In response to the terrorist attack of September 11, 2001 , the NH Department of Health and Human Services (NH DHHS) engaged state and external partners in the design of an early warning surveillance system to support bioterrorism and emergency preparedness. Initially, NH DHHS began collecting four syndrome counts from 13 hospital emergency departments (EDs) by fax. Automation began in 2002, when an over-thecounter (OTC) syndromic surveillance pilot system was implemented by Scientific Technologies Corporation (STC). In 2003Á2004 this system, the Syndromic Tracking and Encounter Management System (STEMS), was expanded to include school absentee and occupational health reports. Over time, an internal death data application was automated to query vital record deaths, and in 2005, a real-time ED surveillance pilot, the Automated Hospital ED Data System (AHEDD), was developed by STC to replace manual ED surveillance. Over the past decade, NH continued to expand the original concept with innovative approaches to identify undetected or underreported disease outbreaks.