LEBANESE INTERNATIONAL UNIVERSTITY School of Business

HEALTH DISASTER MANAGEMENT SYSTEM INFECTIOUS DISEASE OUTBREAK DECISION SUPPORT SYSTEM Prepared by Jalal Abdulwahid Ahmad 10910260 Submitted To: Dr. Adeeb Eit A Graduate Project Submitted in Fulfillment of the Requirement for the Degree of Master of Business Administration (MBA) in Management Information Systems-BMIS695 Spring 2011-2012 Beirut Campus
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Health Disaster Management System Infectious Disease Outbreak Decision Support System

ACKNOWLEDGEMENT

I am deeply indebted to my advisor, Dr. Adeeb Eit, for his constant support, expertise, understanding, and patience, added considerably to my graduate experience. I appreciate his vast knowledge and skill. Without his help, this work would not be possible. Also, my deepest gratitude goes to my parents, wife, sisters, brothers, and relatives for their love, warmth, and support.
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Abstract
Infectious disease outbreak, as major public incidents, can result in serious disasters, which requires immediate and effective government response. However, decisions about Infectious disease outbreak in cities, especially in some undeveloped ones, traditionally rely on the experience and ability of the decision-makers, which inevitably involves too many subjective factors in the process of emergency response. Therefore, it is crucial to strengthen the study on the general design of infectious disease emergency management decision support systems so as to effectively support decision making and response efficiency during outbreak emergency management. In this study, we intend to illustrate the goals, functions, working processes, and structural framework of such a decision support system. In addition, we also discuss the necessary key databases, and finally, some suggestions on implementation are given. Based on the Infectious Disease Surveillance System (IDSS), the decision support system provides decision-makers with the power to choose schemes to manage and direct the actions to be taken more efficiently in the process of immediate and long term recovery.

Table of Contents
Chapter 1 ....................................................................................................................................... 11 Introduction ................................................................................................................................... 11 1.1 Background ........................................................................................................................... 11 1.2 Statement of the Problem ...................................................................................................... 12 1.3 Objective of the study ........................................................................................................... 13 1.4 Research questions ................................................................................................................ 13 Chapter 2 ....................................................................................................................................... 14 2.1 Emergency Management ................................................................................................... 14 2.1.1 Definition. ......................................................................................................................... 14 2.1.2 Process of Emergency Management................................................................................ 15
1-Mitigation ........................................................................................................................................ 16 2-Preparedness: ................................................................................................................................... 16 3-Response: ......................................................................................................................................... 18 4-Recovery: ......................................................................................................................................... 20

2.1.3 Decision Making in Emergency Management. ................................................................ 20 2.2 DSS Overview ................................................................................................................... 21 2.2.2Definition and Characteristics .......................................................................................... 22 2.2.2 DSS and MIS .................................................................................................................... 23
2.2.2.1 The Definition of MIS .............................................................................................................. 24 2.2.2.2 The Difference between DSS and MIS .................................................................................... 24

2.2.3 The Generic Architecture of DSS ...................................................................................... 25 2.2.4 The Types of DSS .............................................................................................................. 27
2.2.4.1 Text-oriented DSS ................................................................................................................... 27 2.2.4.2 Database-oriented DSS ........................................................................................................... 28 2.2.4.3 Rule-oriented DSS ................................................................................................................... 28 2.2.4.4 Compound DSS........................................................................................................................ 28 5

Chapter 3 Structure and Components of the Decision Support System ....................................... 30 3.1 Database Management System ............................................................................................ 31

Data Warehousing ............................................................................................................ 32

3.2 Simulation Modeling ........................................................................................................... 34 Epidemiological Spread Simulator .................................................................................... 35

3.3 Geographic Information System ......................................................................................... 36

Data storage ................................................................................................................................ 36 GIS Functions............................................................................................................................... 36 GIS Benefits ................................................................................................................................ 37

3.4 Expert System........................................................................................................................ 38

1) 2) 3) 4) The User Interface ...................................................................................................................... 38 The Knowledge Base ................................................................................................................... 39 The Shell or Inference Engine ..................................................................................................... 39 Knowledge Acquisition................................................................................................................ 39

3.5 Overall Architecture .............................................................................................................. 40 Chapter 4 Design Infectious Disease Outbreak DSS: ................................................................... 42 4.1 DSS business process and data flow analysis. ...................................................................... 42 4.1.1 Infectious Disease Surveillance System Integrated with DSS .......................................... 42
Overview of Surveillance System ................................................................................................ 42 Why surveillance? ....................................................................................................................... 43 Data Type of Surveillance System .............................................................................................. 44 Data Source in Surveillance System ........................................................................................... 45 Data Entry and Transmission ...................................................................................................... 46 Data Analysis and Outbreak Detection ....................................................................................... 47

4.2 Classification of DSS: ........................................................................................................... 50 4.3 Emergency Plan Management .............................................................................................. 51

4.3.1 Emergency Plan Assessment ..................................................................................................... 51

4.4 Resource Management. ......................................................................................................... 53 4.5 Decision Information Obtainment......................................................................................... 54 4.6 Decision Making Performance Evaluation ........................................................................... 55
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4.7 Requirement Analysis ........................................................................................................... 57

4.7.1 Hardware Support Layer ............................................................................................................ 57 4.7.2 User Interface ............................................................................................................................. 58 4.7.3 Software Support Layer ............................................................................................................. 58

Chapter [5] Implementation .......................................................................................................... 60 5.1 Potential Problem ................................................................................................................. 60

5.1.1 5.1.2 From Investigation .............................................................................................................. 60 From Literature ................................................................................................................... 60

5.2 Suggestion on Implementation ............................................................................................ 61

5.2.1 Organizational environments .................................................................................................... 61 5.2.2 People characteristics ................................................................................................................. 63 5.2.3 Technical Supports..................................................................................................................... 64

Chapter 6 ....................................................................................................................................... 66 5.1 Conclusion ........................................................................................................................... 66 5.3 References ........................................................................................................................... 67

List of Figures
Figure 2.1 Structures of Emergence Headquarters....15 Figure2.2 Process of Emergency Management..16 Figure 2-3 General architecture for DSS (adapted from Burstein & Holsapple, 2008) 26 Figure 3.1Data Warehouse.....34 Figure 3.2 Epidemiological Spread Simulators..35 Figure3.3 GIS Architecture....36 Figure 3.4 Structure of a typical expert system..40 Figure 3.5 Overall Architecture of Infectious disease outbreak DSS....41 Fig. 4.1 The flow of the surveillance system47 Figure 4.2 Design flow of web Electronic Surveillance System platform.49 Figure 4.3 Detection of an outbreak...48 Figure 4-4 Emergency plan assessment working process......51 Figure 4-5 Emergency plan assessment data flow.....52 Figure 4.6 Decision information obtainment data flow.55 Figure 4-7 Decision making performance evaluation working process.56 Figure 4-8 Decision making performance evaluation data flow...56

List of Tables

Table2.1 Summary: Steps in the management of a communicable disease outbreak..17 Table 2.2, Response in Outbreak Disease....19 Table 4.1, Example of resources needed for outbreak response..53

Lists of Acronyms
AHP ATC CDC DSS EDP EOC FEMIS GIS GPS KS LS LAN OCT OIG OTC MIS NIMS NRP PPS PS RS WHO Analytic Hierarchy Process Anatomical therapeutic chemical Centers for Disease Control Decision Support System Electronic Data Processing Emergency Operation Centers Federal Emergency Management Information System Geographic Information Systems Global Position System Knowledge System Language system Local Area Network Outbreak Control Team Outbreak Investigation Group Over the-counter Management Information System National Incident Management System National Response Plan Problem-Processing System Presentation System Remote Sensing World health organization

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Chapter 1 Introduction
1.1 Background
Emerging infectious diseases are one of the most significant health challenges facing the global public health community. Their emergence is thought to be driven largely by socio-economic, environmental and ecological factor. In an analysis of emerging infectious diseases between 1940 and 2004, it has been observed that a majority (about 60%) is caused by zoonotic pathogens and vector borne diseases are responsible for 23% of them. The predicted emerging disease hotspots due to zoonotic diseases and vector borne pathogens are more concentrated in lower latitude developing countries. It is also feared that in all probabilities the next flu pandemic too would raise its head from Asia. A large number of factors are thought to be playing a role in this, with varying degrees of contribution in emergence of each infection. Changes in land use or agricultural practices and changes in human demographics and society are the most common drivers. Followed by poor population health (e.g. HIV, malnutrition), hospital and medical procedures, pathogen evolution (e.g.antimicrobial drug resistance, increased virulence), contaminating food sources or water supplies, international travel and failure of public health system. To mount an effective public health response to a disease outbreak a vibrant public health system is necessary [1]. Management of Emerging infectious diseases and mitigate infections is not an easy task and usually requires a large amount of analysis and resources. In order to reduce the damage and optimize the overall performance of government, the responsible leaders have to make decisions

Jones K.E, Patel N.G, Levy M.A, Storeygard A, Deborah Balk, Gittleman J.L and Peter Daszak, Global trends in emerging infectious diseases. Nature,451:990-993, (2008).

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quickly and effectively. Currently, however, decisions are usually made based on personal judgment of leaders or experts, rather than basing their decisions in the different stages of relief efforts on factual evidence. In addition, the information at the first moment just after disaster occurs tends to be confused, imprecise and incomplete. Besides the lack of accurate information, the situation is further complicated by the pressing time. At an emergency moment, time is life and decision makers need to make decision quickly. Such complexity suggests the introduction of a Decision Support System (DSS) a class of information systems that support business and organizational decision-making activities. This system could be used to help analyze the disaster and assist the leaders in making sensible decisions by means of an inference tool capable of offering an assessment of the consequences of almost every combination of adverse phenomena, based on the available information in the limited time.

1.2 Statement of the Problem

Presently, the major support the government gains electronically is still largely confined to information systems which do not give active decision support. Health disasters always have the characteristics such as an ad-hoc nature, unpredictability and widespread, and how to make the right decision in a limited time becomes important to the leaders. The DSS would be a powerful tool for the decision makers, as it can help to save time and enhance the effectiveness of decisions, which means that the emergency management would be more efficient and more lives will be saved during an infectious disease outbreak. This study is mainly focused on the DSS of Health Ministry. The reasons for choosing Health Ministry are listed below: Firstly, infectious disease frequently occurs in disparate zone, where administrative capability and healthy is relatively low, and, applying the DSS can help to enhance Ministry capacity during the Disease outbreak. Secondly, most of the Health Units do not even have a DSS for daily management, let alone for the emergency situation; thus, the need of the DSS is large.

