On July 9, Hawaii Governor Josh Green (D) signed Act 222, legislation to ensure the continuation of the state’s syndromic surveillance program, which serves as a critical early warning system for emerging health threats. This new law requires hospitals with emergency departments to report certain data to the Hawaii State Department of Health, providing an automated, near-real-time data source. The law transforms syndromic surveillance from a voluntary program to a required form of public health reporting and makes it easier for the Health Department to tailor data collection to fit Hawaii’s needs.
Unlike other forms of public health data reporting, syndromic surveillance data doesn’t contain patient names or other identifying information. As former Kauai District Health Officer Dr. Janet Berreman explained in a recent interview, “Syndromic surveillance is based on symptoms rather than confirmed diagnoses … Data collection happens before other types of disease reporting that a provider or laboratory may submit. It’s also more complete than other types of reporting because it captures the symptoms of everyone who comes through the emergency room, not just people with a specific diagnosis.” In Hawaii, health officials have used syndromic surveillance data to monitor mental health impacts from the Maui wildfires, respond to a norovirus spike on Kauai, and investigate a potential measles outbreak.
Before the passage of Act 222, hospitals were not required to participate in syndromic surveillance, despite its importance to Hawaii’s public health data infrastructure. Instead, the state relied on Medicare payment incentives to drive voluntary participation. Now Hawaii is one of at least 10 states requiring hospitals with emergency departments to participate in syndromic surveillance, making the state more resilient to potential changes in federal financial support through such incentives
The legislation also permits Hawaii’s Department of Health to create a state-based syndromic surveillance system. Currently, syndromic surveillance there (and in many other states) relies on a federal technology platform. Participating healthcare facilities in Hawaii send data to the Centers for Disease Control and Prevention (CDC), and the state Health Department accesses that data from the federal platform. This platform has limited flexibility that doesn’t always meet a state’s specific needs. With a state-based system, federal data sharing would continue, but Hawaii’s Department of Health can customize data elements (such as more specificrace and ethnicity categories) collected through syndromic surveillance and set its own data quality standards. Research from The Pew Charitable Trusts shows that sharing clear guidance on data quality standards with participating medical facilities enables them to collect better data.
A state-based system would allow the Hawaii Department of Health to receive syndromic surveillance data directly from facilities rather than accessing it indirectly through the CDC. This reduces Hawaii’s reliance on federal platforms that may not meet the state’s needs and makes it easier to integrate syndromic surveillance data with other datahreats
Under Act 222, Hawaii’s Department of Health has the authority to expand data collection to other sources in the future, including urgent care facilities. Pew research supports state expansion of syndromic surveillance coverage to such facilities, where a growing share of the population seeks emergency care. In Hawaii, expanding syndromic surveillance to urgent care centers can help reduce “data deserts” in rural areas, ensuring that public health can respond swiftly to health concerns affecting these communities.
Finally, the bill facilitates future collaboration between the Department of Health and other state agencies that may benefit from the data. For example, some states incorporate de-identified school attendance data into their syndromic surveillance feeds to detect outbreaks of influenza, norovirus, and other diseases that spread quickly in group settings
Syndromic surveillance is not only valuable to public health, but it can also inform clinical care. As the Healthcare Association of Hawaii testified, the new legislation will “help providers gain timely guidance and access to coordinated resources … support hospitals in their frontline role, and ultimately help protect the health and safety of our patients and communities.” Although healthcare facilities and providers can sometimes view public health reporting regulations as burdensome, syndromic surveillance demonstrates how automated, electronic reporting mechanisms can relieve that burden and equip providers with up-to-date, high-quality data to help prevent and treat disease.
In a time when health departments are being asked to do more with less, syndromic surveillance is a versatile and cost-efficient data source that states should preserve and expand. Codifying syndromic surveillance provides reassurance that data won’t disappear if federal policies change and offers states more autonomy to collect data that meets their population’s needs. A more robust syndromic surveillance program can help states address pressing public health concerns, including substance misuse, mosquito-borne illness, youth at risk of suicide, and weather-related illness and injury.
Hawaii’s Act 222 was developed by the State Department of Health in consultation with Pew’s public health data improvement team, who provided policy guidance based on its nationwide study of public health data reporting policies and practices. Since 2021, the team has helped states improve how data is accessed, used, and analyzed to improve health outcomes
Devon Genua works on The Pew Charitable Trusts’ public health data improvement project
