As discussed in the previous chapter on architecture, we expect that organizations will increasingly enter into service agreements that cover more than exchange of data. We define a service agreement as one in which an organization agrees to provide a service. For example, a hospital may agree to test a certain number of patients for anthrax for a certain price on request by the health department (or even an automated system running in the health department, as would be feasible if it were simply a case of conducting additional testing on samples already obtained from patients).
Current DUAs (the subject of a previous section) include a description of the data that will be exchanged and perhaps the frequency of transmission, but not the reliability of the data provisioning. In our experience, many organizations are unwilling to agree to provide more than "best effort" reliability at data provisioning. Reliable and timely exchange of data is important; therefore, we expect it to be an increasingly important subject in negotiations of data use/service agreement.
As a concrete example of other services that may be the subject of negotiations, consider the efforts of the New York City Department of Health and Mental Hygiene (DOHMH) to obtain investigation services from the healthcare system. As discussed in Chapter 23, DOHMH operates a syndromic surveillance system that monitors ED visits for gastrointestinal and other syndromes. When this system finds an anomalous number of cases, DOHMH investigates. Balter et al. (2005) reported that efforts to persuade EDs to augment their specimen collections have not succeeded because these laboratory studies typically do not affect clinical care and incur added effort, cost, and burden of tracking results. They also report having piloted sending specimen collection kits to five outpatient clinics with supplies for testing children with chief complaints of vomiting or diarrhea. The results of the data collection were incomplete. For such mechanisms to work, the basic workflows and understandings of duties and responsibilities of the healthcare system must change, and for such changes to occur, high-level buy-in and agreement must be obtained through negotiation.
The above example is but a hint of the types of services that organizations involved in biosurveillance could provide to each other. A more expansive list of services might include testing patient P for tuberculosis; providing electronic access to patient charts (as in the example in Chapter 6); obtaining a travel history for patient Q; testing water supply for cryp-tospordium, providing a cargo manifesto and/or passenger lists; providing the production history of a medicine, an animal, or a foodstuff. Laboratories, water companies, the animal healthcare system, food production systems, and hospital infection control could all contractually agree to prearranged services that might improve the speed at which outbreaks are detected and characterized.
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