Report 2022-102 All Recommendation Responses

Report 2022-102: California Department of Public Health: It Has Missed Opportunities to Collect and Report Sexual Orientation and Gender Identity Data (Release Date: April 2023)

Recommendation for Legislative Action

To ensure that Public Health's branches use the SOGI data it collects to identify and address disparities in health outcomes, and to provide Public Health with an efficient mechanism to fulfill its current reporting requirements, the Legislature should require Public Health to provide an annual report to the public and to the Legislature that includes a description of Public Health's efforts to collect, analyze, and report SOGI data, including a comprehensive list of forms that are required to collect SOGI data, the level of compliance with SOGI data requirements for those forms, the forms exempt from these requirements, and the reasons for such exemptions.

Recommendation for Legislative Action

To ensure that Public Health's branches use the SOGI data it collects to identify and address disparities in health outcomes, and to provide Public Health with an efficient mechanism to fulfill its current reporting requirements, the Legislature should require Public Health to provide an annual report to the public and to the Legislature that includes a description of the status of any improvement or replacement of CalREDIE—Public Health's database used for statewide reporting of communicable diseases.

Recommendation for Legislative Action

To ensure that Public Health's branches use the SOGI data it collects to identify and address disparities in health outcomes, and to provide Public Health with an efficient mechanism to fulfill its current reporting requirements, the Legislature should require Public Health to provide an annual report to the public and to the Legislature that includes a description of the outcomes of data analyses that Public Health has performed or has allowed other qualified researchers to perform using the SOGI data it has collected.

Recommendation for Legislative Action

To ensure that Public Health's branches use the SOGI data it collects to identify and address disparities in health outcomes, and to provide Public Health with an efficient mechanism to fulfill its current reporting requirements, the Legislature should require Public Health to provide an annual report to the public and to the Legislature that includes a description of the steps Public Health has taken or has caused to be taken to improve services or program outcomes for underserved LGBTQ populations.

Recommendation for Legislative Action

To ensure that Public Health's branches use the SOGI data it collects to identify and address disparities in health outcomes, and to provide Public Health with an efficient mechanism to fulfill its current reporting requirements, the Legislature should require Public Health to provide an annual report to the public and to the Legislature that includes a description of, until fully implemented, the progress Public Health has made in implementing recommendations from this audit report.

Recommendation for Legislative Action

To ensure that Public Health collects sufficient data to effectively implement and deliver critical services, the Legislature should amend the SOGI data collection law to require Public Health to collect SOGI data from third-party entities, including local health jurisdictions, on any forms or electronic data systems unless prohibited by federal or state law.

Recommendation for Legislative Action

The Legislature should amend state law to allow voluntarily provided sexual orientation and gender identity data to be included with the immunization data that is reported to Public Health.

Recommendation #8 To: Public Health, Department of

To consistently collect accurate SOGI data, Public Health should standardize its definitions and provide guidance on how its forms should ask questions related to sexual orientation and gender identity, guidance on the minimum categories or response options to be collected, and guidelines on how to aggregate and report responses.

6-Month Agency Response

- The SOGI workgroup created the standardized definition, wording, and format of SOGI data questions and response fields. We are collecting stakeholder feedback and Public Health will post the feedback on its website once it is reviewed and considered.

- The SOGI data display standards are still in discussion. Staff are developing recommendations addressing the major issues that affect the display of SOGI data, including privacy protection of small cell sizes and sources of SOGI denominator data.

- The last form has been updated to meet SOGI standards. See "Form_The California WISEWOMAN Program.pdf"

- Public Health is considering a data collection/forms workgroup to review all data collection forms utilized within the department and streamline data collection practices, including a periodic review of whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of program reasons for not collecting SOGI data in accordance with departmental standards, once those standards are distributed.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

- Public Health is continuing to support the 2022 SOGI Workgroup on the data collection recommendations, which provide updated guidance on SOGI question wording and response options. These recommendations are with the Director's Office for review and approval.

- Planning is underway on reconvening the SOGI Workgroup to address SOGI data display standards. Issuance of data display standard recommendations will complete the goals of this workgroup.

- Of the seven forms identified as non-compliant in the audit report, further investigation has revealed that three of these forms were one-time use only and no longer relevant to the report. Two forms will be compliant by July 1, 2023 and the other form will be compliant by September 30, 2023. Public Health is in conversation with the program responsible for the one remaining form to develop a workplan to make the form compliant.

- Public Health will direct all centers to form data collection/forms workgroups to review all data collection forms utilized within the centers and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of branches' reasons for not collecting SOGI data, in accordance with Departmental standards.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #9 To: Public Health, Department of

To consistently collect accurate SOGI data, Public Health should complete and implement the goals of its 2022 SOGI workgroup.

