Appendix C
Summary of Research into the Costs of Enhanced Public Health Surveillance Systems

Henry Roman

Industrial Economics, Incorporated


In 2003, the U.S. Department of Homeland Security (DHS) initiated an environmental surveillance system intended to detect the intentional aerosolized release of biological pathogens. The program, called “BioWatch,” deploys air samplers, primarily in outdoor locations, in more than 30 jurisdictions throughout the United States. Over the next 4 years, DHS intends to upgrade the capabilities of the current system through improved technology and expanded coverage, both of existing BioWatch jurisdictions and expansion to additional jurisdictions and indoor facilities.

At the request of the Congress, the Institute of Medicine (IOM) and the National Research Council (NRC) have been asked by DHS’s Office of Health Affairs (OHA) to evaluate the effectiveness of the current BioWatch program (BioWatch) relative to planned improvements to the existing program and to current surveillance performed through the U.S. public health and hospital systems. This effort will be conducted by the Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System (the committee). The committee consists of experts in areas that include biological threat assessments, evaluation of biological detection systems, environmental monitoring technologies, biological assays, microbiology, virology, epidemiology, syndromic surveillance, health information technology, the U.S. public health sector, hospital systems, emergency medicine, laboratory operations, statistical methods, systems engineering, operations research, and economic analysis.

IOM/NRC engaged Industrial Economics, Incorporated (IEc), to provide analytical support to the committee to address cost-related aspects of its charge. This support included (1) an assessment of the costs of imple-



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Appendix C Summary of Research into the Costs of Enhanced Public Health Surveillance Systems Henry Roman Industrial Economics, Incorporated I n 2003, the U.S. Department of Homeland Security (DHS) initiated an environmental surveillance system intended to detect the intentional aerosolized release of biological pathogens. The program, called “Bio- Watch,” deploys air samplers, primarily in outdoor locations, in more than 30 jurisdictions throughout the United States. Over the next 4 years, DHS intends to upgrade the capabilities of the current system through improved technology and expanded coverage, both of existing BioWatch jurisdictions and expansion to additional jurisdictions and indoor facilities. At the request of the Congress, the Institute of Medicine (IOM) and the National Research Council (NRC) have been asked by DHS’s Office of Health Affairs (OHA) to evaluate the effectiveness of the current BioWatch program (BioWatch) relative to planned improvements to the existing pro- gram and to current surveillance performed through the U.S. public health and hospital systems. This effort will be conducted by the Committee on Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System (the committee). The committee consists of experts in areas that include biological threat assessments, evaluation of biological detection systems, environmental monitoring technologies, biological assays, micro- biology, virology, epidemiology, syndromic surveillance, health informa- tion technology, the U.S. public health sector, hospital systems, emergency medicine, laboratory operations, statistical methods, systems engineering, operations research, and economic analysis. IOM/NRC engaged Industrial Economics, Incorporated (IEc), to pro- vide analytical support to the committee to address cost-related aspects of its charge. This support included (1) an assessment of the costs of imple- 

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00 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE menting current and future realizations of the BioWatch monitoring system; and (2) research into the costs of “the current and a potential ‘enhanced national surveillance system’ to provide a basis for a rapid response to bioterrorist attacks or other biothreats, including initiation of pre-infection prophylaxis and expedited response and recovery.”1 This memo focuses on IEc’s efforts to acquire and analyze cost data on the public health system both as it currently exists and for cutting-edge programs aimed at improv- ing surveillance and response capabilities. Note that this memorandum is not intended to provide information about the merits of the current or “en- hanced” public health system or provide a snapshot of current public health surveillance capabilities nationwide. Furthermore, for the reasons detailed below, IEc and the committee have concluded that the available data do not support a comprehensive cost analysis of either current or enhanced public health activities related to biosurveillance and outbreak response. Thus, this memo does not present such an analysis; instead, it describes the major challenges to performing a cost analysis of public health programs, describes IEc’s effort to obtain cost data for example programs operating at the state or local level that match key biosurveillance and response activities identified by the committee, and discusses IEc’s observations regarding the limited data set we were able to obtain. We include example costs for specific state and local programs in Table C-2. OBSTACLES TO COST ANALYSIS Significant obstacles preclude our ability to generate a comprehensive cost estimate for the current or an enhanced U.S. public health system’s biosurveillance and response efforts. The primary problem is a general lack of financial transparency and accountability across the U.S. public health system. A number of papers and reports have documented this issue (e.g., Hebert et al., 2007; Honoré et al., 2007; TFAH, 2008). In part, this lack of transparency reflects differences in the organization of the public health system from state to state, where some have a more centralized system of public health responsibilities and others spread those responsibilities across multiple agencies. More importantly, there is no uniformly recognized clas- sification system for expenditures on public health, leading to confusion about what constitutes public health spending. The report from the Trust for America’s Health (TFAH, 2008) presents examples of inconsistencies in cost accounting for specific public health initiatives both across states and 1 “Statement of Task” provided to the committee by the Institute of Medicine and the Na- tional Research Council.

