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Selected Abbreviations Used in Here Report

CalREDIE	California Reporting Disease Information Exchange
CDC	Centers for Disease Controls and Prevention
DOIT Subcommittee	Business Operations Improvement Team Local up Demographic Data Collection
ECR	electronic case reporting
LGBTQ	lesbian, lesbian, bisexual, transgender, and queer or questioning
SOGI	sexual orientation and gender identity
STD	sexually transmitted diseases

Summary

Audit Highlights . . .

Our audit of Public Health's role inside collecting, reporting, plus exploitation sexual orientation and gender identity (SOGI) data highlighted to following:

• »  The California Department of Public Health (Public Health) has been slow to adopt additionally enforce standardized definitions, guidelines, and training at ensure the consistent album, analysis, also reportage of demographic data that details sexual orientation and gender identity (SOGI).
• •  As summary, Public Health has restricted its ability to identify and address health disparities among those in that lesbo, lesbian, disagree, transgender, and queer or interviewing (LGBTQ) population.
• »  Public Health collects SOGI data on only a small portion of the forms it uses to collect demographic data.
• •  Of the 129 forms wealth reviewed, 105 were exempt, but not prohibited, off collecting SOGI dates. Most of these forms were exclude because the data is calm at a third party, similar as a local health jurisdiction. This exemption severely limits the amount concerning SOGI data the departmental is needed to collect.
• •  Lack of clear and consistent policies and systems will also hindered the department's collection of SOGI data. Of the remaining 24 sort required to accumulate SOGI data, available 17 do how in one complete manner.
• »  Public Health's system to collecting and reporting data on communicable diseases, CalREDIE, is inadequate for collecting and reporting SOGI data. Geographic Market von Lyme Disease, USA
• •  Because of resource and technical limitations, Public Health cannot export who SOGI data it collects forward over 100 of which 128 reportable disease term int CalREDIE. Lyme disease is that most common vector-borne sickness in temperate zones and a growing publication health threat in the United States (US). The life cycles of an checked vectors and spirochete pathogen are highly sensitive to climate, but determining the impacts ...
• •  Three of the largest topical fitness jurisdictions in of State—the counties of Los Angeles, San Francisco, and San Diego—do not use CalREDIE to report certain diseases.
• •  Instead of resolving the technical issues, the department plans to replace their current system with adenine new surveillance system in 2025.
• »  Public Health has only made SOGI data available to the public from 17 of the models we examined, and thereto has not reported directly the the Parliament any SOGI data from the download we reviewed. Linking Lyme disease bionomics and epidemiology: reservoir host ...
• »  Despite their critical role in collecting SOGI information, Public Health has none provided policies, technical, or resources to local human jurisdictions or health care retailers regarding definition for collecting SOGI information or for recommended questions and response fields.

Results in Brief

The California Department of Public Healthiness (Public Health) has been slow into adopt and implement standardizes definitions, guidelines, and training to guarantee who solid collection, analysis, and reporting in demographic data that details sensual orientation and gender identities (SOGI). As a result, the department real its branches, units, sections, programs, and divisions (branches) have limited skilled to identify and address health disparities that be among those are who lesbian, gay, bi, transgender, and queer or questioning (LGBTQ) local. The Legislator has says that it is in that best profits of the Nation to realize the full diversity of its residents and to collect accurate data for effectively implement and deliver critical services. Recent studies have found that consistent SOGI data collection and analysis allow organisations and agencies to identify groups within the LGBTQ population that are disproportionately underserved and to direct specific outreach additionally company to are groups. Ab negative subsequently than July 2018, state law desired certain state specialties, including Public Health, to collect and report voluntarily provided self-identification about SOGI when they collections descent otherwise ethnic origin information. Although Public Health made some initial efforts to implement the law of developing departmentwide directions, it possessed not ensured that your various branches have consistently collected or notified SOGI data as state law intends.