6-Month Agency Response

- The SOGI workgroup created the standardized definition, wording, and format of SOGI data questions and response fields. We are collecting stakeholder feedback and Public Health will post the feedback on its website once it is reviewed and considered. See "CDPH Best Practice Recommendations for Collecting SOGI.docx"

- The SOGI data display standards are still in discussion. Staff are developing recommendations addressing the major issues that affect the display of SOGI data, including privacy protection of small cell sizes and sources of SOGI denominator data.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

- Public Health is continuing to support the 2022 SOGI Workgroup on the data collection recommendations, which provide updated guidance on SOGI question wording and response options. These recommendations are with the Director's Office for review and approval.

- Planning is underway on reconvening the SOGI Workgroup to address SOGI data display standards. Issuance of data display standard recommendations will complete the goals of this workgroup.

- Of the seven forms identified as non-compliant in the audit report, further investigation has revealed that three of these forms were one-time use only and no longer relevant to the report. Two forms will be compliant by July 1, 2023 and the other form will be compliant by September 30, 2023. Public Health is in conversation with the program responsible for the one remaining form to develop a workplan to make the form compliant.

- Public Health will direct all centers to form data collection/forms workgroups to review all data collection forms utilized within the centers and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of branches' reasons for not collecting SOGI data, in accordance with Departmental standards.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #10 To: Public Health, Department of

To consistently collect accurate SOGI data, Public Health should periodically identify all of its forms and review whether the forms are required to collect SOGI data or whether a statutory exemption applies.

6-Month Agency Response

- Center for Family Health (CFH). Effective July 1, 2023, the Adolescent Family Life Program (AFLP) has updated the data collection form "Comprehensive Baseline Assessment" (CBA) to be in SOGI compliance. See "CBA July 2023_Required Only.pdf & CBA July 2023_Required Only (sp).pdf"

- Center for Healthy Communities (CHC). Two forms (Common Initial Visit Clinical Care Information and Screening and Risk Reduction Counseling Form) are SOGI compliant as of July 1, 2023. The updated Screening and Risk Reduction Counseling Form was distributed on September 30, 2023. See "Form_CADC Common Initial Visit Clinical Care Information.pdf"

- Center for Health Statistics and Informatics (CHSI). Per Health and Safety Code (HSC) 102425, gender is not included in statute with a Live Birth Certificate, which the "Delayed Registration of Birth Form" closely follows. If a person requests to amend their sex to reflect their gender identity, they may do so without a court order per HSC 103426(a). The Sex (Field 2) portion of the form allows the applicant to choose between (1) Male, (2) Female, and (3) Non-Binary to be within statute and SOGI compliance.

- Center for Infectious Disease (CID). No forms identified as being non-compliant.

Public Health is considering a data collection/forms workgroup to review all data collection forms utilized and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of program reasons for not collecting SOGI data in accordance with the departmental standards, once those standards are distributed.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

- Public Health is continuing to support the 2022 SOGI Workgroup on the data collection recommendations, which provide updated guidance on SOGI question wording and response options. These recommendations are with the Director's Office for review and approval.

- Planning is underway on reconvening the SOGI Workgroup to address SOGI data display standards. Issuance of data display standard recommendations will complete the goals of this workgroup.

- Of the seven forms identified as non-compliant in the audit report, further investigation has revealed that three of these forms were one-time use only and no longer relevant to the report. Two forms will be compliant by July 1, 2023 and the other form will be compliant by September 30, 2023. Public Health is in conversation with the program responsible for the one remaining form to develop a workplan to make the form compliant.

- Public Health will direct all centers to form data collection/forms workgroups to review all data collection forms utilized within the centers and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of branches' reasons for not collecting SOGI data, in accordance with Departmental standards.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #11 To: Public Health, Department of

To consistently collect accurate SOGI data, Public Health should develop and implement procedures to review and approve its branches' SOGI data collection processes, including a review of branches' reasons for not collecting SOGI data.

6-Month Agency Response

Public Health is considering a data collection/forms workgroup to review all data collection forms utilized and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of program reasons for not collecting SOGI data in accordance with departmental standards, once those standards are distributed.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

- Public Health is continuing to support the 2022 SOGI Workgroup on the data collection recommendations, which provide updated guidance on SOGI question wording and response options. These recommendations are with the Director's Office for review and approval.

- Planning is underway on reconvening the SOGI Workgroup to address SOGI data display standards. Issuance of data display standard recommendations will complete the goals of this workgroup.

- Of the seven forms identified as non-compliant in the audit report, further investigation has revealed that three of these forms were one-time use only and no longer relevant to the report. Two forms will be compliant by July 1, 2023 and the other form will be compliant by September 30, 2023. Public Health is in conversation with the program responsible for the one remaining form to develop a workplan to make the form compliant.