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0 APPENdIx C also year-to-year within the same state.2 This lack of transparency makes it difficult to do a top-down analysis of the portion of federal bioterrorism preparedness funds that are spent on biosurveillance and response activities by state and local health departments. It also precludes a “bottom up” ap- proach to estimating funds spent on bioterrorism surveillance and response, given the difficulties both identifying and isolating spending in specific public health categories. Another challenge for the committee is defining the entity—the “en- hanced national surveillance system”—for which costs are to be assessed. No current definition of such a system exists, though efforts to define such a system are ongoing. Given the tight time frame of the committee’s analysis, and not wishing to preempt current efforts in this area, the committee opted to instead highlight opportunities for enhancement of surveillance through the public health and health care systems in broad categories of legally man- dated reporting, automation of health care information systems and public health linkages, laboratory and diagnostic testing capacity, and information integration. We have used these categories to guide our cost research. APPROACH AND DATA SOURCES Faced with these challenges and the timeframe of this analysis, IEc adapted its cost analysis to focus on providing example cost data for activi- ties or programs at the state or local level that match the surveillance- and response-related categories described above. The results were intended to provide some insight into the potential order of magnitude or range of mag- nitudes of the costs of developing and maintaining systems that improve reporting, surveillance, and response. IEc focused its analysis on state or local public health programs and initiatives, though it did review one source reporting cost estimates for implementing electronic laboratory reporting (ELR) nationwide. Data Sources The cost information we obtained came from two categories of sources: • Published reports and journal articles. IEc conducted a thorough review of all cost-related documents on the IOM/NRC portal website sub- mitted by committee members, IOM/NRC staff, and the U.S. Centers for Disease Control and Prevention (CDC) for relevant cost estimates for the categories provided by the committee. IEc also searched for additional pub- 2 Fora discussion of the difficulties of measuring the value of services provided by public health departments, see Neumann et al. (2008).

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0 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE lic health cost analyses using the National Library of Medicine’s PubMed database.3 A table listing all the documents reviewed by IEc has been previ- ously submitted to the committee.4 • Telephone interviews. Most of our data came from e-mail ex- changes and telephone interviews with state and local health officials and representatives of public health organizations such as the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Council of State and Territorial Epidemiologists (CSTE), and the Association of Public Health Laboratories (APHL). The individuals contacted in December 2008 and January 2009 were identified through discussions with the aforementioned organizations, the committee, and IOM/NRC staff. IEc sent inquiries to individuals from state public health departments in Florida, Massachusetts, Michigan, Minnesota, Nebraska, New York, North Carolina, Pennsylvania, and Washington. IEc obtained cost data or conducted follow-up interviews with representatives of all of these states except Michigan, New York, and Pennsylvania. IEc also spoke with committee member James Buehler, who provided cost information about health departments in Georgia. At the local level, IEc interviewed a representative of the Tarrant County, Texas, health department, and we obtained data for the New York City health department from committee member Marci Layton. IEc also spoke with a University of Pittsburgh researcher currently developing a biosurveillance grid covering areas of Pennsylvania and Ohio. Individuals contacted by IEc are shown in Table C-1. RESULTS AND OBSERVATIONS The results of IEc’s research efforts are included in Table C-2. The data are quite limited; however, we can make a few observations. • The level of detail of these costs was generally rather broad, as ex- pected, with responses often given in terms of development and operations and maintenance (O&M) costs. • To the extent we can tell from limited data, the relative scale of the magnitude of costs across states and localities appears reasonable. • We obtained one national-level cost estimate—the cost of imple- menting a national ELR infrastructure, as estimated during a 2007 meeting of 3 IEc also reviewed CDC budget documents online (http://www.cdc.gov/fmo/topic/Budget); however, due to the difficulties in tracking CDC funding to the state and local level, we did not derive any cost estimates from these data. 4 See e-mail messages from Henry Roman, IEc, to Lois Joellenbeck, NAS/IOM, dated De- cember 20, 2008, and January 24, 2009.