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1.3 Objective of the study

The general goal of this research is to formulate an architecture for a computer-based DSS framework which can be used to aid local governments in their decision making process prior to taking any action in infectious disease outbreak emergency management. Due to the limited scope of this study, it explicitly restricts itself to developing an architecture blueprint for the DSS, rather than engaging in the details of its construction, such as programming. The specific objectives are: To build an architecture of DSS To identify the information processing mechanisms of each module To conceive of potential problems that may occur during the implementation of the DSS and give solutions to avoid them To learn how DSS helps managers to avoid the risks and choose the best solution. To learn the role of information technology in reducing the spread of infectious diseases. To knowing what the basic tools which using to face a spread infectious disease.

1.4 Research questions

In order to fulfill the main objective of this thesis, the main research question is: What is an ideal architecture for a DSS on infectious disease outbreak emergency management, and how should it be implemented? Furthermore, some sub-questions are posed as follows: - What is the general structure of the Medical DSS? - What is the function of each module in the Medical DSS? - What is the relationship between each module? - What is the information data flow of each module? - What problems might be encountered when implementing the system? - How can potential problems in implementation be solved?

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Chapter 2
2.1 Emergency Management

2.1.1 Definition.
A simple definition of emergency management is to deal with all risk and risk avoidance. Since risk covers extensive issues, situations and participants, EM is involved in everyones daily lives and should be integrated into daily decisions and not just called on during times of disasters (Haddow, Bullock, & Coppola, 2007). The United States Federal Emergency Management Agency (FEMA) elaborates that emergency management means organized analysis, planning, decision-making, and assignment of available resources to mitigate, prepare for, respond to, and recover from the effects of all hazards and its main aims are to prevent injuries, save lives, and protect property and the environment.2 Emergency management may maintains seven Task Forces, consisting of trained managers of the various sections of the Emergency Headquarters (EHQ), who will be called on to run the EHQ, which will take over the responsibility for all disease control and eradication measures within the Ministry of Health. The major operational sections include the Disease Investigation Group (DIG), the Movement Control Group (MCG), the Epidemiology Group, the IT Support Group, the Resource Centre, (see Figure 2.1). These groups are responsible to the EHQ Controller and his Deputy Controller. The various operational sections have specific responsibilities in the campaign; The EHQ Controller will be in regular contact with the WHO.
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Federal Emergency Management Agency (2010), Fundamentals of Emergency Management. Retrieved online on 1 August, 2010 from http://training.fema.gov/EMIWeb/IS/is230a.asp

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National emergency centre

Epidemiology group

Disease Control Team

Disease Investigation Group

Movement control group

Resource group

Red Crescent

IT Support Group

Figure 2.1 Structures of Emergence Headquarters

2.1.2 Process of Emergency Management

The process of emergency management can be generalized into a four-phase model: mitigation, preparedness, response and recovery. The first two phases are considered proactive actions that are taken prior to an emergency while the final two are both reactive actions that are taken after it has occurred. Emergency management is a cyclical process; the end of one phase is the beginning of another, although one phase of the cycle does not necessarily have to be completed in order for the next to take place. Often several phases are taking place concurrently. Timely decision making during each phase results in greater preparedness, better warnings, reduced vulnerability and/or the prevention of future disasters. The complete emergency management cycle includes the shaping of public policies and plans that either addresses the causes of disasters or mitigates their effects

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on people, property, and infrastructure. The emergency management cycle consists of 4 main phases, see Figure 2.2

Figure2.2 Process of Emergency Management

1-Mitigation is a sustained action to reduce or eliminate risk to people and property from
hazards and their effects. It involves the identification of hazard, evaluation of its frequency and severity, estimation of direct and indirect economic and social costs, determination of tolerable risk level, and the identification of risk-reduction opportunities. There are some widely accepted tools for mitigation to reduce risks: hazard identification and mapping, design and construction applications, land-use planning, financial incentives, insurance, and structural controls (Haddow, et al., 2007, pp. 75-77).

2-Preparedness:
Preparedness refers to the actual planning, training, placement of resources, mutual-aid agreements across jurisdictions, and other coordination efforts before an emergency strikes. As a building block of emergency management, preparedness aspires to create a state of readiness to respond to a disaster, crisis or any other type of emergency situation. It operates in a cycle starting from assessment of threats and vulnerability, moving through implementation of enhancements made through identifying shortfalls, and ending with exercising and training for the revamped preparedness (Haddow, et al., 2007, pp. 75-77).

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 Preparedness in Disease Outbreak

In each emergency situation, the lead agency for health is responsible for preparation for and response to a sharp increase in the numbers of cases of disease. To prepare for such an eventuality, it is essential that: a surveillance system is put in place to ensure early warning of an increase in the incidence or numbers of cases of diseases; an outbreak response plan is written for the disease covering the resources, skills and activities required; standard treatment protocols for the disease are available to all health facilities and agencies and that clinical workers are trained; stockpiles of essential treatment supplies (medication and material) and laboratory sampling kits are available for the priority diseases, such as oral rehydration salts, intravenous fluids, vaccination material, tents, transport media and water purification supplies; a competent laboratory is identified for confirmation of cases; sources of relevant vaccines are identified in the event that a mass vaccination campaign is required, and that supplies of needles and syringes are adequate; sources of additional treatment supplies are identified for non vaccine preventable diseases in case of expansion of outbreak; the availability and security of a cold chain are established.

There are a limited number of diseases with epidemic potential that pose a major threat to the health of a population facing an emergency situation (see Table 2.1). These diseases should be identified during the rapid assessment.

Table 2.1

SUMMARY: Steps in the management of a communicable disease outbreak

1. PREPARATION Health coordination meetings. Surveillance system: weekly health reports to Ministry of Health and WHO (during an outbreak, this may be daily rather than weekly) Outbreak response plan for each disease: resources, skills and activities required. Stockpiles: sampling kits, appropriate antimicrobial, intravenous fluids, vaccines Contingency plans for isolation wards in hospitals (see Annex 7 for organization of an isolation centre).,
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Laboratory support. Preparedness hinges on modeling (archetypal) outbreaks, formulating responses, and assessing likely impacts of those interventions against outbreaks. Operational planning focuses on depicting (actual) emerging outbreaks; selecting and tailoring responses (from predefined plans); and adapting those responses as outbreaks progress and government and public health organizations attempt to contain and address them. Responses encompass logistics (stockpiling drugs and supplies); medical services; public safety; infrastructure continuity, etc. (M.A. Connolly, et al., 2005, pp.107-108).

3-Response:
Response is the actual activation of emergency plans to meet an emergency. Emergency plan in our research refers to the feasible action guidance which is used to solve the problems raised by infectious disease outbreak and guarantee the realization of emergency decision making goal to reduce the deaths and minimize losses on property. The main contents included in the emergency plans are: (1) introduction, including: the purpose, working principles, compilation basis and application scope of the emergency plan;(2) definite the responsibilities and working process of emergency management participating groups or departments; (3) early warning and preventive mechanism, including: information monitoring and reporting, early warning preventive action guide and the early warning level classification; (4) emergency response, including: information sharing and processing rules, communication protection, command and coordination among groups, security protection of victims and emergency workers, impact assessment and resource management; (Haddow, et al., 2007, pp. 75-77).

Response in Disease outbreak:

Investigation of source and modes of transmission The Outbreak control team (OCT) should: meet daily to update the team on outbreak developments; review the human, logistic (stores, stocks, etc.) and financial resources available to manage the outbreak; oversee the investigation of reported cases to assess pathogen, source and transmission; ensure that clinical workers report suspected cases to the team immediately; ensure that clinical workers are using standard treatment protocols;
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ensure that cases are quantified by time and place; produce spot maps and epidemic curves; oversee the implementation of control measures.

The OCT should do three step in order to response to outbreak disease, see table 2.2 Table 2.2 Response in Outbreak Disease The lead health agency should investigate reported cases or alerts to confirm the outbreak situation number of cases higher than expected for same period of year and population; clinical specimens will be sent for testing. Confirmation The lead health agency should activate an outbreak control team with membership from relevant organizations: Ministry of Health, WHO and other United Nations organizations, nongovernmental organizations in the fields of health and water and sanitation, veterinary experts. Investigation Confirm diagnosis (laboratory testing of samples). Define outbreak case definition. Count number of cases and determine size of population (to calculate attack rate). Collect/analyze descriptive data to date (e.g. time/date of onset, place/location of cases and individual characteristics such as age/sex). Determine the at-risk population. Formulate hypothesis for pathogen/source/transmission. Follow up cases and contacts. Conduct further investigation/epidemiological studies (e.g. to clarify mode of transmission, carrier, infectious dose required, better definition of risk factors for disease and at-risk groups. Write an investigation report (investigation results and recommendations for action). Control Implement control and prevention measures specific for the disease. Prevent exposure (e.g. isolation of cases in cholera outbreak).

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Prevent infection (e.g. vaccination in measles outbreak). Treat cases with recommended treatment as in WHO/national guidelines.

An outbreak may be controlled by eliminating or reducing the source of infection, interrupting transmission and protecting persons at risk. Control strategies fall into four major categories of activity: (1) Prevention of exposure: the source of infection is reduced to prevent the disease spreading to other members of the community. Depending on the disease, this may involve prompt diagnosis and treatment of cases using standard protocols (e.g. cholera), isolation and barrier nursing of cases (e.g.viral haemorrhagic fevers), health education, improvements in environmental and personal hygiene (e.g. cholera, typhoid fever, shigellosis, hepatitis A and hepatitis E), control of the animal vector or reservoir (e.g. malaria, dengue,yellow fever, Lassa fever) and proper disposal of sharp instruments (e.g.,hepatitis B). (2) Prevention of infection: susceptible groups are protected by vaccination (e.g. meningitis, yellow fever and measles), safe water, adequate shelter and good sanitation. (3) Prevention of disease: high-risk groups are offered chemoprophylaxis (e.g.malaria prophylaxis may be suggested for pregnant women in outbreaks) and better nutrition. (4) Prevention of death: through prompt diagnosis and management of cases, effective health care services (e.g. acute respiratory infections, malaria, bacterial dysentery, cholera, measles, and meningitis). (M.A. Connolly, et al., 2005, pp.109-111).

