelphia University & J. L. Querry City of Philadelphia Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI In the wake of ongoing economic challenges, many acute healthcare facilities are closing to reduce costs. As a result, the numbers of available hospital beds are shrinking in many urban areas. This presents both a challenge and an opportunity for planners.
  • 27. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The use of GIS can provide timely analysis of a region’s shuttered facilities with the potential for reactivation and utilization during a mass casualty incident. The use of GIS can help identify at-risk primary and secondary sites through Hazard Vulnerability Analyses and assist with enhanced logistical planning of evacuation routes. The integration of GIS in regional planning could ultimately lead to a more accurate identification of the best facilities in the region for the sheltering of evacuated patients and long-term patient care during and after a mass casualty incident.
  • 28. GIS at Emergency Medical Center Zagreb Vlatko Roland GISDATA Zagreb, Croatia Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Emergency Medical Center Zagreb (EMCZ) provides medical help to citizens of Zagreb, Croatia using a sophisticated computer aided dispatch system based on GIS technology. The project was funded by the World Bank.
  • 29. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Incoming calls are located on the map and a medical doctor enters relevant information and determines level of emergency. This data is captured in incident database.
  • 30. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Dispatchers retrieve this data, determine the nearest available vehicle and assign the incident to the team in the field. This allows faster response and more efficient utilization of emergency resources.
  • 31. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Since 2002., when the system was implemented, more than a million interventions have been recorded in the database.
  • 32. The Emergency Response System Agent 9-1-1™ Sabatni Monatesti, Jack Murphy, Jeff Sherer, Stephen Beller, Paul D. Cacciamani & David G. Smith ES Enterprises Inc., JJM Associates, Instaknow Inc., NHDS Inc., Synergist Technology Group, Inc. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The 1st responder and the Trauma unit are faced with many difficulties in a disaster including dynamic triage relocation, effective apparatus dispatch, decision processing, situational awareness, victim search & rescue, and real time victim identification. 32
  • 33. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI This system is designed to leverage GIS technology in a unique way using a patented, interoperable technology which ensures that hospitals and healthcare facilities benefit from bringing disparate databases together for improvements to situation awareness, resource inventory & allocation, and decision support. 33
  • 34. Hospital Preparedness Planning for Evacuation and Sheltering with GIS Jared Shoultz, Doug Calvert, Guang Zhao & Max Learner, DHEC Division of Public Health Informatics & Office of Public Health Preparedness South Carolina Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI At the South Carolina Department of Health and Environmental Control GIS plays a critical role in all emergency response, preparedness, planning, and routine public health activities. It has developed a system that is accessed by coastal hospitals for emergency preparedness and planning.
  • 35. Critical Data Sheets System • Designed for Hospitals, Nursing Homes, and Hospice Facilities along the SC Coast. •If facilities have any intentions of “sheltering-in- place” for a Category III or less hurricane they must have all information completed so it can be reviewed for approval by DHEC before evacuation. Non-spatial Benefits •Linked to license database to pull data •Accessible from any PC with web access and data stored offsite from facility •Standardized for reporting on vehicles requested, sheltering agreements, transport vendor arrangements •All info needed to evaluate sheltering requests (communications plans, emergency contacts, emergency generator, wind loads, supplies, etc..) Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The Critical Data Sheets System integrates licensing data from the state with critical emergency response GIS layers such as shelters, flood zones, surge zones, evacuation routes, transportation infrastructure, and evacuation zones to provide hospitals without GIS capabilities the ability to enter and evaluate their Shelter in-place plans against these crucial layers.
  • 36. Spatial Benefits • Spatial Tools for facilities with no “in-house” GIS • Advanced Analysis, Visualization and Reporting •Predefined overlays with surge zones, evacuation zones and evacuation routes •“Real-time” overlay capabilities with weather and hurricane track data Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI This gives the hospitals the ability to access these plans from anywhere at any time and provide updates to DHEC in real-time while allowing DHEC to more fully comply with the NIMS architecture and have the ability to do full reporting and spatial queries from any location on the plans currently in place for each facility. DHEC uses these plans and the associated spatial data to determine if a request to shelter in-place for a Category III or less hurricane will be approved.
  • 37. GIS in Preparedness Preplanning Using Hospital Operational Condition Modeling Nathanial Szejniuk HICS Educational & Training Center Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Disaster preparedness and response is multi-dimensional. Factors that need to be considered include hazard event, location, distance, time, and staffing functions, among others. A concept that is gaining ground in health care is the Healthcare Operational Conditions or HOPCON readiness model. This application addresses the application of GIS in healthcare preplanning, as well as, post event recovery issues.