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03 APPENdIx C local, state, federal, and private-sector experts sponsored by CDC through its cooperative agreement with APHL. The initial estimates included $50 million for planning and building basic infrastructure where needed, $600 million for development, and $100 million per year for O&M costs. • IEc was most successful in identifying cost information for the larger information technology (IT)-related efforts—ELR, syndromic surveil- lance systems, health information exchanges (HIEs), and electronic disease surveillance and outbreak management software. However, these data were often incomplete—for example, missing O&M costs in some cases because the systems are too new. IEc was least successful obtaining cost estimates for marginal expansion of laboratory testing and diagnostic capabilities, clinical decision support tools and point-of-care diagnostic tools, health alert networks, and fusion centers. • The interconnectedness of some of these systems makes it difficult to separate out costs of individual systems. For example, to implement ELR in North Carolina, the health department needed to develop a National Electronic Disease Surveillance System (NEDSS) function in order to receive ELR information. To do this, North Carolina funded the development of the Maven software system at a cost of over $3 million, with $650,000 annually in O&M costs. To estimate costs across the current categories, one would need to develop an approach to dividing the development (or purchase) and O&M costs of Maven across categories when such overlap exists, to avoid double-counting. • Another complicating factor in assessing the costs of these initia- tives relates to accounting for costs to all parties involved. For example, the true costs to hospitals that participate in ELR or syndromic surveillance systems may not be included in these estimates. Also, in the case of Wash- ington State, one of their major syndromic surveillance systems (Electronic Surveillance System for the Early Notification of Community-based Epi- demics, or ESSENCE) was provided to them by Johns Hopkins University at no cost, including an estimated $50,000 in hardware (Wayne Turnberg, WADOH, personal communication). • Customization can be a driving factor in the costs of syndromic surveillance systems, and the difference in cost can be dramatic. In addi- tion to the ESSENCE example above, the Real-time Outbreak and Disease Surveillance (RODS) system, developed at the RODS laboratory at the University of Pittsburgh, is an open-source system that is available at no cost to health departments. If a department wishes to customize RODS, it either needs to have the IT resources available in-house to modify the code, or it needs to contract out the modifications to an IT firm (Rich Tsui, Uni- versity of Pittsburgh, personal communication). The Outbreak Detection Information Network (ODIN) syndromic surveillance system, developed by Washington State to complement ESSENCE, features greater customization

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0 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE options and incorporates additional data sources; the cost of developing ODIN was approximately $5 million over 4 years. • In some cases, notably the HIEs, we observe a significant range in development costs—from a Tarrant County system with development costs under $200,000 to the PA-OH surveillance grid system ($1 million) to the Washington State HIE, which is being developed under a $5 million CDC grant. The Tarrant County effort, described as a “rudimentary” HIE that covers 50 to 60 hospitals, illustrates a less highly tailored approach, using open-source syndromic surveillance systems (RODS and ESSENCE) “off the shelf” to implement surveillance (William Stephens, Tarrant County (TX) Health Department, personal communication). While some of the cost differences with the other systems may be due to scope or other factors, we expect much of the difference reflects a focus on front-end development, providing greater customization and flexibility and features. REFERENCES Hebert, K., N. Henderson, and E. Gursky. 2007. Building preparedness by improving fiscal accountability. Journal of Public Health management and Practice 13(2):200–201. Honoré, P.A., R.L. Clarke, D.M. Mead, and S.M. Menditto. 2007. Creating financial trans- parency in public health: Examining best practices of system partners. Journal of Public Health management and Practice 13(2):121–129. Neumann, P.J., P.D. Jacobsen, and J.A. Palmer. 2008. Measuring the value of public health systems: The disconnect between health economists and public health practitioners. American Journal of Public Health 98(12):2173–2180. TFAH (Trust for America’s Health). 2008. Shortchanging America’s health 008: A state- by-state look at how federal public health dollars are spent. Washington, DC: Trust for America’s Health. http://healthyamericans.org/reports/shortchanging08/ (accessed March 27, 2009).