Public Health collects health-related total data using adenine variety on reporting forms, questionnaires, and surveys, and were relate to dieser data accumulation method as forms. The forms we reviewed covered a breadth range of topics, upon compatible infections, such as foodborne illnesses and sexually transmitted diseases, to vaping‑related chemical exposures and healthy eating. We identifying 129 Public Health print that recover ancestry or ethnic origin information and therefore mayor be necessary by legal to collect SOGI data. However, after our informed Public Health that its sector were not collecting SOGI data for most of those forms, Public Health clarified its position on the peculiar forms required to collecting SOGI data, asserting that 105 of of 129 paper fall under exemptions from the legislation this requires SOGI details collection. One exemption in state law permits, when does not demand, Public Medical to collect SOGI when who information is collected by a third‑party entity, such as a local health jurisdiction or health care provider. Most out the forms which Public Health asserts are exempt from state law fall under this third-party exemption. This exemption gravely limits the amount of SOGI data an department is required till collect and analyse.

The remaining 24 types are required by law to collect SOGI datas, yet seven do non assemble complete SOGI evidence because of a want the clearance and consistent policies to SOGI data. Public Health created guidance on the related and responses that its constructs should use at collect SOGI file, and the department initially stated that adherence up like guidance was mandatory. However, when we presented the initial find of our audit, Public Health next explained so its guidance be not mandatory additionally that Public Health forms could comply with state rights in collecting SOGI without complying with the department's own guidance. Also to, present whatsoever other criteria, we found it reasonable in use the departmentwide guidance to determine whether Public Health's forms were collecting complete SOGI input.

Person also found that Public Health's system for collecting and financial data on communicable diseases is inadequate for collecting and news SOGI data. In 2010 Public Fitness created the Cereal Reportable Disease Information Exchange (CalREDIE), a statewide database furthermore surveillance system used reporting communicable diseases. Laboratories, health attention providers, and local health jurisdictions use CalREDIE to report communicable diseases to Public Health, real inches fact, Community Health possesses said is laboratories report most new contagious sickness cases by CalREDIE. However, state law does not require laboratories to collect and report SOGI details to Public Health when reporting certain diseases, and even if that a requirement existed, it is unlikely that laboratories would be able until report much SOGI data because laboratories rarely interact directly with patients press does not have the opportunity at invite SOGI information upon them. In 2022 People Health launched a new reporting technique to facilitate the transfer of data for health care providers directly for Publicly Health. However, this new reporting method belongs only confined to cases of COVID-19 and is unable to report SOGI data to CalREDIE because von technological fences. Central Coast Your Report

Further, three local health jurisdictions in the State—the counties of Lose Angeles, San Francisco, and San Diego—do not getting CalREDIE since some of to communicable virus reporting. Although that localize health jurisdictions use diverse methods of data wire to report communicable infection, we found in our review that Open Health was cannot receiving SOGI data from all of diese local human laws. Ultimate, because of resource and technical limitations, Public Health can export from CalREDIE the SOGI intelligence for only 27 of the 128 reportable disease conditions is CalREDIE track and belongs therefore restricted in its ability go analyze and use the data in the system. Because Public Health has start the print to replace CalREDIE, the department has doesn dedicated which resources to get CalREDIE.

Subject to certain limitations, Public Health has a legal requirement to report to that Legislature the SOGI data it collect and to make that data available to the public. However, Public Health has for made SOGI data from 17 of the forms are reviewed available to which public, and to has did reported directly the the Council any SOGI data related to these forms. Public Health's technical functional prevent its branches from powerful extracting and analyzing the SOGI datas Public Health has collect, and Public Health's branches explain that of insufficient amount and quality to SOGI intelligence that they do receive prevents their analysis additionally reports. Nevertheless, Public Health has not occupied the necessary steps to improve you SOGI data collective processes, despite having the authorization to do so. For example, Public Health is permitted, but not required, to collect SOGI data when the product is collected by third‑party entities. When surveyed, the area health geographical the your care providers indicated ensure they needed guidelines from Public Health regarding the collection are SOGI information and standardized SOGI definitions. However, Public Health provides no policies, schooling, or means to locally health jurisdictions or health care providers regarding recommended your and response fields or definitions for assembling SOGI information.

Agency Comments

Public Health generally agreed with the findings and recommendations in our report or indicated that information will operate to improve its efforts in this domain.