4-Recovery:
Recovery consists of the actions taken by government to restore order and vital systems in the disaster-impacted zone and to provide assistance by way of temporary housing, food, or medical attention. It often commences a few hours or days after a disaster and can last for months or years. Recovery function encompasses a variety of participants such as government at all levels, individuals and the business community in making decisions about how to conduct the mission so as to restore normal life and ensure a safer future for the zone (Haddow, et al., 2007, pp.7577).

2.1.3 Decision Making in Emergency Management.

In this part of the literature review, the main objective is to focus on emergency decision making and to get a general idea of what kinds of information are relevant to design the theoretical
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architecture of the DSS, which factors will affect the decision making and which of them should be considered in our DSS framework. Emergency decision making is characterized by the following factors: [3] The environment of decision making is continuously changing according to the different stage of disaster. Uncertainty is the main characteristic of emergency decision making: the emergencys nature, scale, form and when and where it will take place is all unsure. Decision makers should give quick response, which means they are usually under the pressure of limited time. Information shortage. The information needed for decision making may be inexact or incomplete.

2.2

DSS Overview

Before going into the detail of DSS, the concept of information systems (IS) should be introduced. According to Laudon & Laudon (1995), DSS is a sub-category of the IS discipline, and thus, a DSS is actually an information system. Thus, knowledge about what IS is can help to better understand DSS. According to Silver, Markus, & Beath (1995, p. 356), IS are the inclusive super systems, whereas people and procedures-the stuff of business processes-and tools-such as computers and programs-are the subordinated subsystems. This definition is from the view-point of organization, and the main purpose of the system is to improve operational efficiency and effectiveness. DSS and IS share many common characteristics, such as purpose (improve the working efficiency) and approach (computer-based). The biggest difference between the two systems is that DSS is an advanced IS, which is more focused on supporting and improving managerial decision-making. The details of DSS are discussed in the following section.

Dai, J., Wang, S., & Yang, X. (1994). Computerized Support Systems for Emergency Decision Making. Annals of Operations Research, 51(7),313-325.
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2.2.2 Definition and Characteristics

The concept of DSS was first introduced by Morton (1971) in his book Management Decision Systems. This text presents DSS as an intelligence human-computer interactive system, which is based on management science, operation research and behavioral science, applied through the means of computer technology, simulation and information technology to assist the decision making of unstructured or semi-structured decision problems. Sprague and Carlson (1982) also hold the same understanding of DSS. They, too, emphasize that DSS is helping decision makers to solve semi-structured or unstructured problems by taking advantage of data and models. In the past decades, many scholars have given their definitions on the concept of DSS; here three well known ones are listed to provide a general understanding of DSS. Mittra (1986) suggests that DSS are systems using database and mathematical models to help users generate information they need and assist decision-making. In addition, from his point of view, DSS should have the following functions: In order to make decision, users can try What-If functions (a simulation capability of DSS to answer what-if questions) and according to the result of what if questions to test which is a better decision. DSS is constructed by a database management system, a group of mathematical models and a human-computer interactive interface. DSS uses one control module to combine three other modules to answer the decision question, namely, data access module, data transformation module (to retrieve data, generate graphs and reports) and modeling module ( to save mathematical models and use simulation techniques). Keen (1987) asserts that DSS is the combination of decision, support and system,which means that through the development of computer technology on system construction and the gradual expansion of the function of computer support a better decision can be achieved. The support here emphasizes exploring alternatives proactively or even making decision on all alternatives. Burstein & Holsapple (2008) define DSS in terms of the roles it plays in decision processes. They argue that DSS can provide knowledge and knowledge processing capability that is instrumental in making decisions or making sense of decision situations. It can enhance the outcome and efficiency of decision making.
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So far, there still is no generally accepted definition of DSS. All the technologies which help to achieve the goal of decision support can be used to construct DSS. The structure of DSS may be totally different because of the different times, different application purpose and different technologies which we use to construct DSS. However, one thing that is common to all DSS is that: DSS must be able to play the role of decision support. Therefore, grasping the basic characteristics of DSS has very important significance. The basic characteristics of DSS can be summarized as follows: DSS is a subcategory of IS. It is a computer-based system. The basic components of DSS include databases, model bases, data processing technique, and information presentation system. DSS is designed for decision makers. The input, output, origin needs and objectives of DSS are all from the decision makers. It has a human-computer communication interface for non-computer professionals to easily operate. It has an emphasis on decision support, but it does not replace the decision-makers in making decision. The payoff is in extending the range and capability of managers decision making processes to help them improve the effectiveness of their decisions. It is user oriented. Because the decision-making process is dynamic, decisions should be made dynamically according to different environment, different users requirements, the understanding of users decision question and the available knowledge.

2.2.2 DSS and MIS

Over the years, there have been disputes regarding DSS and Management Information Systems (MIS). Some scholars think that MIS includes DSS, while others suggest that MIS is a subconcept of DSS. Still others suggest that DSS is a separate category all together. The reason why people cannot distinguish the two systems is because both are sub categories of IS and can help improve the efficiency and effectiveness of an organization. In addition, they can, to some extent, assist in making decisions as well. Therefore, it is necessary and important to understand the difference between the two systems.

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2.2.2.1 The Definition of MIS

According to O'Brien and Marakas (2005), Management Information System (MIS) is regarded as a subset of the overall internal controls procedures in a business, which covers the application of people, documents, technologies, and procedures used by staff members to solve business problems. Academically, the term is commonly used to refer to the group of information management methods tied to the automation or support of human decision making. The functions of MIS are mainly as follows: Provide timely and comprehensive information and data to help achieve the goal of a given decision. Prepare and provide a unified format for the information and data and simplify all statistical work. Use specified mathematical models to analyze the data, and then predict the future based on past situations. According to the requirements, give different reports to different level of managers, with the prospect of helping them to analyze and interpret the reports as soon as possible to make the decision more efficient.

2.2.2.2 The Difference between DSS and MIS

The relationship between DSS and MIS is an ongoing question of debate. In this study, DSS and MIS are considered related, but not the same. Based on the study of Sprague (1980), the major differences between the two concepts are summarized below: Different user

DSS is mostly designed for senior staff to assist them in making decisions whereas MIS is generally used by middle class managers or staff members to serve their daily operations. Different problems to deal with

DSS supports semi-structured decision-making. Such decisions are complex, and they cannot always be accurately described. In addition, a large amount of calculations are needed. It is necessary to apply the computer and users participation to achieve satisfactory results. On the other hand, MIS employs back structured decision-making, and such decisions are known, predictable, and often repetitive.
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Different system structure

DSS is always a model driven system and has a model base. DSS is constructed through a combination of multiple models to support decision-making, and its analysis is focus on the needs of policy makers. Meanwhile, MIS is generally a data driven system and has a data base. MIS is an integrated multiple-transaction EDP (Electronic Data Processing) based on the transaction functions (production, marketing, personnel etc.). Its analysis focuses on the overall information needs of the system, and the pattern of output report is fixed. Different pursuit

In general, DSS is used to assess validity, that is, whether decisions are effective. However, the pursuit of MIS is efficiency, which needs quick inquiry as well as quick statistical results and reports. In conclusion, DSS is user-oriented and emphasizes support for decision makers from external environmental information, internal comprehensive information and personal experiences etc. However, MIS focuses on the integrity of the information flow inside of the management system, to provide all staff the information needed. MIS cannot meet the requirement of decision makers to assist them in decision making, as it cannot provide the external information or adapt to personal decision making style, which are important elements of decision making.

2.2.3 The Generic Architecture of DSS

According to Burstein & Holsapple (2008), the generic architecture of DSS consists of four essential parts: Language system (LS), Presentation System (PS), Knowledge System (KS) and Problem-Processing System (PPS). The first three are representational systems, which are used by the PPS (the active component of DSS). The relationship among the four elements can be illustrated by the graph below:

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Figure 2-3 General architecture for DSS (adapted from Burstein & Holsapple, 2008)

User

Theoretically, the user of a DSS could only be the decision maker. However, administrators, DSS developers, data entry persons and facilitators can also be considered as users. LS

The LS consists of all information the DSS can accept, including the language for users or models to retrieve data and the language by which users can operate the computer. Decision makers use the LS to describe their problems as the first step to get the final decision. The main function of this system is to accept knowledge, clarify knowledge and recall knowledge. PS

The PS consists of all messages the DSS can emit. It consists of two parts: providing knowledge and seeking knowledge. According to the order, the PS first seeks the knowledge it needs to emit. By choosing a PS element to present, it provides users responses that PPS emits. KS

The KS is constructed by all knowledge the DSS has stored and retained, including descriptive knowledge, procedural knowledge or reasoning knowledge. All the knowledge is subject to use by PPS. PPS

The PSS is the core of DSS, which tries to recognize and solve problems during the decision making process. There are two types of abilities in the PPS, first order ability and second order ability.
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The first order ability is mainly constructed by five knowledge manipulation abilities, namely, knowledge acquisition, knowledge assimilation, knowledge selection, knowledge generation and knowledge emission. These abilities are primary, front line abilities and contribute to the outcome of a particular decision episode. The second order ability includes the function of coordination, control and measurement, which are concerned with governance of the first order ability within and across decision episodes. The PSS is asked to process a LS element, and this processing requires the PPS to select some portion of the KS contents (first order ability) and then apply second order ability to change the knowledge held by coordination, control and measurement. In other words, some portion of the PSS are covert (strictly internal, yielding assimilations of knowledge into the KS) and others are overt (witnessed by the user via PPS knowledge emission of PS elements). This generic DSS architecture only provides the fundamental common parts of DSS. To fully appreciate any specific DSS, we should know the particular requests making up its LS, the particular responses making up its PS, the particular knowledge representation existing in its KS, and the particular knowledge processing capabilities of its PPS.

2.2.4 The Types of DSS

Although we learned the common base and some fundamental terms from the generic architecture of DSS, it is necessary to distinguish among different DSS. In the research by Burstein & Holsapple (2008) , eight types of DSS are introduced. For the purposes of the current study, these can be summarized into four types which provide the overall picture of the development of DSS. 2.2.4.1 Text-oriented DSS In a text-oriented DSS, the LS contain requests concerned with the allowed manipulations as well as user requests for assistance from the DSS. The PS consists of images of stored text that can be emitted. In addition, the KS of text-oriented DSS is made up of electronic documents; each message in the KS is potentially interesting to the decision maker. Finally, the PPS is constructed by some software that can perform various manipulations on contents of any of the stored documents. With a text-oriented DSS, people can easily keep electronic notes, supporting decision makers by electronically keeping track of textually represented knowledge.

