A Location-based Health Information Service

1. A Location-based Health Information Service Applying geographic filters to enable access to immediately relevant information Maged N Kamel Boulos, PhD

2. Agenda • Background • Location Matters • The Power of Where • Location-specific Health Information • Location-based Services Defined • Knowing Where Users Are • Stopgap Solutions: Choose Your Location • IP Geo-targeting/ Geolocation Solutions • Related Technology: Hypertag • Aim • Objectives • Example Scenario • Important Issues and Concerns Related to the Proposed Service • Different Device Capabilities • User Privacy • Resource Pool Visualisation and Navigation Issues • Other Issues of Concern • Research Potentials and Opportunities • Conclusion

3. Location Matters - 1 • The concept that location can influence health is well known in medicine and public health science. • Certain diseases tend to occur in some places and not others. Health information needs and services also vary with location. • Different places on Earth are usually associated with different profiles that can also change with time: physical, biological, environmental, economic, linguistic, social, cultural, and sometimes even spiritual profiles, that do affect and are affected by health, disease, and healthcare.

4. Location Matters - 2 • On the following two slides I am using GIDEON (Global Infectious Disease and Epidemiology Network—<http://www.gideononline.com/>) to diagnose a case of splenomegaly (no other clinical findings were input to the program). • The two screenshots show the “Diagnosis Results” (with probabilities) for the same patient but with a different country of disease acquisition in each screenshot (Kenya and United Kingdom in this example). • You can clearly see how the differential diagnosis and probabilities differ in each case by just changing the geographical location of disease acquisition.

5. Location Matters - 3

6. Location Matters - 4

7. The Power of Where - 1 • Brute health information delivery risks overloading users with unnecessary information that does not answer their actual needs, and might even act as noise, masking any other useful and relevant information delivered with it. • Caregivers need to know not only the history of patients they treat but also information about the social and environmental context within which those patients live.

8. The Power of Where - 2 • Patients and the public in general also have similar needs that vary with location. • A big challenge for online health information services today remains to find and push location-specific knowledge to users based on their location and associated needs (location awareness). Location matters, and the Internet should be no exception to this rule.

9. Location-specific Health Information • Examples include: • local disease rates, maps and guidelines; • targeted health education; • addresses of local healthcare facilities; • local health news; • local weather, pollen and air quality alerts and maps (e.g., for asthmatics); • local health risks and hazards; • travellers’ health information; • local drugs/ drug trade names and prices (in local currency); • information whose digital distribution rights are limited to some location(s); • in addition to serving up content (and interface) in language(s) relevant to the viewer’s location. Fact: 75% of the world’s population do not speak English.

10. Location-based Services Defined • Location-based services blend information about a person’s location with other useful content, providing relevant, timely and local information to consumers when and where they need it (IBM). • The market for location-based services is expected to reach US $20 billion by 2005, according to industry analyst Ovum (<http://www.ovum.com/>), especially with the advent of the wireless Web and the convergence of different information delivery media. • Location-based services need not be limited to mobile devices or to routing (e.g., where is/ how to reach the nearest pharmacy) and service dispatch functions. The field of application of location-based services is much wider than mobile devices only (Hogeweg, 2001).

11. Choose Your Location - 1 • The inability of online information services to deliver relevant content on the fly has forced the adoption of stopgap solutions like asking the user to “choose location” (Parekh, 2002). • After Web site visitors have made the effort to choose their city, country and language, they try to find the information they are looking for. The effort is entirely made by the visitor, but on the Internet usually visitors do not want to make too much effort. If the effort required is too high, visitors will leave, and maybe go to see what competitors are offering (van Leeuwen, 2001).

12. Choose Your Location - 2

13. Choose Your Location - 3 • Allowing the user to manually enter his/ her location (and other “user profile” information if they wish so) remains a good option (complementary to automatic IP geolocation) and I am not excluding it, e.g., to offer visitors the possibility to choose a different language and/ or set of location-specific content other than that automatically chosen by the service.

14. IP Geo-targeting - 1 • Internet Protocol (IP) geolocation is the science of determining the location (up to city and sometimes postal code levels) of a Web site visitor based on his/ her IP address (Quova—<http://www.quova.com/>). IP addresses consist of four blocks of numbers, e.g., 138.40.220.250. They can be compared to telephone numbers and are needed by computers on the Internet to communicate with each other. It is impossible to communicate without IP addresses. A maximum of 4.25 billion IP addresses can be issued because the four blocks range from 0 to 255.