  • 38. 6/4/2009 1 2 3 4 Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI An example of GIS is to support concept of operations and situation awareness planning is illustrated here. This is a view of a hospital that is relatively close to a main railroad line. Maps such as this can reveal the importance of understanding hazards outside the healthcare facility, such as transportation incidents, hazardous materials storage, crime, flooding, etc. CHCER - Szejniuk 38
  • 39. Interagency Logistical Support during Emergencies Jerry D. VanVactor US Army Medical Service Corps Afghanistan Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Only recently have healthcare organizations begun to develop “partnerships among disciplines, across sectors, or with private sector and media in relation to disaster preparedness”.
  • 40. • Logistics readiness is a factor in each phase of emergency management • Preparation • Mitigation • Response • Recovery • Health care logistics does not begin and end with the first responder; in some cases, the institution can assume multifaceted roles before, during, and after a trigger event occurs. Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Preparedness, one of the the national emergency planning elements, involves leaders within multifaceted healthcare practices to conduct business processes in a state of readiness to respond to a disaster, crisis, or any other type of emergency situation. The hypothesis here is that logistics needs/demands extend beyond first responders and the emergency department during various phases of crisis intervention. GIS can aid in this aspect of emergency management. Technological developments are always evolving to allow organizations to manage inventory, track shipments, analyze cost and purchasing information, and develop trend analyses. 40
  • 41. Supply Node Supply Disaster Node Impact Area Downwind direction Medical Center Supply Supply Node Node Supply Node Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI This example depicts how the integration of multiple GIS can provide insight during a disaster for a healthcare logistics manager. Note that the hospital and one supply node is in the affected/impact area. Another supply node is affected by being down wind of the affected/impact area and is also inaccessible for re-supply operations. Another primary supply node cannot access the hospital through the disaster area. Planning that incorporates this kind of spatial analysis can provide the healthcare logistician with in-transit visibility and real time shipping data related to incoming supplies so that the medical center can maintain a continued access to supplies. 41
  • 42. Improving Prehospital and Disaster Response Using a Geographic Information Interface Elizabeth Walters, MD, Stephen W. Corbett, MD, PhD, & Jeff Grange, MD, Loma Linda University Hospital Loma Linda, CA Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI The Advanced Emergency Geographic Information System (AEGIS) AEGIS is reportedly the first integrated emergency system to provide the user access to a suite of tools necessary to manage resources and respond effectively and efficiently during prehospital and disaster incidents. Interoperable communications among a variety of devices is facilitated by AEGIS via text messaging to an individual or group participating through the system. Personnel in critical locations can be identified and given specific instructions, and personnel or assets in other locations can be redeployed to more strategic positions. This interface can be used universally at the response or command level, and across political and jurisdictional boundaries. It allows users to consider a diversity of pertinent information, interpret and analyze trends and threats, share information, and communicate with other responders. It is especially suited for operations where a great amount of information from multiple sources must be distributed and analyzed quickly for appropriate decision-making. It is designed to be agency independent and can be used for daily operations as well as for incident response. The system is designed to provide secure access to information sources, and to expand and contract to include only the information that is necessary for the level of response needed and operational success.
  • 43. •Hospital Name •Status •Time •Updated every minute •Air Photos •Fire Stations •Police Stations •Sheriffs Stations Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI AEGIS incorporates both static and dynamic information into a single user-friendly interactive map creating a unique level of situation awareness. Static information includes a variety of typical maps with the location and attributes of key facilities and resources. Dynamic information includes hospital diversion status, real time traffic information, weather conditions, and updated major incident information. AEGIS also visualizes ground and airborne emergency assets in real time.
  • 44. CA Highway Patrol Incidents CA Highway Patrol Incidents •Location •Location •Type •Type •Time •Time •Updated every minute •Updated every minute Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI Information from CHP’s CAD system, along with traffic and hospital information, allows the hospital to make better decisions in routing ambulances traffic. AVLs show where rescue and air evac helicopters are currently located, even shows direction and airspeed.
  • 45. ??? Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI These are just handful of the applications on how GIS is an evolving technology being widely utilized by hospitals and healthcare facilities as they enhance and improve emergency management and disaster preparedness and response. I want to thank all the contributors to this presentation. I’ve only included here what time will allow. An extended version of this presentation that includes all my contributors will be posted by URISA in the conference proceedings. And now, I can take few questions.
  • 46. Ric Skinner, GISP The Stoneybrook Group LLC Sturbridge, MA ric.skinner@gmail.com www.healthGISguy.com Ric Skinner, GISP The Stoneybrook Group LLC URISA GIS/Public Health Conf., June5-8, 2009, Providence, RI