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2.2.4.2 Database-oriented DSS The main differences between text-oriented DSS and database-oriented DSS focus on KS and PPS. In database-oriented DSS, all files that make up of the KS hold information about table structures plus the actual data value contents of each table. The PPS consist of three kinds of software: a database control system, an interactive query processing system and various custombuild processing systems. The database control system consists of capabilities for manipulating table structures and contents (e.g., defining or revising table structures, finding or updating records, and building new tables from existing ones). The query processing system can respond to certain standard types of requests for data retrieval, and the custom-built processing system is developed to meet the specific needs of the DSS user on marketing, production, financial or other application. In all, the data handled by database-oriented DSS tend to be primarily descriptive, rigidly structured and extremely voluminous. 2.2.4.3 Rule-oriented DSS Rule-oriented DSS is constructed by a knowledge management technique that involves representing and processing rules. The logic of decision making is if the premise is true, then the conclusion is valid. Users of rule-oriented DSS can issue requests, and then LS contains requests for advice and requests for explanation. Correspondingly, the PS includes messages presenting advice and explanations. In addition, the KS holds one or more rule sets which can pertain to reasoning about what recommendation or explanation to give a user regarding a particular subject. Finally the PSS has capabilities for creating, revising and deleting state descriptions, and it also has the ability to explain its behavior both during and after conducting the inference. 2.2.4.4 Compound DSS Compound DSS frameworks tend to combine more than one knowledge-management techniques (text, database, or rule management) together to support the decision maker. There are two ways to make compound DSS: Multiple DSSs, each oriented toward a particular technique

In this framework, because each DSS has its own LS and PS, multiple staff assistants are needed to operate each system and then decision maker has to translate responses from one DSS into requests to another DSS in order to get the final decision. Single DSS, encompassing multiple techniques
28

This option only needs a staff assistant who is good at multiple knowledge management techniques as there are one LS and one PS for decision maker to learn. The effort required of a decision maker who wants to use results of one technique in the processing of another technique varies depending on the way in which the multiple techniques have been integrated into a single compound DSS.

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Chapter 3 Structure and Components of the Decision Support System

The purpose of a DSS is to provide a set of tools to help in the interpretation of data. The DSS should grant decision makers an appreciation of the risks implicit in particular decisions, and the factors which can be varied to modify those risks. One approach is to use an expert system with a database management system (DBMS). An ideal application area for DSS is in emergency response systems, where typically decision makers have to cope with large volumes of diverse and often imperfect data, inadequate time and resources are available to devote to complex problem-solving, and the outcomes of decisions can have far-reaching consequences. Berke and Stubbs (1989) present a thorough argument in favor of DSS for hurricane mitigation planning. A successful control and eradication of an avian influenza epidemic is contingent on the rapid identification and elimination of all virus sources. This involves an understanding of the dynamics of the disease, combined with adequate procedures that identify record and deal with all events that may contribute to further spread of the disease. A key function of such a system is management of the large volume of data typically generated during an emergency. A computerized DBMS is ideally suited to such a task. The need to understand the dynamics of the disease in a spatial context, led to the evaluation and subsequent adoption of a geographic information system (GIS) in infectious disease outbreak DSS. Computer simulation models are programs which seek to represent the dynamics of real world systems. Models can be linked to information systems to provide procedures for the evaluation of management options based on an analysis of the current situation. In this manner, the information collection system serves to provide parameter estimates for the model. These estimates are updated as new information is acquired. Expert systems, which can emulate aspects of human reasoning, have an obvious role to play in interpreting epidemic data and aiding in the decision making process. Each of these technologies is defined in more detail below.

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3.1 Database Management System [4]

As one of the oldest components associated with computers, the database management system, or DBMS, is a computer software program that is designed as the means of managing all databases that are currently installed on a system hard drive or network. Different types of database management systems exist, with some of them designed for the oversight and proper control of databases that are configured for specific purposes. Here are some examples of the various incarnations of DBMS technology that are currently in use, and some of the basic elements that are part of DBMS software applications. As the tool that is employed in the broad practice of managing databases, the DBMS is marketed in many forms. Some of the more popular examples of DBMS solutions include Microsoft Access, FileMaker, DB2, and Oracle. All these products provide for the creation of a series of rights or privileges that can be associated with a specific user. This means that it is possible to designate one or more database administrators who may control each function, as well as provide other users with various levels of administration rights. This flexibility makes the task of using DBMS methods to oversee a system something that can be centrally controlled, or allocated to several different people. There are four essential elements that are found with just about every example of DBMS currently on the market. The first is the implementation of a modeling language that serves to define the language of each database that is hosted via the DBMS. There are several approaches currently in use, with hierarchical, network, relational, and object examples. Essentially, the modeling language ensures the ability of the databases to communicate with the DBMS and thus operate on the system. Second, data structures also are administered by the DBMS. Examples of data that are organized by this function are individual profiles or records, files, fields and their definitions, and objects such as visual media. Data structures are what allow DBMS to interact with the data without causing damage to the integrity of the data itself.
4

Raghu Ramakrishnan, Johannes Gehrke (2005). Database Management Systems second edition & http://www.wisegeek.com/what-is-dbms.htm , 31

A third component of DBMS software is the data query language. This element is involved in maintaining the security of the database, by monitoring the use of login data, the assignment of access rights and privileges, and the definition of the criteria that must be employed to add data to the system. The data query language works with the data structures to make sure it is harder to input irrelevant data into any of the databases in use on the system. Last, a mechanism that allows for transactions is an essential basic for any DBMS. This helps to allow multiple and concurrent access to the database by multiple users, prevents the manipulation of one record by two users at the same time, and preventing the creation of duplicate records. [5] So, a number of countries that pursue exotic disease eradication strategies similar to New Zealand's or U.S have implemented computerized systems for managing the task of storing and managing the data gathered from foreign animal/human disease investigations. An organization can consolidate information from several databases into a data warehouse by copying tables from many sources into one location or by materializing a view that is defined over tables from several sources. Data warehousing has become widespread, and many specialized products are now available to create and manage warehouses of data from multiple databases.

Data Warehousing [6]

Data warehouses contain consolidated data from many sources, augmented with summary information and covering a long time period. Warehouses are much larger than other kinds of databases; sizes ranging from several gigabytes to terabytes are common. Typical workloads involve ad hoc, fairly complex queries and fast response times are important. These characteristics differentiate warehouse applications from OLTP applications, and different DBMS design and implementation techniques must be used to achieve satisfactory results.

http://www.wisegeek.com/what-is-dbms.htm Raghu Ramakrishnan, Johannes Gehrke (2005). Database Management Systems second edition

pp680

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A distributed DBMS with good scalability and high availability (achieved by storing tables redundantly at more than one site) is required for very large warehouses. A typical data warehousing architecture is illustrated in Figure 3.1 There are many different models of data warehouses including Online Transaction Processing (OLTP) which is a warehouse built for speed and ease of use. Another type of data warehouse is called Online Analytical processing (OLAP), this type of warehouse is more difficult to use and adds an extra step of analysis within the data. Usually it requires more steps which slows the process down and much more data in order to analyze certain queries. [Raghu, Johannes 2005, pp.679-680] The number one reason why you should implement a data warehouse is so that Decision maker or end users can access the data warehouse and use the data for reports, analysis and decision making. Using the data in a warehouse can help you locate trends, focus on relationships and help you understand more about the environment that your business operates in. Data warehouses also increase the consistency of the data and allow it to be checked over and over to determine how relevant it is. Because most data warehouses are integrated, you can pull data from many different areas of your business, for instance human resources, finance, IT, accounting, etc.[7] An organization's daily operations access and modify operational databases. Data from these operational databases and other external sources (e.g., customer profiles supplied by external consultants) are extracted by using gateways, or standard external interfaces supported by the underlying DBMSs. A gateway is an application program interface that allows client programs to generate SQL statements to be executed at a server. Standards such as Open Database Connectivity (ODBC) and Open Linking and Embedding for Databases (OLE-DB) from Microsoft and Java Database Connectivity (JDBC) are emerging for gateways.

http://ecommercecenter.net/management/what-is-a-data-warehouse.html

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External Data Sources

Hospitals

Traffic DB

EXTRACT LOAD REFRESH CLEAN

OLTP or OLAP

DRC*
.. ..

Operational Databases

Figure 3.1Data Warehouse

**Disease research center

3.2 Simulation Modeling [ 8]

Computers serve as virtual laboratories where researchers can study problems not easily examined in real life. The experiments consist of computer simulations representations that closely match the demographics and geography of a real location. In these synthetic environments, researchers can introduce an infectious agent with certain characteristics and then watch it spread. Scientists create these simulations with the help of customized programs called computational models. Different models address different questions. The ones frequently used for studying diseases are agent-based, which model how a virtual person could behave in the synthetic community. Each individual has a chance of catching or spreading an infection through encounters with others at home, work, school and elsewhere. In constructing these models, the scientists start with assumptions about how people interact and how infectious agents spread. Onto this they add known or estimated information about actual communities and the infectious agent. They also can introduce different interventions, such as vaccination or quarantine. Researchers can change the models to simulate different situations,

http://www.nigms.nih.gov/Research/FeaturedPrograms/MIDAS/Background/Factsheet.htm 34

such as a more urban community or a more contagious virus. Finally, they analyze and compare the outcomes to better understand how an outbreak could spread in a variety of scenarios. Because no single set of results or single model can predict exactly what will happen, scientists often will ask different models the same questions. When different models yield similar results, researchers have more confidence in the predictions. There are many applications which use as simulation model in case infectious disease outbreak, so we explain Epidemiological Spread Simulator component as example to know what benefits of simulation tools. Epidemiological Spread Simulator [9] This component generates a large scale spatial simulations over census tract, zip code and/or county level populations. Population and demographic10 data is provided as input to the back-end simulation functions. The simulation then outputs information on the number of sick and dead within a given population by areal unit (e.g., county, zip code) and provides color coded geographical representations of the data. System control menus are then defined to incorporate the appropriate mitigative response measures that users can apply. Specific simulations used as case studies are described in Figur 3-2 For a given model, the epidemiological spread simulator generates the epidemic spread data for specified number of days based on the given scenario and model parameters. Figure 3-2 here we illustrate the effects of utilizing decision measures within the confines of a

Paper:Visual Analytics Decision Support Environment for Epidemic Modeling and Response Evaluation by Shehzad Afzal&David S. Ebert @2011 10 United States Census Bureau. Population demographics, 2000. Figure 3.2 Epidemiological Spread Simulators

35

pandemic influenza simulation. In the left image, the analyst has used no decision measures and is visualizing the spread of the pandemic on day 36 of the simulation. In the right image, the analyst has decided to see what effects (on day 36) deploying the strategic national stockpile on day 3 would have had on the pandemic.