- Public Health will direct all centers to form data collection/forms workgroups to review all data collection forms utilized within the centers and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of branches' reasons for not collecting SOGI data, in accordance with Departmental standards.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #12 To: Public Health, Department of

Public Health should develop a process to verify that all local health jurisdictions that do not use CalREDIE are reporting SOGI data to Public Health and are complying with SOGI data reporting requirements by October 2023.

6-Month Agency Response

Public Health prepared a high-level plan to prepare the technical infrastructure, the Integrated Infectious Disease Data (I2D2) Warehouse, to receive data from jurisdictions that do not use CalREDIE in June 2023. This project plan was recently revised with input and dependencies from the Information Technology Services Division (ITSD). CID is simultaneously building out the I2D2 infrastructure and working with Los Angeles (LA) county through March 2024 to pilot the process of receiving LA county data, including SOGI data, for a limited number (5-20) of reportable disease conditions. Information gained from this pilot will inform and guide the process for the remaining reportable disease conditions from LA County, as well as San Diego and San Francisco for diseases that are not in CalREDIE. CID currently estimates that data from all LHJs not using CalREDIE will be available in I2D2 by March 2026.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Center for Infectious Diseases (CID) is developing a plan to ensure that the local health jurisdictions (LHJs) that do not use California Reportable Disease Information Exchange (CalREDIE) report all communicable disease data, including SOGI data, to Public Health. This plan relies on the utilization of technology, staff, and processes implemented during the COVID-19 pandemic. There are two components to this plan: (1) Preparing the CID technical infrastructure for receipt of automated data files, utilizing the cloud-based data warehouse that was established for COVID-19. (2) Working with the LHJs that do not use CalREDIE for all disease conditions (e.g., Los Angeles, San Diego, and San Francisco) to inform them of the technical specifications their jurisdictions will need to implement to transmit automated data files, including collected SOGI data, to CID. In order to have a documented process by October 2023, CID will have a high-level project plan for preparing the technical infrastructure by the end of June 2023; initiate discussions with LHJs in June 2023; and have a final documented project plan by October 2023 for the activities the LHJs will need to do to report SOGI data to Public Health, and what CID will need to do to ensure LHJs are complying with SOGI data reporting requirements.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #13 To: Public Health, Department of

Public Health should develop an action plan to ensure that CalREDIE users and Public Health programs can extract SOGI data for all of the reportable disease conditions currently in CalREDIE by October 2023.

6-Month Agency Response

CID continues to add SOGI data elements to each data extract in the CalREDIE Data Warehouse so that they are available to public health programs. As of September 20, 2023, 80 of the 128 extracts have been updated with SOGI data elements, an increase of 31 since the last update was reported. Updates to the CalREDIE Data Warehouse are scheduled to be completed by the end of April 2024. In addition, to make access to and analysis of the available SOGI data more efficient, CID continues work to move the CalREDIE data warehouse and all communicable disease data to a cloud-based data warehouse. The data warehouse is called the Integrated Infectious Disease Data (I2D2) Warehouse. Public Health prepared a high-level plan to prepare the technical infrastructure in June 2023. This project plan was recently revised with input and dependencies from ITSD. CID is building out the I2D2 infrastructure and plans to have local health jurisdictions able to access CalREDIE data via cloud-based data warehouse I2D2 in October 2024.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Center for Infectious Diseases (CID) is developing an action plan to ensure that the local health jurisdictions and CID programs can extract SOGI data on all the reportable disease conditions currently in California Reportable Disease Information Exchange (CalREDIE), with two components: (1) Continuing the ongoing work to add SOGI data elements to each data extract in the CalREDIE data warehouse. As of May 17, 2023, 49 of 128 extracts have been updated, an increase of 22 since the list was provided to the auditors on February 14, 2023. (2) Developing and implementing a plan to move the CalREDIE data warehouse and all communicable disease data to cloud-based data warehouse that was established for COVID-19 leveraging technology, staff, and processes implemented during the COVID-19 pandemic. Moving the CalREDIE data to the cloud-based data warehouse is expected to result in efficiencies to modifying the data extracts to allow extraction and analysis of the available SOGI data. For example, for those extracts that are not updated to include SOGI data in the CalREDIE data warehouse, movement to the cloud-based data warehouse will facilitate updates to those extracts to include SOGI data elements more quickly. CID plans to have a schedule for the remaining data extracts in the CalREDIE data warehouse by 6/1/2023; and a high-level schedule for moving all the CalREDIE data to a cloud-based data warehouse by the end of June.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #14 To: Public Health, Department of

Public Health should work with local health jurisdictions and the future vendor of the new surveillance system by October 2023 to ensure that the system will be able to receive SOGI data from local health jurisdictions, and be able to extract and report SOGI data for all reportable disease conditions.

