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The Impact of Law on Syndromic Disease Surveillance Implementation

Purtle, Jonathan, DrPH, MSc; Field, Robert, I., JD, PhD, MPH; Hipper, Thomas, MSPH, MA; Nash-Arott, Jillian, MA; Chernak, Esther, MD, MPH; Buehler, James, W., MD

Journal of Public Health Management and Practice: January/February 2018 - Volume 24 - Issue 1 - p 9–17
doi: 10.1097/PHH.0000000000000508
Research Reports: Research Full Report

Context: Legal environments influence how health information technologies are implemented in public health practice settings. Syndromic disease surveillance (SyS) is a relatively new approach to surveillance that depends heavily on health information technologies to achieve rapid awareness of disease trends. Evidence suggests that legal concerns have impeded the optimization of SyS.

Objectives: To (1) understand the legal environments in which SyS is implemented, (2) determine the perceived legal basis for SyS, and (3) identify perceived legal barriers and facilitators to SyS implementation.

Design: Multisite case study in which 35 key informant interviews and 5 focus groups were conducted with 75 SyS stakeholders. Interviews and focus groups were audio recorded, transcribed, and analyzed by 3 coders using thematic content analysis. Legal documents were reviewed.

Setting: Seven jurisdictions (5 states, 1 county, and 1 city) that were purposively selected on the basis of SyS capacity and legal environment.

Participants: Health department directors, SyS system administrators, legal counsel, and hospital personnel.

Results: Federal (eg, HIPAA) and state (eg, notifiable disease reporting) laws that authorize traditional public health surveillance were perceived as providing a legal basis for SyS. Financial incentives for hospitals to satisfy Meaningful Use regulations have eased concerns about the legality of SyS and increased the number of hospitals reporting SyS data. Legal issues were perceived as barriers to BioSense 2.0 (the federal SyS program) participation but were surmountable.

Conclusion: Major legal reforms are not needed to promote more widespread use of SyS. The current legal environment is perceived by health department and hospital officials as providing a firm basis for SyS practice. This is a shift from how law was perceived when SyS adoption began and has policy implications because it indicates that major legal reforms are not needed to promote more widespread use of the technology. Beyond SyS, our study suggests that federal monetary incentives can ameliorate legal concerns regarding novel health information technologies.

Department of Health Management & Policy (Drs Purtle, Field, and Buehler), Department of Environmental and Occupational Health (Dr Chernak), and Center for Public Health Readiness and Communication (Mr Hipper, Ms Nash-Arott, and Dr Chernak), Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania; and Drexel University Dornsife Thomas R. Kline School of Law, Philadelphia, Pennsylvania (Dr Field).

Correspondence: Jonathan Purtle, DrPH, MSc, Department of Health Management & Policy, Drexel University Dornsife School of Public Health, 3215 Market St, Philadelphia, PA 19104 (

This study was funded by a Public Health Law Research grant from the Robert Wood Johnson Foundation. The authors acknowledge Joe Gibson, Richard Hopkins, and the International Society of Disease Surveillance for their guidance and support.

The authors declare no conflicts of interest.

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