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0 APPENdIx C TABLE C-1 Public Health Cost Data Contacts Health Department/ Organization Contacts APHL Scott Becker Chris Mangal Michelle Meigs Patina Zarcone (January 23, 2009) ASTHO James Blumenstock CSTE Lisa Dwyer Emory University James Buehler* (December 17, 2008) Florida Richard Hopkins (January 14, 2009) Massachusetts Dina Caloggero Michigan James Collins Minnesota Richard Danila NACCHO Jack Herrmann, William Stephens (Tarrant County (TX) Public Health, December 18, 2008) Nebraska Thomas Safranek (January 14, 2009) New York City Marci Layton* New York State Robert Burhans North Carolina Jeffrey Engel (January 16, 2009) Pennsylvania Veronica Urdaneta University of Pittsburgh Fu-Chiang (Rich) Tsui (December 18, 2008) Washington State Michael Davisson John Erickson Margaret Hansen Judy May Wayne Turnberg (all January 20, 2009) NOTE: Interview dates in parentheses. APHL, Association of Public Health Laboratories; ASTHO, Association of State and Territorial Health Officials; CSTE, Council of State and Territorial Epidemiologists; NACCHO, National Association of County and City Health Officials. *IOM/NRC committee member.

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0 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE TABLE C-2 Public Health Cost Matrix: Examples of Surveillance Program Costs Category Example Programs Environmental Monitoring Programs Enhance animal, wildlife, vector Canada’s National Wildlife Disease Strategy testing Legally Mandated Reporting and Surveillance Systems: Notifiable Diseases, Outbreak Reporting, Vital Event Registration Enhance electronic laboratory 1. APHL/ANSER/CDC estimate for developing a reporting systems national ELR system 2. NC (online for 2 labs) 3. WA: PHRED (online for 5 of larger hospital labs, about 50% of test results) 4. NE (developing) 5. MA

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0 APPENdIx C Cost Information Cost Information Reference Comments No data yet on Canadian Kuiken et al. (2005) program. Paper identified by committee member Seth Foldy suggests $4–5 million over 3 years to design and implement global animal surveillance system for zoonotic pathogens 1. Development: $650 million 1. APHL et al. (2007) MA values assume ~$53,000 to plan ($50 million) and labor, $140,000 in software, implement ($200 million/yr and ~$3,000 in hardware over 3 years). Planning includes support for 6 servers building state public health LIMS where needed ($25 million). O&M: $100 million/ yr estimated O&M costs 2. Development: $400K for 2. Jeffrey Engel, NC, STARLIMS product for labs; personal communication cost per hospital can vary, can be as much as $40,000. O&M: no data yet. Costs to Receive ELR: needed to develop NEDDS systems; Development: $3.25 million to develop and implement Maven system; O&M: $650,000 ($500,000/yr for Maven; $150,000/yr for ELR coordinator) 3. Development: do not have 3. Michael Davisson, yet; O&M: about $200,000/ Wayne Turnberg, Judy yr (half technology, half May, WA, personal operations) communication 4. Development: estimates 4. Thomas Safranek, $600,000 ($20,000 per lab); NE, personal O&M: estimates $50,000– communication 75,000/yr personnel costs 5. Development: pending; 5. Dina Caloggero, MA, O&M: $196,000/yr personal communication continued

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08 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE TABLE C-2 Continued Category Example Programs Enhance notifiable disease reporting by clinicians (outreach, electronic reporting procedures, 24/7 call line) Enhance electronic death reporting 1. Boston surveillance system receives death systems certificate data issued in City of Boston 2. WADOH (5 counties) Automation of Healthcare Information Systems and Public Health Linkages Enhance use clinical decision eTriage support tools for diagnosis, VisualDx reporting, & management (e.g., triage, isolation, treatment)