3.3 Geographic Information System

11

Geographic information systems (GIS) are computerized information systems that allow for the capture, storage, manipulation, analysis; display and reporting of geographically referenced data. GIS software packages are essentially a combination of computerized mapping technology and database management systems, which allow spatial data sets from diverse sources to be managed and analyzed. Geographic information is organized in the form of various layers of thematic maps (coverage) with their related attributes. GIS have developed from purely inventory to management tools. They are being used as part of decision support systems (DSS) or as intelligent geographic information systems where they can be combined with simulation models and expert systems. See figure 3.2

Data storage Data stored within the GIS is generally derived by digitizing (tracing) location information from existing maps, or is captured directly from aerial photographs and satellite images. Another option used in ecological studies is the direct capture of coordinate locations using radio telemetry. GIS Functions 1. Database of Geographically Referenced Data Figure3.3 GIS Architecture

The database component provides for the management of the geographic data. Any information that is spatially indexed, such as country, province, district, or which contains actual latitude/longitude coordinates, can be stored and manipulated in the GIS. The advantage of using a GIS over non-spatial DBMS is that the data can be viewed, queried and summarized visually
11

Spatial Information Technologies for Remote Sensing Today and Tomorrow, by Marble, D.F

36

through the graphical environment. Moreover, because the data has topology i.e. there are spatial relationships such as adjacency within the data; a variety of spatial processing functions which are not possible on a DBMS can be employed in data analysis. 2. Neighborhood Analysis This function allows an investigator to find and list all features which meet certain criteria and are adjacent to a particular feature. For example, a disease controller may want to identify and list all livestock units adjacent to an infected farm. 3. Network Analysis This technique allows modeling of networks and calculation of parameters such as shortest distance between two locations, or response times for services such as fire appliances or medical services, where routes between points are constrained by a network (of roads, rivers, pipes, cables, etc.). It may be of use in the sitting of fire stations, schools, hospitals etc. and can also be used for water flow analysis along reticulation systems. Possible applications of network analysis include the tracing of animal or product movements from infected properties to other destinations, or the study of the spread of diseases such as Cholera or Johne's disease along ground water drainage systems. 4. Surface Area / Distance Calculations Accurate measurements of distances between two or more points, or the surface areas of selected features on a three-dimensional surface can be obtained using a GIS. These computations could be used in an epidemiological investigation such as a case-control study where, for example, areas of certain classes of vegetation and soil types, or distances between farm properties are study variables. GIS Benefits 12 1. Improved Communication GIS-based maps and visualizations greatly assist in understanding situations and in storytelling. They are a type of language that improves communication between different teams, departments, disciplines, professional fields, organizations, and the public. 2. Better Decision Making
12

http://events.esri.com/uc/QandA/index.cfm?fuseaction=answer&conferenceId=2a8e2713-1422-24187f20bb7c186b5b83&questionId=2441

37

GIS is the go-to technology for making better decisions about location. Common examples include real estate site selection, route/corridor selection, evacuation planning, conservation, natural resource extraction, etc. Making correct decisions about location is critical to the success of an organization.

3.4 Expert System

Traditionally, a DBMS is mostly a repository of information to be later retrieved by an ad-hoc query language. If some data are currently unavailable in the system, or the query is not properly issued, the system can return either an error or a non-answer. This is not really the case when a specific question is asked to a human expert, in this case the expert digs in his or her memory looking for an answer, if no proper answer is found the expert perhaps starts looking for alternative, and approximate, responses. Actually, the expert uses his or her knowledge in a sort of cooperative way trying to make the user as more satisfied as possible. [13] Expert System is computerized tools designed to enhance the quality and availability of knowledge required by decision makers in a wide range of industries. Decision-making is important for the financial institutions involved due to the high level of risk associated with wrong decisions. The process of making decision is complex and unstructured. The existing models for decision-making do not capture the learned knowledge well enough. Expert system has three components 1) user interface 2) knowledge base 3) Inference Engine 4) knowledge acquisition. We give brief description about them in the following: 1) The User Interface [14] The user interface is the means of communication between a user and the expert systems problem-solving processes. A good expert system is not very useful unless it has an effective interface. It has to be able to accept the queries or instructions in a form that the user enters and translate them into working instructions for the rest of the system. It also has to be able to translate the answers, produced by the system, into a form that the user can understand. Careful attention should be given to the screen design in order to make the expert system appear friendly to the user.

13
14

Paper: Expert System Shell Toreason on Large Amounts of Data by G. GiufSrida

http://year12ipt.ash.com/untitled-7.html

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2) The Knowledge Base The knowledge base stores all the facts and rules about a particular problem domain. It makes these available to the inference engine in a form that it can use [15]. The facts define the objects, their attributes, values and relationships with each other. Objects can be physical objects, such as a village, farm or more abstract concepts, such as an event. Objects have properties (or attributes) e.g. the size of a village, the number of village people. Rules define how an expert reasons about the objects in the problem domain. They take the form of if-then rules. The if component comprises the premises of the rule, and consists of all the conditions that need to be satisfied for the rule to fire (i.e. for the rule to be found to be TRUE). The then component is the hypothesis (or conclusion of the particular rule) which is being evaluated. For example: Rule 1 If the village is contiguous to pig farm, And pig farm is infected with pig influenza, Then risk from local spread of pig influenza is high, And write current village to At-Risk table in DBMS, And set risk = high. 3) The Shell or Inference Engine The inference engine is the program that locates the appropriate knowledge in the knowledge base, and infers new knowledge by applying logical processing and problem-solving 4) Knowledge Acquisition The knowledge acquisition component allows the expert to enter their knowledge or expertise into the expert system, and to refine it later as and when required.

15

http://year12ipt.ash.com/untitled-7.html

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Expert, Knowledge Engineer

User interface

Facts, Rules Knowledge Acquisition Facility Facts, Rules

Knowledge Base of

Queries Facts Facts Rules& heuristics

Facts, Querie s Inference Engine

Advice, Consultation, Justification

External Program Interface Figure 3.4 Structure of a typical expert system

3.5 Overall Architecture

Figure 3.5 shows the overall architecture of Infectious disease outbreak DSS, the emergency response data contains different database such as traffic department database which stores data of traffic ,another database is hospital department database which contains hospitals information such as name of hospitals that prepared to deal with these diseases and their locations and Red crescent , ambulances. Also, level of medical staff. The simulation model provides information about the velocity of diseases spread and how it grows, multiply. Will be extracting and aggregating these data and transformed into data warehouse to store like as meta data and statistical information to provides the decision makers when happen a disease outbreak .

40

Data Warehouse

Link

User

Browser GUI

GIS System

Decision Makers
Parameters & queries
EXTRACT LOAD REFRESH CLEAN

Routing &context Information

Server

Internal DB

Report Service Analysis Service

Traffic Dep.DB

Health Dept.

Fire Database

Laboratory database

Electronic Surveillance System,

Expert System

Simulation Model

World Health Organization (WHO)

GIS System

Emergency Response Data Providers/Data Sources

Figure 3.5 Overall Architecture of Infectious disease outbreak DSS

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Chapter 4 Design Infectious Disease Outbreak DSS:

4.1 DSS business process and data flow analysis.
This section will give an analysis of the working process and data process for each function. The reason why we limit the discussion to only working process and data process is, firstly, our research question is focused on the general architecture of DSS and many functions should be discussed, and accordingly, choosing two important factors of DSS construction to analyze is reasonable; secondly, analyzing the information allocation mechanism is one of our secondary research tasks.

4.1.1 Infectious Disease Surveillance System Integrated with DSS

Overview of Surveillance System

To aid the early detection of bioterror events and infectious disease, public health officials and researchers have developed a new method called syndromic surveillance. This type of surveillance involves collecting and analyzing statistical data on health trends such as symptoms reported by people seeking care in emergency rooms and another health care settings and even sales of flu medicines as example. By focusing on symptoms rather than confirmed diagnoses, syndromic surveillance aims to detect bioterror events earlier than would be possible with traditional disease surveillance systems. Many city and state public health agencies have begun investing substantial sums to develop and implement these surveillance systems. Early identification of an infectious disease outbreak is an important first step towards implementing effective disease interventions and reducing resulting mortality and morbidity in human populations. In the majority of cases, however, epidemics are generally well under way before authorities are notified and able to control the epidemic or mitigate its effects.[16] An electronic surveillance system encompasses not only predictions of disease in time and space but also active disease surveillance and a pre-determined set of responses. The distinction
16

Stoto, Michael A., Matthias Schonlau, and Louis T. Mariano, Syndromic Surveillance: Is It Worth the Effort? hance, Vol. 17, No. 1, 2004, pp. 1924.

42

between prediction and early warning must be clearly defined: early warning is prediction but not all prediction is early warning. In the context of this research, early warnings are considered to come from both model predictions and disease surveillance (i.e. early detection), and include consideration of operational conditions and responses. Why surveillance?