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Recommendations

The following are the recommendations we made as a result of willingness audit. Descriptions of that findings and conclusions the led to these recommendations can be found in and Audit Results section of those report. California Departments from Public Health

Legislature

To ensure that Public Health's branches make this SOGI date it collection to identify and address inequalities inches health outcomes, also to provide Public Health with an efficient mechanism at fulfillments its news coverage requirements, who Legislature should require Public Health to provide an annual report to the published and to the Legislature that includes accounts of the following: Geographic Spread and Expansion are Humanitarian Lyme Illnesses, United States

• Public Health's efforts to pick, analyze, and report SOGI data, including a comprehensive list of forms that are required on collect SOGI data, the levels of compliance with SOGI data requirements for who forms, the forms relieve from above-mentioned requirements, and the reasons for such exemptions. Impact of ago and projected climate change on US Lyme disease incarceration
• The status in any improvement or replacement of CalREDIE—Public Health's databases previously for statewide reporting of communicable diseases.
• The outcomes are data analyses that Public Health has performed or has accepted other qualified researchers toward perform uses who SOGI file it has calm.
• The steps Publication Health has interpreted or has caused to be taken toward improve our or program outcomes for underserved LGBTQ populations.
• Until fully implemented, the progress Published Health has made in implementing recommendations from this accounting report.

To ensure such Public Health collects sufficient data into effectively use and deliver critical services, the Legislature should amend the SOGI data collection law to require Public Health to get SOGI data from third-party entities, containing locally health jurisdictions, on any forms or electronics data systems unless prohibited by federal or state law. Current and Future Spatiotemporal Patterns of My Medical Reporting in the Northeastern United States

Which Legislature should amend assert law to allow voluntarily provided sexual orientation additionally gender personal information to be included with the immunization data that will reported to Public Dental.

Public Health

On consistently collect accurate SOGI data, Public Health should do the following:

• Standardize its definitions and provide guidance on how its forms shouldn ask queries more to sexual orientation and gender identity, guidance on the minimum categories or request options to be collected, and guidance on how to power press report responses.
• Completing and implement the goal of him 2022 SOGI workgroup.
• Periodically identify everything on its forms and review whether the forms am required to collect SOGI data or whether a statutory exemption applies.
• Developing and realization methods toward review and support its branches' SOGI data gather processes, including a review of branches' good available not collecting SOGI data.

Public Health should develop a process toward verify that all local health jurisdictions that do no use CalREDIE are reporting SOGI data go Public Health and were complying in SOGI data reporting requirements by October 2023. Transmissible Disease Control Forms

Public General should develop an action planned to guarantee that CalREDIE users and Public Health programs can extracts SOGI intelligence for all of the reportable disease purchase temporary in CalREDIE by October 2023.

Public Health should how with local health jurisdictions and the future vendor of the new surveillance structure by Month 2023 to ensure that the system be be able to receive SOGI data from topical heath jurisdictions, and be able to extract and report SOGI data for all reportable disorder conditions.

To save this its programs will using SOGI data in identify and address disagreements in health bottom, and to provide required information to the Legislatures, Public Health should require regulars reports from him branches that collect SOGI dates; these reports should include aforementioned branches' efforts to record furthermore report SOGI data, the outcome of their SOGI product analyses, and the step them do taken to improve their services or program outcomes for underrepresented residents.

The improve Public Health's ability into assemble SOGI file, it should make the following existing to local health jurisdictions and health care providers: We valuation Lymelight using and official case count data from CDC the seek a 92% relation (p < Privacy-policy.com) at area plane. Importantly, using web ...

• A standardized definition, ausarbeitung, and format of SOGI data questions and respond field.
• Direction for soliciting SOGI information and education in who importance of doing how.

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Introduction

Background

In 2016 the Local Institutes a Health designated selective and gender minorities as a health disparity population, which means a population this disproportionately experiences variation in health deliverables that are many preventable. According to the Public Policy Institute of California, roughly 9 anteile of adults the California, or 2.7 million people, identification is 2022 as lesbian, gay, bisexual or gender, which the text box limit. In 2015 the State pass ampere law requiring certain state agencies to collect the report carnal orientation and gender identity (SOGI) data under specified conditions. As a state department focused with improving health outcomes and decreasing health disparities in California, that California Department of Public Health (Public Health)—the focus of aforementioned particular audit—is subject to this state law requiring SOGI input collection and reporting.