15. IP Geo-targeting - 2 • IP geolocation does not use any DNS reverse look-ups, or WHOIS look-ups to determine a visitor’s location. They use very frequently updated proprietary databases to resolve a visitor's IP address to the corresponding geographical location. • IP Geo-targeting can be seen as the GPS (Global Positioning System) of the Internet. Internet services that make use of geo-targeting will travel with (and adapt to) users, wherever they go (Hogeweg, 2001). • IP targeting enables Web information services to recognise the geographical location of visitors in real-time and serve content relevant to location.

16. IP Geolocation Solutions - 1 Source: Quova GeoPoint—<http://www.quova.com/>

17. IP Geolocation Solutions - 2 Source: Digital envoy NetAcuity—<http://www.digitalenvoy.net/>

18. IP Geolocation Solutions - 3 Source: Geobytes GeoSelect— <http://www.geoselect.com/>

19. IP Geolocation Solutions - 4 • InfoSplit—<http://www.infosplit.com/> • GeoIP City Edition—<http://www.maxmind.com/app/city> • The National Security Agency: Network Geo-location Technology—<http://www.nsa.gov/programs/tech/factshts/20020506.htm>The National Security Agency, America’s cryptologic organisation, claims its methodology is very accurate, does not produce any false positive results and will scale well compared to other methods when the world moves from IP version 4 with 32 bits of address space to IP version 6 with 128 bits. Related Articles: van Leeuwen A. Geo-targeting on IP Address - Pinpointing Geolocation of Internet Users. GeoInformatics. July/August 2001 - <http://www.geoinformatics.com/issueonline/issues/2001/07_2001/pdf_07_2001/28_31_iptar.pdf> Hogeweg M. Relocation Based Services. GeoInformatics. September 2001 - <http://www.geoinformatics.com/issueonline/issues/2001/09_2001/pdf_09_2001/13_hogeweg.pdf>

20. Hypertag Technology - 1 • Location-based services need to know where users are. • Hypertag (<http://www.hypertag.co.uk>), a Cambridge-based company, has created cheap, smart tags that can be installed in information posters and adverts on the street to beam Web links to mobile phones and PDAs. • Consumers who see an interesting advert can point and click their phone or PDA at the advert to instantly access corresponding Web-based information. • Online content is thus delivered where it will be most useful and relevant.

21. Hypertag Technology - 2 Targeted health education example(Idea: MN Kamel Boulos) Link to http://www.cdc.gov/ChooseYourCover/

22. Aim • To develop a pilot location-aware online health information service targeting caregivers, patients and the public in general (with different content for different user roles). • This implies the development of a localised clinical/ health content server with the functionality to customise content to the location and needs of the viewer in real time.

23. Objectives at a Glance Metadata* Collect/ Describe Reasoningwith Metadata** Select Optimised UserExperiencePresent Personal Profile Content (Resource)Selection and FormattingModels/ Rules Goal: For every user, always serve the right personalised content in suitable form and format Device Profile Location Profile Resource Descriptions Enabling access to information that is immediately relevant to users *Including spatial (where) and temporal (when) metadata about user and resources **User’s spatial history, if known, can improve results

24. Objectives - 1 • To apply suitable methods for gathering and storing user profiles, including detecting their location (online user-filled forms and automatic location detection using for example GeoSelectIP geolocation technology–see<http://www.geoselect.com/Demo.htm>); • To determine the different location profiles of target users (a location profile describes the language, health and healthcare makeup/ problems and corresponding clinical/ health information needs associated with that location); Metadata ontologies are needed to define and store user, device, location and resource characteristics and relationships (profiles or descriptions).

25. Objectives - 2 • To develop the necessary content selection models or rules for different locations; • To create a suitable clinical/ health content (metadata) pool for the proposed service based on existing, freely accessible Web resources and health news sources(plus any suitable resources developed in-house).Selected resources must be adequately indexed regarding topic, provenance, coverage or scope, language, intended audience and other relevant aspects, in order for the proposed service to be able to unambiguously match content to location and user; “If you do not index it, it does not exist. It is out there but you cannot find it, so it might as well not be there.”—Barbara Quint, ASI San Diego Conference, 1994

26. Objectives - 3 • To implement a suitable language, interface and content customisation engine that can act on all of the above metadata and selection rules to always serve the right content in suitable form and format; • To continually evaluate the service during its development; and • To regularly document and publish results of the above steps in internal reports and appropriate peer-reviewed journals. • There is also a possibility of submitting the clinical/ health-specific metadata frameworks that are expected to arise out of this project to the appropriate standards bodies.