According to definitions of CDC and WHO, Surveillance is the systematic collection, analysis and interpretation of outcome specific data for use in planning, implementation and evaluation of health practice and includes the timely dissemination to those who can undertake effective prevention and control actions. In other word, disease surveillance systems may be partitioned into collection, analysis, and reporting. The collection component contains lists of available data sources, collection strategies for data sources, instructions for formatting the collected data, and storage solutions. The analysis component stores a wide variety of computational methods used to extract significant signals from the collected data. The final component, reporting, contains the procedures for communicating analysis results to interested parties. The results may be presented in many forms: statistical analysis, incidence plots, heat maps, or simply as messages advising experts to check a data source for further information. According to Grard Krause, Doris Altmanns research that published at [2007], Surveillance of infectious disease outbreaks is important because outbreaks often require immediate intervention by the public health service. In addition, outbreaks may indicate deficiencies in infection control management and provide unique opportunities to investigate clinical and epidemiologic characteristics of the infectious agents, particularly in emerging infectious diseases. Timely and comprehensive outbreak reports need to be available not only at the affected administrative level but also at state, national, and international levels to detect and control multistate outbreaks. Electronic documentation and transmission of data are needed for rapid information exchange between institutions in charge of conducting, coordinating, and reporting control measures and should minimize additional work load for the public health service. A crucial goal of infectious disease surveillance is the early detection of epidemics, which is essential for disease control and tries to limit the outbreak of the disease see Fig. 4.1. Also, send an alert signal in the case of the diseases spread in order to make the best decision.
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In the following section, we will display the perception and description of the data flow of the surveillance system and its data source. Data Type of Surveillance System The data type most commonly used among surveillance systems is symptoms or diagnoses of patients from Emergency Department and/or physician office visits. Other types of data identified in other studies include emergency call center and nurse advice lines. Other types of data being used include sales of over-the counter health care products, prescriptions, telephone call volumes to health care providers and drug stores, and absenteeism. Data sources most often used for syndromic surveillance, ordered by availability, from earliest to latest, are as follows [17],[18]: triage nurse line calls work and school absenteeism prescription drug sales emergency hotline calls emergency department visit chief complaints laboratory test orders ambulatory visit records veterinary health records hospital admissions and discharges laboratory test results case reports

In an overview of operational syndromic surveillance systems [19], it was reported that the 52 systems surveyed monitored markedly the following data sources: emergency department visits (84%), outpatient clinic visits (49%), over the-counter medication sales (44%), calls to poison

17

) M. Berger, R. Shiau, and J. M. Weintraub, Review of syndromic surveillance: implications for waterborne disease detection, Journal of Epidemiology and Community Health, vol. 60, no. 6, pp. 543550, Jun.2006 18 ) S. Babin, S. Magruder, S. Hakre, J. Coberly, and J. S. Lombardo,Understanding the data: Health indicators in disease surveillance, in Disease Surveillance: A P ublic Health Informatics Approach, 1st ed., J. S. Lombardo and D. L. Buckeridge, Eds. Wiley-Interscience, apr 2007, ch. 2, pp. 4390.
19

) J. W. Buehler, A. Sonricker, M. Paladini, P. Soper, and F. Mostashari,Syndromic surveillance practice in the United States: findings from a survey of state, territorial, and selected local health departments,Advances in Disease Surveillance, vol. 6 , no. 3, pp. 120, 2008.

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control centres (37%), and school absenteeism (35%). Another review by [20] examined 56 systems, with a comparable distribution of data source usage. The availability of data sources depends on the local context of the project: jurisdiction of the organization responsible for the system, diagnoses to be monitored, existing laws regulating data access, and technical concerns such as ensuring sustained connectivity to the data sources. Recent research suggests that additional sources such as Web search queries [21], and Twitter posts can also contain important clues to the spread of disease. In other word, Syndromic surveillance involves the systematic (usually automated) gathering of data on nonspecific health indicators that may reflect increased disease occurrence. Syndromic surveillance typically relies on the following types of information: Preclinical information, which does not depend on access to health-care (e.g., school and work absenteeism, sales of over-the-counter drugs, calls to poison control centers); Clinical prediagnostic information, which requires contact with the health-care system but not definitive diagnosis or reporting (e.g., emergency department chief complaints, ambulance dispatches, and lab test orders); Post diagnostic data, which requires contact with the health-care system and some degree of diagnosis (e.g., hospital discharge codes). Data Source in Surveillance System In electronic surveillance system, syndromic surveillance [22] aims to complement traditional case report surveillance. Compared with conventional surveillance, syndromic surveillance is the gathering of data for public health purposes before confirmed information is available. Besides the existing information source in the hospital based case report system for notifiable diseases, three different data sources of syndrome information are collected. See Fig.4.1 Besides the existing information source in the hospital based case report system for notifiable diseases, three different data sources of syndrome information are collected.
20

)H. Chen, D. Zeng, and P. Yan, Infectious Disease Informatics: Syndromic Surveillance for Public Health and Bio-Defense, 1st ed. Springer, Dec. 2009.
21

)J. Ginsberg, M. H. Mohebbi, R. S. Patel, L. Brammer, M. S. Smolinski, and L. Brilliant, Detecting influenza epidemics using search engine query data, Nature, vol. 457, no. 7232, pp. 10121014, Feb. 2009.
22

) The term syndromic surveillance refers to the ongoing, systemic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health [8,9]

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(1) Patients main symptoms when they present at health clinics: ten major symptoms are determined after literature review, experts consultation, panel discussion and field investigations, including fever, cough, sore throat, nausea/vomiting, diarrhea, rash, mucocutaneous hemorrhage, headache, convulsion and disturbance of consciousness. In addition, other basic information including patients age, sex, home address, visiting time and date is also collected. (2) Over the-counter (OTC) medication sales: staff in pharmacies collects the daily sold amount of the selected drugs. Different medicines related to respiratory and gastrointestinal infectious diseases are selected for surveillance based on local historical sale records. The pharmaceuticals are grouped according to Anatomical therapeutic chemical (ATC) classification system recommended by WHO as well as possible syndromes, such as antipyretics, ant diarrheal drugs, compound cold medicine, cough suppressants, etc. (3) Primary school absenteeism: the numbers of and reasons given for absenteeism of students in primary schools are collected by teachers in charge of students health daily. Besides the above information, the age, sex and class of each absent student are also collected. (4) Complaint Chief/Complaint Processing: Establish a formal process for receiving complaints from the public. Use a standard process to collect information, including a standard intake form. Collect as much information as possible at the initial call. If possible, a single person should receive or process all illness complaints so patterns can be identified quickly. Alternatively multiple staff could take the calls using standardized data collection forms, which are then reviewed by one individual. Staff receiving calls and backup staff should be trained to give appropriate instructions to callers about prevention of secondary spread and seeking health-care services. Data Entry and Transmission We should develop a web-based integrated surveillance system for data collection and analysis via user-friendly interface (Figure 4.2). Daily data are typed or imported by data collectors in health care units, retail pharmacies and primary schools, and transferred to the central database within 24 hours mainly by Internet. If the data cannot be transferred by computer and Internet in some surveillance units, other communication tools like mobile phones, landlines, and fax machines are used for transferring instead. Staff in local Centers for Disease Control (CDC) will

46

receive the data and then type them into the central database manually. Raw data will be checked for logically erroneous data and duplicate records.

School absenteeism

Detection algorithm

Syndrome surveillance

Alert signal

Outbreak?

Chief Complaints

Timeliness
Data Processio n
Central Database

Disease Area

Compare and evaluate

OTC Sales

Nurse hotline calls Conventional surveillance

Alert signal

Validity
Outbreak?

Case report

Geographic Information System

Data Source

Data Collection

Data procession and analysis

Fig. 4.1 The flow of the surveillance system

Data Analysis and Outbreak Detection

After cleaning and backup, the data in the central database is ready for automated analyzing, which includes descriptive module and alarm trigger module. The descriptive module includes basic statistical analysis, for example the distribution of targeted symptoms across different time, space and population. The alarm trigger module incorporates models to detect aberrations from daily surveillance data. There are different methods documented in the literatures for outbreak modeling and detection research. Since there is no available historical data for modeling, models that require long-term historical data to establish the normal threshold arent being used. Nine methods
[23]

, including Moving

Average (MA), Exponentially Weighted Moving Aver-age (EWMA), Cumulative Sums (CUSUM), Recursive-Least-Square (RLS) Method, Shewhart Chart (PChart), Small Area Regression and Testing (SMART),Bayesian spatial scan statistics, Space-time Scan Statistics and What is Strange About Recent Event (WSARE) are being used in the project to detect aberrations. If an alert is generated from more models, it indicates the possibility of being a real alarm increasing.
23

These algorithms are being used in the project to detect aberrations and data analysis.

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The automated analysis models run at fixed times set by users each day, and when there is an alert triggered, the system send e-mail and/or SMS alerts automatically to its specified users. The users will conduct further epidemiologic analysis, interpretation, investigation and laboratory tests in response to the alerts. We design web service (e.g. V.S.NET) to get the last of update
information about disease from World health organization (WHO).

This system should integrate with infectious disease outbreak decision support system to generate alert signal to Decision Makers about disease outbreak and then they must do meeting in order to discuss this emergency situation. See figure 4.3
DETECTION
(Data Analysis)

Collection Data Outbreak investigation Team Clinical/laboratory data

Is this an outbreak?

CONFIRMATION

Verify diagnosis Link between cases time/place? Laboratory confirmation

No

Figure 4.3 Detection of an outbreak

Yes
Decision Makers

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School absenteeism

SMS
GPRS

Data Process & Analysis System

WAP Server Data Filter & Backup process
Backup Data

Chief complaint

Email

OTC Sales Case Report Syndromic Surveillance

Internet Server
Interne t

Raw Data

Operator Manageme nt
Data Collection System

Epidemiologic Analysis

Central Database

Outbreak detection model

Alert Signal

Interpretation

Outbreak?
Investigation

DM

GIS

World Health Organization (WHO)

Web service

Laboratory Test

User Management

Detection Algorithm

24

Figure 4.2 Design flow of web Electronic Surveillance System platform.

24

These figures Fig.4.1&4.2 published at (2012) in the http://www.biomedcentral.com and I modify it to suit my research.

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4.2 Classification of DSS:

A structured decision process is a process in which the procedures are standardized, the objectives are clear and the input and output are clearly defined. Specific characteristics of a highly structured task include (Alter 1996)25: Information requirements are known precisely; Methods to process the information are known precisely; Desired format of the information is known precisely; Decisions or steps within the tasks are clearly defined and repetitive; Criteria to make decisions are understood precisely; Success in execution of the tasks can be measured precisely. Unstructured processes are fuzzy, complex problems for which there are no ready to hand solutions. An unstructured task is so poorly understood that the information to be used, the method of using the information and the criteria for deciding whether the task is being well done cannot be specified. Unstructured decisions tend to be performed based on experience, intuition, trial and error, rules of thumb and vague qualitative information (Alter 1996, Turban26 1990). Semistructured processes fall between the structured and the unstructured problems, involving a combination of both standard solution procedures and individual judgment. The information requirements and procedures are generally known although some aspects of the task still rely on human judgment (Alter 1996,Turban 1990). Successful information systems impose the amount of structure that is appropriate for the activity being supported (Alter 1996). Information systems supporting decision making are often classified according to the degree of structure in decision processes they support (Turban 1990, Alter 1996). However, system categories are not mutually exclusive. Next, four categories of information systems will be briefly discussed. A detailed discussion of different categories of information systems can be found in Alter (1996), Inmon (1993) and Turban (1990).

25

Alter S: Information systems: a management perspective.The Benjamin / Cummings Publishing Company, Inc. Menlo Park, U.S.A. 1996. ISBN 0-8053-2430-5, 728 pp.
26

Turban E: Decision support and expert systems:management support systems. 1990. Macmillan Publishing Company. New York, ISBN 0-02-421663-1, 846 pp.