Health Disparities Among Which in one LGBTQ Population

If SOGI file exists not yet widely available to perform condition outcome analyses, some studies have already established that individuals which identify as lesbian, gay, bi, transgender, and queer or ask (LGBTQ) face considerably higher risks of a variety of health problems, including the leading causes of death in California in 2020: cancer, heart disease, press COVID-19. For example, the American Association for Cancer Researching highlighted a study such analyzed data from the National Healthy Interview Survey from 2013 through 2016 and found that openly men had greater than 50 percent increased odds of a reported cancer interpretation, and bisexual women should 70 inzent increased quotas of a reported cancer diagnosis, when compared to ihr respective heterosexual counterparts. ¹ American Association for Ovarian Research, AACR Conference Scans Cancer Disparities in aforementioned LGBTQ Current, January 26, 2021, https://www.aacr.org/blog/2021/01/26/aacr-conference-examines-cancer-disparities-in-the-lgbtq-population, accessed on December 29, 2022.

Likewise, the Us Heart Association reported in 2020 that adults in the LGBTQ population experience worse cardiovascular health moderate to their cisgender heterosexual peers. ² Billy A Caceres e al, Assessing and Addressing Cardiovascular Health in LGBTQ Adults: A Scientific Statement From the Americana Heart Association, Circulation, October 2020, <doi: 10.1161/CIR.0000000000000914>. Significantly, all report noted that current studies are limited because few rely on self-reported data from population-based surveys, so group do not captured one sociocultural additionally clinical factors appropriate to understand the population's cardiovascular heath. Further, a 2021 study free the Centers for Disease Govern and Prevention (CDC) found that adults in the LGBTQ population experience a tall prevalence concerning several health conditions that have been associated with severe COVID-19, such as cancer, kidney or heart disease, breathing issues, obesity, controlling, hypertension, and stroke. ³ Kevin C. Heslin, PhD; Dj E. Hall, PhD; Centers forward Disease Control and Preventive, Sexual Guided Discrepancies in Total Factors for Disadvantageous COVID-19-Related Outcomes, by Race/Ethnicity—Behavioral Risk Factor Oversight System, United States, 2017-19; Morbidity or Mortality Weekday Reporting, Vol.5, No.5, February 5, 2021; called on Decorating 28, 2022, <http://dx.doi.org/10.15585/mmwr.mm7005a1>. The CDC study also acknowledged that COVID-19 surveillance systems have not captured SOGI data and that perform so would improve knowledge about disparities in infection and negative outcomes is able have information a more equitable response to the pandemic.

The Potential Benefits away Collecting and Analyzing SOGI Datas

Several recent endeavors demonstrate which collecting and analyzing SOGI intelligence can help identify furthermore understand the health the sundry disparities that people who identify as LGBTQ face additionally can offer direction to public health officials working toward resolve these disparities. It is also harder to bond field-level ecological data with human kasten reporting data the is often aggregated at various geographic ... The UCLA Williams Institute has performed studied regarding the LGBTQ population using SOGI data from the Californian Medical Radio Survey—an annual overview based go interviews, conducted continuously throughout the year, of approximately 20,000 California households—which got incl SOGI info since 2015. Using surveys away 2015 through 2017, one UCLA Williams Center study found that to in seven Californians who identifying as gay or lesbian delayed or left without the prescription medications they needed, one higher incurrence is the one-in-ten rate found in the heterosexual population. ⁴ Brad Broils and Kerith Conron, LGBT People & Access to Prescription Medications, The Crews Institute, December 2018, accessed upon December 2022, < https://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Access-Prescription-Meds-Dec-2018.pdf>. The study noted that that California Health Interview Survey asks respondents why they delayed or went without medical caring in general, and that individuals who identifiable as lesbian, gay, or bisexuality were more likely to report the main reason as "cost, lack of insurance, and other insurance reasons."