27. Example Scenario - 1 • IP targeting enables Web information services to recognise the geographical location of visitors in real-time, e.g., at the instant someone enters a Web site, it is recognised that the visitor is from Illinois, USA. Based on that knowledge, content can be shown which is likely to be relevant to visitors from this country, region or city.

28. Example Scenario - 2 Health content tailored to suit the needs of a visitor accessing the proposed IP-based/ location-based health information service from Illinois, USA, on 23 October 2002 Location-specific Health Problem: West Nile Virus (WNV) Visitor IP: 163.191.183.220Location detected: Springfield, Illinois, USA

29. Example Scenario - 3 Health content tailored to suit the needs of a visitor accessing the proposed IP-based/ location-based health information service from Illinois, USA, on 23 October 2002 WNV Latest News

30. Example Scenario - 4 Health content tailored to suit the needs of a visitor accessing the proposed IP-based/ location-based health information service from Illinois, USA, on 23 October 2002 WNV Prevention Information

31. Different Device Capabilities • User devices used to access a service might change with location, e.g., a desktop or laptop computer at home or in the clinic and a more limited mobile device on the road. • The drawback of the small size of mobile devices is that display is considerably smaller and input much more difficult (e.g., no full-scale keyboard). • Location-based services should ideally take into consideration the input and output characteristics of different devices by carefully choosing, personalising and formatting the content to display on such devices. Photo Caption: The first phone powered with Microsoft® SPV* Smartphone 2002 will be available at retail on 11 Nov 2002 in the UK for £180 (*SPV = Sound Pictures Video).

32. User Privacy - 1 • IP geolocation alone does not rely on cookies, profiles, registration data, or any other privacy-invasive techniques to identify the geographic location of an Internet user’s IP address and is incapable by itself of collecting other personally identifiable information. • Moreover, because IP addresses can be shared by hundreds of different devices (users) over the course of a few hours, individual privacy is further ensured (van Leeuwen, 2001).

33. User Privacy - 2 • Consumers’ personal privacy becomes an issue of concern when extra personal information is collected besides IP location for enhanced health content personalisation (e.g., age, gender, occupation, etc., using user-filled forms) and when cookies are used to memorise preferences and track users. • Services should publish their Privacy Policy and respect consumers’ choices in this regard, or better still adopt the emerging P3P initiative (Platform for Privacy Preferences—<http://www.w3.org/P3P/>).

34. User Privacy - 3 P3P is a machine-readable vocabulary and syntax for expressing a Web site’s data management practices. A site’s P3P policies present a snapshot summary of how the site collects, handles and uses personal information about its visitors. P3P-enabled Web browsers and other P3P applications will read and understand this snapshot information automatically, compare it to the Web user’s own set of privacy preferences, and inform the user when these preferences do not match the practices of the Web site he or she is visiting.Figure and Caption Source: <http://p3ptoolbox.org/guide/section2.shtml#Iia>

35. Resource Pool Visualisation and Navigation Issues • As online information portals accumulate metadata descriptions of Web resources, it becomes necessary to develop effective ways for visualising and navigating the resultant huge metadata repositories as well as the different semantic relationships and attributes of described Web resources. Interactive graphical maps provide one good method to visualise, understand and navigate a world that is too large and complex to be seen directly like the Web.Maps based on familiar metaphors taken from users’ everyday life are much easier to understand. Associative and pictorial map icons that enable instant recognition and comprehension are preferred to geometric ones and are key to successful maps for browsing medical/health Internet information resources.

36. Presentation Matters Recognition Not RecallScreenshot of parts of HealthCyberMap† and Visual Net navigational maps for resources on “heart diseases”. Notice the difference in map iconicity between HealthCyberMap and Visual Net approaches, and the map clutter resulting from Visual Net’s way of representing each resource directly on the map using a distinct point symbol. †The author’s PhD project. Only HealthCyberMap uses GIS and a clinical ontology to classify Web resource data and render the maps.