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4.3 Emergency Plan Management

Emergency plan management refers to a whole working process that analyzes monitoring information, predicts the development trend of disease outbreak and makes corresponding plans. Once the infectious disease outbreak happens, action should be taken according to these emergency plans. Then based on the terms of the specific situation, emergency plans need to be adjusted to minimize the possible loss. According to Wu & Liu (2003a), three functions which are related to DSS in emergency plan management, will be discussed in detail here. These are emergency plan assessment, emergency plan selection and emergency plan dynamic adjustment. 4.3.1 Emergency Plan Assessment Emergency plan assessment is the evaluation of existing emergency plans rationality and operability. Its goal is to find potential problems and improve the quality of emergency plans. (1) Emergency plan assessment working process Based on Jiang (2006), an evaluation module and a computer simulation module need to be integrated in emergency plan assessment process. The working process is shown in Figure 4-4 below.
General Evaluation Evaluation Methods Evaluation Index

Input Plans

Evaluation

Comprehensive Evaluation and Modification

Computer Simulation

Figure 4-4 Emergency plan assessment working process

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There are two ways to assess the emergency plans: one is evaluation, the other is computer simulation. With the same working logic as classification, the evaluation is realized in DSS by using evaluation methods to compare the input emergency plans with the evaluation index and then get the evaluation result automatically. Meanwhile, the computer simulation module can also be used to simulate the implementation of the emergency plans in the DSS and the help to optimize the emergency plans. According to the results of two assessments, a comprehensive evaluation and modification takes place. Finally, the evaluation results and modification suggestion are sent to decision makers. (2) Emergency plan assessment data flow According to the working process discussed above, the emergency plan assessment data flow can be designed as in figure 4-5. On the one hand, after importing the emergency plan information, the general evaluation module will do some assessment by combining the emergency plan information with emergency plan evaluation index system (D3.1), and then the expert evaluation result (D3.2) will be generated. On the other hand, inputting the emergency plan information will also be utilized to simulate the implementation and produce a computer simulation result (D3.3). Based on the results from the general evaluation module and the simulation module, DSS can do a comprehensive evaluation of the emergency plans and generate an evaluation result and some modification suggestions. Finally, decision makers can easily get all the emergency plan evaluation results and suggestions from the DSS to help them make a decision.
D3.1 Plan evaluation index system

Figure 4-5 Emergency plan assessment data flow

Input Plan Information

General evaluation module

D3.2 Evaluation result Input Evaluation result

Input Plan Information

Computer simulation

Comprehensive Evaluation and Modification

Decision maker

D3.3 Computer simulation result

Input Simulation Result

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4.4 Resource Management.

Resource Management: Resources (such as personnel, equipment, or supplies) are needed to support critical incident objectives. The flow of resources must be fluid and adaptable to the requirements of the incident. NIMS[27] defines standardized mechanisms and establishes the resource management process to identify requirements, order and acquire, mobilize, track and report, recover and demobilize, reimburse, and inventory resources. Effective resource management includes establishing resource acquisition procedures. It is important to consider the tradeoffs (e.g., shelf life, warehousing costs) and determine the optimal acquisition strategies, including: Acquiring critical resources in advance and storing them in a warehouses Supplying resources just in time, typically using a pre incident contract. Table 4.1 Example of resources needed for outbreak response

Personnel (trained staff) Supplies (e.g. oral rehydration salts, intravenous fluids, water containers, water-purifying tablets, drinking cups, vaccines, vitamin A, monitoring forms, vaccination cards, tally sheets)

Treatment facilities (location, beds available, stocks of basic medical supplies) Laboratory facilities (location, capacity, stocks of reagents, etc.) Transport (sources of emergency transport and fuel, cold chain) Communication links (between health centers; between Ministry of Health, nongovernmental organizations and United Nations agencies) Computers for data analysis Capabilities and equipment for conference calls Multiple phone lines Computers, laptops, software (e.g., data entry, statistical), portable printers, paper, graph paper, pens, clipboards

Camera

27

National Incident Management System pdf (2008). Pp.7-8

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Sterilization equipment for sample collection In an outbreak requiring a vaccination campaign: safe injection equipment (e.g. auto-destructible syringes and safety boxes (punctureresistant boxes) vaccination facilities (location, capacity) cold chain equipment (number and condition of refrigerators, cold boxes, vaccine carriers, ice-packs) Availability of essential vaccines and vaccination equipment (e.g. measles vaccines, injection material and cold chain equipment).

4.5 Decision information obtainment

In order to obtain decision information quickly, it is better to extract useful information from a variety of sources and then integrate them effectively. (1) Decision information obtainment working process The decision information obtainment working process can be summarized in three steps: firstly, obtain useful decision making related information from a wealth of related channels, such as, professional emergency management information systems, surveillance system and chief Complaints at hospitals, plan database. Secondly, integrate such scattered information logically to allow this information to be better managed, used and shared by decision makers. The final step is to use some technical means such as a data warehouse to ensure decision makers can get information quickly and accurately. In this project, we suggested use data warehouse which contains information from different resources such as simulation data, traffic data and GIS, hospitals data. After the electronic surveillance system generated alert signal this signal will send to
decision makers group and they must do meeting in order to discuss this emergency situation and they obtain all require information by queries from data warehouse. See figure 3.5 chapter 3, section 3.5

Overall Architecture. (2) Decision information obtainment data flow According to decision information obtainment working process, its data flow can be expressed as shown in figure 4-6. First, various decision-making information can be obtained from professional emergency management information systems, surveillance system, data warehouse (D3.4), and resource distribution list (D4.6). Then through the information integration module,

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and with the support of relevant technology, the useful integrated information can be obtained quickly by decision makers.

Professional Emergency MIS

Surveillance System

Relevant technical means

D3.4 Data warehouse

Decisionmaking information acquisition

Information resource integration

Information obtainment

Decision maker D4.6 Resource distribution list

Figure 4.6 Decision information obtainment data flow

4.6 Decision Making Performance Evaluation

(1) Decision making performance evaluation working process The final step is performance evaluation which will be executed after outbreak the infectious disease, not in the process of emergency management. Feng & Xu (1999) presented an integrated system in which a knowledge-based decision support system is integrated with a multilayer evaluation index system. Based on this idea, the working process of decision making performance evaluation is outlined as shown in figure 4-7 and the specific evaluation steps are as follows. During the performance evaluation process, we need to input some basic information about the result of decision making performance in the phases of emergency management and response, such as how many people are healing and whether people are satisfied about health care. Next,

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DSS will operate immediately by comparing this information with the internally installed evaluation index system, and then the evaluation result will be produced.

Database

Decision making performance result related information

Analysis

Installed evaluation index system

Evaluation Results
Figure 4-7 Decision making performance evaluation working process

(2) Decision making performance evaluation data flow Decision making performance evaluation data flow is illustrated in figure 4-8. Firstly, from D6.1 DSS can get the basic information of decision making performance immediately. Calling upon the decision making evaluation index system database (D6.2), DSS will combine the two information sources utilizing its installed model base and automatically perform the analysis and assessment automatically. Finally, the evaluation results will be generated and reported to decision makers.
D6.1 Decision-making performance information Analyze D6.2 Decision-making evaluation index database

Evaluation results

Decision maker

Figure 4-8 Decision making performance evaluation data flow

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4.7 Requirement Analysis

4.7.1 Hardware Support Layer Chen & Xu (2001) state that the physical layer is the platform for information transportation, and is the basis of DSS. Combining this idea with our research, the hardware support layer should be placed in the bottom of the system and includes at least the following three parts: computer network system, communication system and basic hardware devices. (1) Computer network system A computer network is any set of computers or devices connected to each other with the ability to exchange data (Kizza, 2005, p.3). The computer network system is the foundation of information transmission, information sharing and intelligent decision-making. . It should rely on the network infrastructure of the Ministry of Health in order to connect with units of health in each city. Utilizing the development of network technology and the interoperability of the local area network (LAN), the Health's Ministry should build a safe, reliable, advanced, practical and standardized computer network system for DSS. Based on the study of Liu & Zhang (2007), the content of network infrastructure should include at least the following three parts: Emergency department network

Emergency department network is any set of computers or devices connected to each other with the ability to exchange data in emergency departments. Its construction mainly consists of three separate parts: a network for public service (devices used in order to exchange data with the public) and a network for confidential transportation (devices are set up to transport the confidential data). This network is mainly designed for the transportation of basic information among different emergency departments. Emergency command network

An emergency command network is a group of connected computers or devices with the ability to exchange data in the emergency command center. This network is the base for decision makers to obtain or transfer information and to get the decisions made by DSS automatically. This network is mainly designed for decision makers. Communication system

Based on the definition of Schwartz, Bennett, & Stein (1995), a communication system is a collection of individual communication networks, transmission systems, and data terminal
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equipment by which users can exchange information. It usually is capable of interconnection and interoperation which forms an integrated whole. The application of many decision making functions depends on the relevant data and signals extracted from the terminals, and then transmitted them in the DSS. (2) Other hardware devices Other hardware devices are the rest of the hardware equipments not used in the computer network system or the communication system, which needs to be configured into the DSS. These could include monitoring equipments, servers, transmission equipment, on-site monitoring devices and on-site rescue command vehicles, cameras, scanners, printers.

4.7.2 User Interface

User interface, as an integral part of the DSS, is the bond that connects people and the DSS system. On the one hand, people import information to DSS or submit their decision needs to the system; on the other hand, the DSS provides solutions or decision support information to people through the interface. Additional information from people through the interface may be required to complete some decision tasks, such as a data that related to surveillance system. Also user interface such as website, wap site (mobile website) that use to deliver information and public services to citizens/ stakeholder about disease and how can them avoid it. Based on the architecture of Burstein & Holsapple (2008), our user interface is mainly concerned on the Language System (LS) and Presentation System (PS). According to Gao (2005), the main tasks of the user interfaces includes the following: Control DSS: it allows decision makers to control the system through the interface. Provide decision makers with various forms of interaction with interface: decision makers can access DSS through Web page, client-side system, cell phone, PDA and other channels according to their permission levels. Input and output: decision makers correctly input data and relevant parameters, and the DSS should be able to correctly output the operation results to decision makers. Adaptability: the interface should be able to expand and adapt to changes.

4.7.3 Software Support Layer

These are some of the software that uses to implement DSS as following: 1. Oracle or SQl Server to design database and Data warehouse.