6-Month Agency Response

CID has included functional requirements (listed below) for the new surveillance system to receive SOGI data collected from local health jurisdictions and for the extraction and reporting of SOGI data for all reportable disease conditions. As part of the project process, there will be a "requirements traceability matrix", as well as an independent verification and validation process to ensure project requirements and objectives are met once a contract is executed with a vendor. The initial phase of the procurement for FDSS has begun. The full replacement of the surveillance system will not occur unless additional funding is secured for the FY24-25 year and beyond.

Additional functional requirements for new surveillance system:

o The Master Person Index (MPI) must capture sexual orientation and gender identity (SOGI).

o The MPI must allow users to view the history of sexual orientation and gender identity, which may change over time, for an individual.

o The system must provide functions to enable "versioning" of individuals in the MPI, whereby unique demographic data for an individual (e.g., names, addresses, SOGI) is stored in the system and associated with a specific time period.

o The system must provide a user interface that allows users to map and populate any data from an incoming Health Level 7 message (including future reporting requirements for SOGI information) to incident or patient records in FDSS, customizable by disease.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Center for Infectious Diseases has included functional requirements (listed below) for the new surveillance system to receive SOGI data collected from local health jurisdictions and for the extraction and reporting of SOGI data for all reportable disease conditions. As part of the project process, there will be a requirements traceability matrix as well as independent verification and validation (IV&V) to ensure project requirements and objectives are met once a contract is executed with a vendor.

1. The Master Person Index (MPI) must capture SOGI.

2. The MPI must allow users to view the history of SOGI, which may change over time, for an individual.

3. The system must provide functions to enable "versioning" of individuals in the MPI, whereby unique demographic data for an individual (e.g., names, addresses, SOGI) is stored in the system and associated with a specific time period.

4. The system must provide a user interface that allows users to map and populate any data from an incoming Health Level 7 message (including future reporting requirements for SOGI information) to incident or patient records in Future Disease Surveillance System, customizable by disease.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #15 To: Public Health, Department of

To ensure that its programs are using SOGI data to identify and address disparities in health outcomes, and to provide required information to the Legislature, Public Health should require regular reports from its branches that collect SOGI data; these reports should include the branches' efforts to record and report SOGI data, the outcomes of their SOGI data analyses, and the steps they have taken to improve their services or program outcomes for underrepresented populations.

6-Month Agency Response

Public Health is considering a data collection/forms workgroup to review all data collection forms utilized and streamline data collection practices, including a periodic review whether forms are required to collect SOGI data, assessment of SOGI data collection processes, and review of program reasons for not collecting SOGI data, in accordance with departmental standards, once those standards are distributed. Public Health is in the process of deciding how to develop a reporting structure and reporting requirements for its branches to provide regular reports to the Legislature.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

Public Health is currently developing an automated system to regularly collect reports from all its programs to track progress on the objectives listed on this recommendation, including the programs' efforts to record and report SOGI data, the outcomes of their SOGI data analyses, and the steps they have taken to improve their services or program outcomes for underrepresented populations.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #16 To: Public Health, Department of

To improve Public Health's ability to collect SOGI data, it should make available to local health jurisdictions and health care providers, a standardized definition, wording, and format of SOGI data questions and response fields.

6-Month Agency Response

The SOGI workgroup created the standardized definition, wording, and format of SOGI data questions and response fields.

We are collecting the stakeholder feedback and Public Health will post the feedback on its website once it is reviewed and considered.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The standardized definition, wording, and format of SOGI data questions and response fields is part of the SOGI Workgroup recommendations. Currently these recommendations are pending review from the Director's Office (DO). Once the DO approves, the SOGI recommendations will be posted on a public website for providers and local health jurisdictions to satisfy this recommendation.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

Recommendation #17 To: Public Health, Department of

To improve Public Health's ability to collect SOGI data, it should make available to local health jurisdictions and health care providers, directions for soliciting SOGI information and education in the importance of doing so.

6-Month Agency Response

The SOGI workgroup created the standardized definition, wording, and format of SOGI data questions and response fields.

We are collecting stakeholder feedback and Public Health will post the feedback on its website once it is reviewed and considered.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The standardized definition, wording, and format of SOGI data questions and response fields is part of the SOGI Workgroup recommendations. Currently these recommendations are pending review from the Director's Office (DO). Once the DO approves, the SOGI recommendations will be posted on a public website for providers and local health jurisdictions to satisfy this recommendation.

California State Auditor's Assessment of 60-Day Status: Pending

We look forward to reviewing Public Health's progress towards implementing this recommendation.

All Recommendations in 2022-102

Agency responses received are posted verbatim.