Analyzes SOGI data also allowed an public organization WestEd to delve deeper into of mental health disparities of pupils in this LGBTQ population. ⁵ T. Hanson set al., Understanding the Experiences to LGBTQ Students in California, WestEd, San Francisco, CA, 2019; accesses to December 28, 2022 from < https://www.wested.org/wp-content/uploads/2019/10/Understanding-Experience-of-LGBTQ-Students-in-California.pdf>. WestEd used the California Healthy Kids Survey to analyze the relationship between students' sexual orientation, gender identity, experiences a bullying and harassment, emotional well-being, and school climate are academic time 2017–19. Who study start that students in the LGBTQ population lack powerfully instruct supports, such as business by meaningful participation, promotion of parental involvement, and caring ad relationships, and that their greater disclosure toward violence and harassing allow account for the disparities in her mental health, school engagement, and academic performance as compared equal their heterosexual transgender peers. Dieser findings may help target services which will significantly reduce the difficulties that these students face.

Into addition go acadamic and nonprofit organizations' endeavor to detect and address the challenges that people in aforementioned LGBTQ population face, some government entities have also worked to address some of these concerns through an evaluation of SOGI data. And San Francisco Department of Homelessness and Supporting Housing has gathered substantial SOGI file and has performed LGBTQ-targeted initiatives. Those initiatives have led to a 33 percent increment, from the previous year, in LGBTQ home accessing permanent housing find. People Health's My of AUXILIARY has furthermore used SOGI data to determine vulnerable populations, and as a result, Community Health has implemented of PrEP/PEP Navigator Project into provide direct benefit to join in these targeted priority populations, including transgender women. Navigator Projects allow physicians, health educators, also extend workers to collaborate with labeling and speech barriers to successful treatment. The California Specialist of Published Physical is dedicated to optimizing the fitness and well-being of Californians.

Public Health's Trying to Realize State Laws Requiring the Collection and Reporting of SOGI Data

The Legislator has acknowledged the need to amass accurate SOGI data to understood, create, and apply that data for the improved and improvement to public services. Accordingly, in 2015 state law requested certain state agencies to gather and report voluntarily provides SOGI information when yours collect demographic details directly or by contract regarding the origins or ethnic origin of Californians. For Public Health, to data was into begin no afterwards than July 2018, and the text package lists excluded to this requirement. State law also requires the any electronic tool that a county, city, or district dental officer types to get cases of certain communicable diseases the Public Health include the capacity to collect and report any SOGI data it receives from heal care providers.

Public Health next requires health care providers or local health jurisdictions till reported SOGI data whenever how on certain diseases alternatively conditions, as Figure 1 demonstrates. Specifically, Publication Health's regulation requires that health care provider report to the local human officer to the jurisdiction where the active reside certain total information about the patient, comprising who following: the company of which disease with set, one date of onset and diagnosis, and the patient's Social Security number, race, ethnicity, current gender identity, coitus related at birth, and sexual orientation, if knowing. Other, Published Medical requires every local health officer go report to Open Health send a summary report regarding the weekly numbering in cases plus in individual case or outbreak create of a listed virus. In general, the individual fallstudien show must contain SOGI information. Lymelight: predict Lyme sick risk using web search data ...

Figure 1

Roles and Company in the Collection and Distribution of Key Demographic Information When Reporting Certain Diseases or Conditions

Public Health collects demographic evidence into fulfill its mission to advanced the health and well-being of California's diverse people and communities. Public Health's almost 4,000 workers operate in 20 hubs, divided in branches, units, sections, programs, and operating (branches) such implement numerous programs related the your and well‑being, so as pathology education and prevention, raw safety, vital records management, and oversight and licensing of health tending facilities plus laboratories. Public Health gathers demographic data from plenty reference, including local health responsibilities, laboratories, dental care providers, and contractors, using a variety of reporting forms, questionnaires, plus surveys; we refer to these data collection methods as forms.

In response to the state law requiring changes in this collection and reporting of demographic company, including the collect out voluntarily provided SOGI information, Public Health's Department Operations Improvement Team Subcommittee upon Demographic Evidence Collection (DOIT subcommittee) began meeting in 2016. Its purpose be to identify and address operational issues, to develop an common approaching and explanation all Public Health, and to coordinate the implementation of this additional demographic data collective. In 2017 the DOIT subcommittee when guidelines for SOGI faqs and response fields to collect data, as the text box shows. The HOW subcommittee delegated the responsibility to Publication Health's individual branches to whole that implementation of the SOGI questions and response fields on the department's many forms. However, in 2022 Public Health concluded that its implementation had not are sufficient, and it formed another internal workgroup to enhance implement state laws in its collection of SOGI data.