37. Other Issues of Concern - 1 • The overall accuracy of IP geolocation varies between 95% and 98% depending on the currency, coverage, and granularity/ resolution* of the underlying geolocation provider database. This figure will never become 100% due to the existence of dynamic IP addresses and organisations that enter the Internet through one proxy server (van Leeuwen, 2001). • Users should be allowed to manually override IP locations determined by the service (if needed—this could be done once then stored in a personal profile that can be updated as often as necessary). • * Country only vs. country, region/ state, city and maybe also postal code.

38. Other Issues of Concern - 2 • Other issues: information quality*, maintaining service currency, scalability of developed solutions, etc.* See: Kamel Boulos MN, Roudsari AV, Gordon C, Muir Gray JA. The Use of Quality Benchmarking in Assessing Web Resources for the Dermatology Virtual Branch Library of the National electronic Library for Health (NeLH).Journal of Medical Internet Research 2001;3(1):e5 <URL: http://www.jmir.org/2001/1/e5/> [PubMed ID: 11720947]

39. Research Potentials and Opportunities - 1 • There are great potentials and opportunities for research into this innovative, cross-disciplinary topic that brings together the health informatics, health geographics, geoinformatics and Semantic Web communities. • Location-based information means information that is immediately relevant, which is the essence of the Semantic Web (see <http://semanticweb.org>). • Research literature on location-based health information services is currently very scarce (only one peer-reviewed paper by the author in PubMed/MEDLINE as of March 2003*). * Kamel Boulos MN. Location-based health information services: a new paradigm in personalised information delivery.International Journal of Health Geographics 2003 Jan;2:2 <URL: http://www.ij-healthgeographics.com/content/pdf/1476-072X-2-2.pdf> [PubMed ID: 12556243]

40. Research Potentials and Opportunities - 2 • More pioneering publications are expected to arise out of this research, besides its potential strategic value to international and national online health information services, for example: • National electronic Library for Health (<http://www.nelh.nhs.uk/>); • Public Health electronic Library/ Network (PHeL—<http://www.phel.gov.uk/>); and • NHS Direct Online (<http://www.nhsdirect.nhs.uk/>).

41. Conclusion • Delivering real-time, location-enhanced and personalised health information and services can help consumers and providers accelerate and optimise their decision-making process in many medical/ health situations and problems. • The integration of a carefully selected variety of medical/ health Internet information services and resources with users’ tasks, needs, preferences and their device capabilities should enable users to focus more on informed decision-making and result in better health outcomes.

42. Some Related Peer-reviewed Papers by the Author • Kamel Boulos MN, Roudsari AV, Carson ER. Health Geomatics: An Enabling Suite of Technologies in Health and Healthcare (Methodolical Review).Journal of Biomedical Informatics 2001 Jun;34(3):195-219 <doi:10.1006/jbin.2001.1015 - URL: http://www.idealibrary.com/ links/ doi/ 10.1006/ jbin.2001.1015> [PubMed ID: 11723701] • Kamel Boulos MN, Roudsari AV, Carson ER. Towards a semantic medical Web: HealthCyberMap’s tool for building an RDF metadata base of health information resources based on the Qualified Dublin Core Metadata Set.Medical Science Monitor 2002 Jul;8(7):MT124-36 <URL: http://www.medscimonit.com/ pub/ vol_8/ no_7/2615.pdf> [PubMed ID: 12118210] • Kamel Boulos MN, Roudsari AV, Carson ER. A Dynamic Problem to Knowledge Linking Semantic Web Service Based on Clinical Codes.Medical Informatics & The Internet in Medicine 2002 Sep;27(3):127-137 [PubMed ID: 12507259] • Kamel Boulos MN, Roudsari AV, Carson ER. HealthCyberMap: A Semantic Visual Browser of Medical Internet Resources Based on Clinical Codes and the Human Body Metaphor.Health Information and Libraries Journal 2002 Dec;19(4):189-200 [PubMed ID: 12485148] • Kamel Boulos MN. The use of interactive graphical maps for browsing medical/ health Internet information resources.International Journal of Health Geographics 2003 Jan;2:1 <URL: http://www.ij-healthgeographics.com/ content/ pdf/ 1476-072X-2-1.pdf> [PubMed ID: 12556244]