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2. CLIPS [28]: CLIPS is a public domain software tool for building expert systems. The name is an acronym for "C Language Integrated Production System., CLIPS is a productive development and delivery expert system tool which provides a complete environment for the construction of rule and/or object based expert systems, it is probably the most widely used expert system tools because it is fast, efficient and free, we can download from: http://clipsrules.sourceforge.net/ Or Nexpert Object v3 program 3. Visual studio.NET (ASP.NET&AJAX) or PHP to developing Electronic Surveillance System, Apache or IIS 4. Simulation program to imitate the spread of disease such as Epidemiological Spread Simulator 5. GIS Map that provides information geographic such as distances and location of disaster, we can use Google Map or Arc/Info v. 10.1, Grid v. 10. Tin v. 10. 6. Statistics program - Sun workstation or SPSS v.18

28

http://en.wikipedia.org/wiki/CLIPS , http://clipsrules.sourceforge.net/WhatIsCLIPS.html

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Chapter [5] Implementation

When we implement decision support system may face some potential problems and challenges, in this chapter we will analysis some of these problems.

5.1 Potential Problem

There are many potential problems that may occur when implemented DSS we explain some potential problem based on investigation and literature review the potential problem that found from my investigation as follows:
5.1.1 From Investigation

1. Decision-makers or staff of local, national organizations whose actions depend on the results of the rapid assessment may not be trained in epidemiology. 2. Some of employees in emergency management dont know any things about DSS, they need to training. 3. Some want implement DSS but the IT level and financial budget cannot afford to do this. 4. May be there are an experts who can deal with DSS but we need a specialist for medical care, who can know how to deal with medical crises. 5. The government cannot adoption this idea because this government cannot afford the good environment for these crises ,this kind of situation needs a huge resources of an infrastructure (computer, internet access, data ware housing data mining and expert people who can use the DSS in order to responding to this situations. 5.1.2 From Literature Since the literatures on DSS implementation is relative scarce, and DSS is an information system, a review of relevant literatures on information system (especially, Enterprise Resource Planning system) implementation also suggests some potential problems with the implementation of DSS: (1) Lack of top management support, data accuracy, and user involvement are potential problems that lead to information system implementation failures (Sum, Ang, & Yeo, 1997).

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(2) Education, training and understanding of cross-functional working processes are often reported as other important factors in information system implementation (Markus, Axline, Petrie, & Tanis, 2000). (3) Working process changes during the implementation of a DSS system are needed (AlMashari & Zairi, 2000). (4) Zhang, Lee, Zhang, & Banerjee (2003) claim that lack of top management support, lack of discipline, resistance, and lack of broad-based inter-organizational commitment are the major factors that slow down the process of information system implementation. (5) When adopting an information system, there is a need to recognize the unique local government context in which the system will be embedded (Moosbruker & Loftin, 1998). (6) Maintaining the software and hardware sustainably has a positive impact on information system implementation success (Zhang, et al., 2003).

5.2 Suggestion on Implementation

Based on the potential problems analysis, suggestions on implementation are classified into three categories: organizational environments, including top management support, working process setting, Ministry -wide commitment, financial resources and establish Outbreak Control Team (OCT) , Outbreak Investigation Group(OIG) ; people characteristics, including user involvement and education & training; technical supports, including data accuracy and construction of hardware and software. We will discuss each of them in detail below:

5.2.1 Organizational environments

(1) Leader support Much research has emphasized that leader support is a necessary component in information system implementation (Burns & Turnipseed, 1991; Duchessi, Schaninger, & Hobbs, 1989). Since infectious disease emergency management DSS is an inter-organizational information system, its design, implementation, and operation require the cooperation of all people from all segments of the Healths Ministry or government. Leader support can help in solving disputes and clarifying doubts. Leaders should create an environment for implementing a DSS system. Their support in DSS implementation can be divided into two main facets: first, providing leadership, and, secondly,

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giving necessary resources. To implement an information system smoothly and successfully, leaders are required to participate in DSS construction meetings, monitor the implementation efforts, and provide clear directions for the project. Willingness to provide the necessary resources is another indicator of top management commitment to DSS implementation. The implementation could be blocked if some of the critical resources (e.g., people, funds and equipment) are not provided. (2) Financial resources The financial budget is the most serious problem that facing the leader in a organization, the leader should obtain resource such as, mutual funds, government bonds that cavers all requirements of disease outbreak such as medical and equipments of laboratories see Table 4.5. (4) Government-wide commitment Since DSS is a government-wide information system that integrates information within and across all-administrative organizations, it is necessary to get support from all segments of the health command center. Every person or organization is partially responsible for the overall system, and key users from different administrative organizations must commit to DSS implementation. Government-wide support should involve two aspects: first, leaders of each administrative organization should support the construction of the DSS; Secondly, as worker within each organization grow to understand the benefits of the system for their work, they will be willing to support the DSS. (6) Outbreak Control Team (OCT)[29] Once the surveillance system detects an outbreak, or alerts have been received, the lead health agency must set up an OCT to investigate. Membership will essentially be similar to the health coordination team but may have to be expanded depending on the disease suspected and the control measures required. The OCT should include:
29

a health coordinator, a clinical worker, a laboratory technician, a water/sanitation specialist,

Communicable disease control in emergencies A field manual Edited by M.A. Connolly , WHO Library Cataloguing-in-Publication Data 2005,pp116-117 62

a vector control specialist, a representative of the local health authority, health educators, Community leaders.

One member of the team should be the team leader; this is usually the health coordinator of the lead health agency. Each agency should be given a clear role for response to an outbreak, such as the establishment of an isolation centre or the implementation of a mass vaccination programme. (7) Outbreak Investigation Group 30 Typically, the responsibility for conducting an infectious disease outbreak investigation, recommending control measures, and monitoring their implementation falls on a core team of individuals. The composition of the core team should be determined before an outbreak occurs and should include individuals with knowledge and skills to address the responsibilities common to most outbreaks, such as Team leader Epidemiologic investigator Environmental investigator Laboratory investigator, and Depending on the unique characteristics of the disease or the outbreak, individuals with other expertise may be needed in an outbreak investigation. Such individuals might include statisticians, health educators, and health-care providers; however, those specific needs probably cannot be anticipated before an outbreak occurs.

5.2.2 People characteristics

(1) User involvement User involvement refers to the participation of DSS users in the system development and implementation processes. The DSS system is designed to facilitate decision makers jobs. Not to satisfy their needs.

30

Communicable disease control in emergencies A field manual Edited by M.A. Connolly , WHO Library Cataloguing-in-Publication Data 2005,pp117

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We need involve the user in the following two areas [31] firstly, definition (demand analysis) in DSS requires user involvement; and secondly, user participation is needed in the implementation process of DSS. Involving users in the stage of defining DSS needs can decrease their resistance to the potential system. (2) Education & training Based on the definition of Sum, C., Ang, J., & Yeo, L. (1997), education and training in this context refers to the process of providing users with the logic and overall concepts of DSS system and system operation. Thus, people can increase their awareness about using DSS and have a better understanding of how their decisions are made and to what extent the DSS system can help them. The main reason for education and training is to increase the consciousness of people who will use DSS as well as their expertise or knowledge level. Three important aspects of the training contents are: 1) logic and concepts of DSS; 2) features of the DSS (how to benefit users); and 3) operation training. Concept and features of DSS training show users why the DSS system is implemented, how the decisions are made and to what extent this system can help decision makers. Operation training helps those decision makers who are computer illiterate to operate the system.

5.2.3 Technical Supports

(1) Data accuracy Since the databases in DSS are intricately linked to one another, it is important to make sure the input data is accurate. Otherwise, inaccurate data input into one database will adversely affect the functioning of the others. This would result in the final decision which decision makers get from DSS being unhelpful or even misleading. This would reduce the incentive to use the DSS system. Thus data accuracy is a major determinant of DSS system success (Markus, et al., 2000). (2) Construction and interoperability of software and hardware DSS vendors may use different hardware/software platforms, databases, and operation systems which are not compatible with upper-level governments databases and operation systems. In order to consider the future use of the DSS (communicate with upper lever government DSS, e.g ministry of health), a hardware/software requirements analysis should be conducted first to
31

According to Zhang, Lee, Zhang, & Banerjee (2003)

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explore potential hardware/software problems. The hardware/software then is selected according to the specific DSS requirements. As time goes by and environment changes, the DSS may not as fully meet the decision makers needs, especially when the government organization or the resource locations has some changes. Thus, to increase the chance of success, the hardware/software should be updated periodically in order to closely fit with decision makers requirements.

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Chapter 6
5.1 Conclusion
The emergence management of health disease is a complex and dynamic process, which necessitates a comprehensive preparation .Computerized support of managerial decision making, is considered very important as a basis for effective and efficient management of large disease emergencies. so, to mitigate the effects of risks to infectious disease outbreaks that face people, Ministry of health need to have systems in place to identify, trace and record the source of identified problems in a timely manner in order to provides decision makers to make best decision and rapid response to the outbreak disease, this research aims to introduce an architectural structure of an infectious disease outbreak emergency decision support system. We present in the chapter (1) the statement of problem which are the Health disasters always have the characteristics such as an ad-hoc nature, unpredictability and widespread, and how to make the right decision in a limited time becomes important to the leaders. And present some objectives of the study such as to build architecture of DSS, to identify the information processing mechanisms of each module and to conceive of potential problems that may occur during the implementation of the DSS and give solutions to avoid them. In the chapter (2) given some fundamental concepts about DSS, In the chapter (3) we present the structure and components of the Decision support system which are database management system, simulation modeling and expert system, geography information system and overall architecture of infectious disease outbreak DSS that explain how working together. In the chapter (4) we present an architecture structure of surveillance system that provides information of outbreak disease, and alert signal to decision makers and present how decision makers obtaining of information, emergency plan management and requirement analysis. In the chapter (5) we present some potential problem that may occur when we implement DSS and give some suggestion on implementation. Finally, the DSS would be a powerful tool for the decision makers as it can help to save time and enhance the effectiveness of decisions, which means that the emergency management would be more efficient and more lives will be saved during an infectious disease outbreak.
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Websites:
http://www.wisegeek.com/what-is-dbms.htm http://www.isgdatabasedevelopment.com/data_warehouse.html http://ecommercecenter.net/management/what-is-a-data-warehouse.html http://events.esri.com/uc/QandA/index.cfm?fuseaction=answer&conferenceId=2a8e2713-1422-24187f20bb7c186b5b83&questionId=2441 http://year12ipt.ash.com/untitled-7.html
www.who.int

www.cdc.gov

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