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0 APPENdIx C Cost Information Cost Information Reference Comments Outreach programs generally Assume 1 junior involve 1 staff member epidemiologist FTE working full-time as liaison for Outreach “liaison” (~$54,000/yr) in public health department in GA Outreach materials can cost (James Buehler, personal up to several hundreds of communication) thousands of dollars per year “though staff varies with (upper bound, NYC) size of department, e.g., percentage of several For Internet-based systems, MDs’ time employed there is a startup cost plus in outreach in NYC” 1 IT FTE to maintain it (Marci Layton, personal (~$48,000/yr). communication). Outreach materials: Marci Layton, personal communication Cost of full-time staff from the State of Hawaii Department of Health Bioterrorism Preparedness Response Program–FY 2005 Salary Survey 1. $74,389 (development; also 1. Kirkwood et al. includes costs for 911 and (2007) EMS data) 2. Development: awaiting 2. Michael Davisson, costs on latest version; O&M: WADOH, personal unknown communication VisualDx: $20,000 per hospital continued

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0 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE TABLE C-2 Continued Category Example Programs Enhance use of information Syndromic Surveillance systems such as RODS, from EMRs and other electronic ESSENCE health information sources to detect unusual cases of disease or Systems in many states, including MA, NY, NC trends (public health collects and (NCDetect), WA collates information from multiple institutions) Also local HIE efforts to increase integration with EHRs, beyond typical syndromic surveillance features—more public health user control over data reporting, reachback features (e.g., WA state, Indiana, NY?) Electronic Support for Public Health (ESP): an automated, secure, portable public health detection and messaging system for cases of notifiable diseases. Uses electronic medical data and supports an optional case management workflow system for case notification control. All relevant clinical, laboratory, and demographic details are transferred to the local health authority

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 APPENdIx C Cost Information Cost Information Reference Comments Boston, MA: An electronic, Kirkwood et al. (2007) emergency department-based syndromic surveillance system for the Boston Public Health Commission cost $422,899 between December 2003 and July 2005. This included: $141,227 in development costs $74,389 for enhancements $196,302 in annual O&M costs NYC: O&M for syndromic Heffernan et al. (2004) surveillance system estimated to be $130,000–$150,000/yr NC: NCDetect, statewide. Jeffrey Engel, NC, Development: $1.9 million personal communication over 3 years (does not include some costs to hospitals); O&M: $600,000/yr. Also, 60 hospitals have reachback enhancement for an extra $3 million ($50,000 per hospital) WA: uses ESSENCE and Michael Davisson, 40 hospital partners for ODIN; ESSENCE provided at Wayne Turnberg, Judy HIE in WA; CDC grant for no cost to WADOH; minimal May, WA, personal HIE went to University of staff maintenance/review time. communication Washington, INHS (a RHIO), ODIN (Kitsap and Pierce SAIC counties) Development: ~$5 million over 4 years; O&M: unclear, some minimal staff maintenance and review time. HIE with EMR extraction for syndromic surveillance Development: $5 million in CDC grant over 3 years No cost data yet on ESP ESP developed through a collaboration between CDC, the CDC-funded Center of Excellence in Public Health Informatics based at Harvard, Harvard Vanguard Medical Associates, and the Massachusetts Department of Public Health continued

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 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE TABLE C-2 Continued Category Example Programs Massachusetts eHealth Collaborative, which uses health information technology through community- based implementation of EHRs and health information exchange Enhance use of regional health 1. Tarrant County, TX system information exchanges to detect unusual cases of disease or trends (public health interfaces with area-wide exchange that involves multiple institutions) 2. PA-OH BiG (under development) Enhance public health capacity to electronically alert healthcare sector of important public health events (e.g., inform evaluation, triage, isolation, treatment) Laboratory and Diagnostic Testing Capacity Expand access to rapid diagnostic Luminex tests, “point of care” tests Extend capacities to characterize pathogens and coalesce reports to identify emergence or spread of related cases of infectious disease (e.g., PulseNet model)

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3 APPENdIx C Cost Information Cost Information Reference Comments Goroll et al. (2009) eHealth Collaborative: $50 million was pledged by Blue Cross Blue Shield of Massachusetts to establish an all-stakeholder organization that would implement three full funded community-wide EHR demonstration projects across Massachusetts over 3 years 1. Development costs: 1. William Stephens, $150,000; O&M: manager, Southwest $70,000–$75,000/yr; Future Center for Advanced enhancements (includes adding Public Health Practice; ELR): $150,000–$200,000 Tarrant County Public Health, personal communication 2. Development costs: $1 2. Rich Tsui, University million ($500,000 over 2 of Pittsburgh, RODS years); O&M: similar to laboratory, personal maintenance costs in current communication public health system NYC: Several million in Marci Layton, personal startup costs plus 3–4 communication FTEs to operate/maintain (~$200,000/yr) Cost of full-time staff from the State of Hawaii Department of Health Bioterrorism Preparedness Response Program, FY 2005 Salary Survey Development costs: $4–6 million over 2 years; unit cost: <$50,000 continued

