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  1. Purtle, Jonathan DrPH, MSc
  2. Field, Robert I. JD, PhD, MPH
  3. Hipper, Thomas MSPH, MA
  4. Nash-Arott, Jillian MA
  5. Chernak, Esther MD, MPH
  6. Buehler, James W. MD


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.