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Special Communication |
From the Department of Community and Family Medicine, Dartmouth Medical School, and The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
Correspondence: Corresponding author: Ethan M. Berke, MD, MPH, The Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Parkway, Room 206, Lebanon, NH 03766 (E-mail: ethan.berke{at}tdi.dartmouth.edu)
In the mid-1800s, London was undergoing rapid urbanization and sanitation was poor. An outbreak of cholera in the Soho district of London in 1854 killed 127 residents over 3 days and caused the exodus of nearly three quarters of the population. Eight days after the initial case, the death rate in Soho had risen to twice that of the rest of London. Anesthesiologist John Snow created maps of these cholera deaths—now well known to students and practitioners of public health—and stopped the epidemic by removing the handle on the Broad Street pump.1 What was once thought to be an airborne disease was now confirmed to be one transmitted through consumption of contaminated water. Snow's discovery prompted a renewed effort to improve sanitation and the sewage infrastructure of the rapidly expanding city and cemented the role that healthy habitats play in the wellness of a population.
Mapping of disease mortality on a map of Soho, Snow applied the basics of geographic information science. Geographic information systems (GIS), be they computer programs or on paper, have the power to relate a disease or process to a particular location. Importantly, they can also link significant nonspatial data (eg, medical record information, claims data, neighborhood measures of poverty, or environmental pollutant measurements) to that same point in space, creating a rich picture between the relationship of exposure and outcome and its variation across space. The ability to add "layers" of spatially referenced data to a research study, health promotion project, or health access intervention moves beyond a traditional relational database and frames a health issue for a user within the context of geography.
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GIS in the Research Setting |
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Practice-based research networks are growing as a means to translate research into everyday practice and to better understand the role of primary care in the health system.2 Practice-based research networks perform a range of research, including interventional studies, health services research, prevention research, and work pertaining to disparities. They often leverage electronic health records across an array of practice settings to better understand the spatial distribution of a population of patients, identify gaps in access to care, and allocate resources. GIS can play a significant role in these analyses through the use of individual- and area-level mapping, as well as more advanced spatial analysis.
Projects such as the Dartmouth Atlas of Health Care use large, claims-based data sets and GIS to describe variations in health care delivery and cost.3 This and other applications of small-area analysis4 to areal units such as primary care service areas have let us understand patterns of care and how patients access our health system.5 The Robert Graham Center of the American Academy of Family Physicians’ HealthLandscape is a powerful, easily accessible GIS web site that allows even more primary care physicians and researchers access to understanding spatial patterns of health and access.6 These and other applications of GIS have brought the where back to the "5 Ws" of gathering and understanding health information.
GIS has the capability to integrate contextual factors of a person's environment with health characteristics. Research programs such as the Public Health Disparities Geocoding Project measure and describe socioeconomic inequalities in health and access to care by creating US Census-derived area-based measures of socioeconomic status.7 Continued use of GIS to characterize the social determinants of health at multiple levels is vital to ensure equal access to quality care and to better understand the interplay between individual and neighborhood factors.8–10
Advancing the Science to Individuals
Although population-based and health services applications of GIS are clearly important and should continue, we can go further. Every individual lives somewhere and interacts with their built and natural environment. These responses to habitat, be they physical or emotional, define who we are and, importantly, impact our physical and mental health. Work in Seattle demonstrated the protective association between walkable neighborhoods and depression in older adults.11 Others have shown associations between the built environment and levels of obesity.12 Because we spend 100% of our time somewhere, it is reasonable to expect that place matters when it comes to our health.
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GIS: A New Tool for Primary Care Researchers |
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TopNotesGIS in the Research...GIS: A New Tool...Translating Spatial Research to...References |
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Translating Spatial Research to Clinical Practice |
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TopNotesGIS in the Research...GIS: A New Tool...Translating Spatial Research to...References |
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As primary care physicians we are trained to consider the context of the individual and family. It is now time to start considering the context of where a person lives at it relates to their health. As healthy lifestyles and chronic disease prevention take a more pivotal role in our health care system, the opportunities for integrating our knowledge of individuals and their families’ habitat into health assessments, decision making, and treatment become obvious.
GIS technology, spatial analysis, improved data about land use and location of clinical services, and information from our patients about their perceived environment can be integrated to better understand the context in which people live healthy or unhealthy lives. Place becomes a vital sign—as important as a blood pressure, pulse, or pain score in providing optimal primary and secondary care to our patients. Obtaining and using information about place can be simply a qualitative assessment of our patient's habitat. As technology continues to advance, quantitative assessments more in line with traditional vital signs will be possible. For example, there are now numeric scales of neighborhood walkability.14,15 With the integration of health information and GIS, it is possible to envision data in an electronic health record pertaining to location, nearest places for exercise or healthy food, social services, measures of walkability, and other data important in promoting healthy lifestyles. Recommendations could be tailored to each individual patient, taking their own habitat and, importantly, their perceptions of that habitat into account. The physician could alert a patient to opportunities for healthy lifestyle habits of which they might not have been aware. Suddenly, the discussion of wellness and treatment of illness becomes personalized, with an increased chance of success.
The tools need not be advanced. Most practicing physicians have access to Internet resources, including Google Earth and Google Maps. These programs, and others, are GIS, with the capability to view multiple data sources in relation to each other across space. Physicians could easily use these online tools to start understanding the neighborhoods of their patients and available resources nearby that will help shape shared treatment and decision making.
At a service delivery level, place as a vital sign would be valuable in better understanding issues pertaining to access, group health behaviors, and resource utilization. These data could identify optimal neighborhood environments that are associated with health and aid in the distribution of resources to communities with poor health that would benefit from interventions to improve the habitat.
By considering place as a vital sign, measuring an individual's opportunity to achieve wellness through access to health-promoting resources and environments, we increase the power of prevention in medicine and public health and better understand the lives of those we serve.
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Conflict of interest: none declared.
Received for publication May 18, 2009. Revision received May 20, 2009. Accepted for publication May 20, 2009.
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  M. N. Oliver Mapping Primary Care: Putting Our Patients in Context J Am Board Fam Med, January 1, 2010; 23(1): 1 - 3. [Full Text] [PDF]
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