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 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE TABLE C-2 Continued Category Example Programs Expand/enhance capacity to collect and test clinical specimens as part of public health surveillance systems, either ongoing or in response to possible alerts Information Integration Improve integration and analysis 1. Maven Electronic Disease Surveillance and Outbreak of public health information Management (Consilience Software) in NY, MA, MN (e.g., epidemiologic, laboratory, environmental, program) 2. WATrac: checks ED status and bed availability, and has incident management functions for disaster response; includes patient tracking (no users yet) Enhance integration and analysis of BioPHusion, BWIC project, NBIS/NBIC (DHS) public health and other information sources that characterize public health threats (e.g., BioPHusion model, fusion centers) NOTES: APHL, Association of Public Health Laboratories; BWIC, Biological Warning and Incident Characterization; CDC, Centers for Disease Control and Prevention; DHS, Depart- ment of Homeland Security; ED, emergency department; EHR, electronic health record; ELR, electronic laboratory reporting; EMR, electronic medical record; ESP, Electronic Support for Public Health; ESSENCE, Electronic Surveillance System for the Early Notification of Com- munity-based Epidemics; FTE, full-time equivalent; FY, fiscal year; HIE, health information

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 APPENdIx C Cost Information Cost Information Reference Comments 1. Maven in NC: 1. Jeffrey Engel, NC, Devevelopment: $3 million; personal communication; O&M: $500,000/yr (overlap Rich Danila, MN, with ELR?); Maven in MN: personal communication $800,000 to purchase; no O&M given 2. WATrac Development: 2. Margaret Hansen, WATrac: bed tracking and $160,000; O&M: $45,000 WADOH, personal ED status in 82% of WA communication hospitals; resource and pharmaceutical tracking anticipated to be implemented in 2009 statewide exchange; IT, information technology; LIMS, laboratory information management system; NEDSS, National Electronic Disease Surveillance System; NBIC, National Biosurveillance Information Center; NBIS, National Biosurveillance Information System; O&M, operation and maintenance; PHRED, Public Health Reporting of Electronic Data; RHIO, regional health information organization; RODS, Real-time Outbreak and Disease Surveillance; WADOH, Washington State Department of Health.

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 BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE REFERENCES APHL (Association of Public Health Laboratories), ANSER, and CDC (Centers for Dis- ease Prevention and Control). 2007. Framework for electronic laboratory reporting: Recommendations to policymakers. A report of the Electronic Laboratory Reporting Consensus-Building Meeting, October 30, 2007. Arlington, VA: Analytic Services Inc. http://www.aphl.org/policy/Documents/Electronic_Lab_Reporting_2007.pdf (accessed March 26, 2009). Goroll, A.H., S.R. Simon, M. Tripathi, C. Ascenzo, and D.W. Bates. 2009. Community-wide implementation of health information technology: The Massachusetts eHealth Collabora- tive experience. Journal of the American medical Informatics Association 16:132–139. http://www.jamia.org/cgi/content/full/16/1/132 (accessed August 10, 2009). Heffernan R., F. Mostashari, D. Das, M. Besculides, C. Rodriguez, J. Greenko, L. Steiner- Sichel, S. Balter, A. Karpati, P. Thomas, M. Phillips, J. Ackelsberg, E. Lee, J. Leng, J. Hartman, K. Metzger, R. Rosselli, and D. Weiss. 2004. New York City syndromic surveillance systems. morbidity and mortality Weekly Report 53(Suppl.):23–27. Kirkwood, A., E. Guenther, A.T. Fleischauer, J. Gunn, L. Hutwagner, and M.A. Barry. 2007. Direct cost associated with the development and implementation of a local syndromic surveillance system. Journal of Public Health management Practice 13(2):194–199. Kuiken, T., F.A. Leighton, R.A.M. Fouchier, J.W. LeDuc, J.S.M. Peiris, A. Schudel, K. Stohr, and A.D.M.E. Osterhaus. 2005. Public health: Pathogen surveillance in animals. Science 309(5741):1680–1681.