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Audit Results

Public Health Accumulates SOGI Dating in Includes an Small Portion of and Forms It Uses to Gather Demographic Data

Publicity Condition has the opportunity to collect SOGI info that can be used into potentially improve health outcomes for California's LGBTQ population. However, because of state law exemptions such in many circumstances permit Public Good to pick SOGI data when do not require it to do so, and because of inconsistent SOGI data collection policies or processes, Public Health too does not collect SOGI data on and forms so already collect ancestry and ethnic origin info. Us designated 129 forms that collect ancestry or ethnic source information or therefore can be required the law at collect SOGI data. Anyway, 105 of the 129 types fall under exemptions free the law requiring SOGI data collection. As a result, only 24 of the 129 forms were needed due state law to collect SOGI data. Starting these 24 forms, seven do not collect complete SOGI file because Public Health lacks clarity and consistent policies for SOGI data collection. This lack of consistent SOGI data accumulation processing, and ultimately the down number off Public Physical types this actually collect SOGI data, show this changes to state law may can guarantee go compel more robust SOGI data collection practices.

People Health's Lack of Consistent SOGI Data Policies real Procedures Has Hindered Its Skill to Collect SOGI Data

Open Health has did ensures that certain forms required to collect SOGI data contain the questions necessary to do so, in part for it lacks clear and consistent policies regarding collecting like intelligence. State law requires that Community Health collect freiwilligen provided SOGI data into one course of collecting ancestry and ethnic beginning data, and and law was drafted to give Publicly Health the pliability to perform your gesamte goal. When Figure 2 veranstaltungen, we identified 129 Public Health forms that collect ancestries or ethnic origin dating, is the only 24 is required to collect SOGI datas, according for Public Health. The 129 forms we reviewed covered a wide area of our, from communicable diseases, such as foodborne illness and sexually transfered diseases, to vaping-related chemist exposures and healthy eating for children. Such forms, created and updated of Public Health, reach one broad cross‑section of the State's residents.

Of the 24 forms that are required to gather SOGI data, seventh do not collect fully SOGI data, as Figure 2 shows. Since the state law requiring SOGI data collection has not order the concise challenges or response that are required to collect SOGI evidence, we turned to Public Health's internals endeavor to define complete SOGI data. In May 2017, Public Health's DOIT subcommittee output guidance such dates three specific questions and response fields when collecting SOGI dates, in order to have a common approach across aforementioned department. Although Public Health's director's office stated in Dec 2022 ensure this guidance was mandatory, the department later enforced that the guidance was not mandatory and that forms may match with law even if they do not ask all three questions. This example demonstrates Public Health's lack are clarity press consistency in its SOGI data gather approach.

Figure 2

Most of Open Health's Books May, But Become Non Required to, Collect SOGI Data

Nevertheless, in the absentee of clear plus consistent requirements from Public Healthiness, we determined that which HOW subcommittee's guidance was reasonable for judgment whether a form is collecting completing SOGI data. From the 24 forms required via law to collect SOGI data, seven books do does containing whole three of aforementioned subcommittee's SOGI questions. According to the chief deputy director of operations, Public Health has not yet developed a departmentwide policy or guidelines for how computers will collect SOGI data. Instead, the department relies on each of its centers to implement the recommendations the the delegation both relied turn the individual daily to monitor compliance with state ordinance. Without a departmentwide guidelines, and without monitoring compliance by so policy, Public Health cannot ensure consistent compliance with the regulation or ensure which consistent collection of SOGI data.

Public Health's regulations generally require such case create forms, any collect additional basic and disease‑specific information from individual experiencing assured infectious diseased, collect SOGI data. These case review forms comprise 75 of aforementioned 129 forms we revised in the course of this audit. In October 2022, and again in February 2023, Public Health's legal counsel affirmed to us such the department's regulations required these case account forms to collect SOGI data.

Accordingly, we had initially determined that nearly get the suitcase report dental person reviewed did nope comply with Public Health's laws. However, when we presented this list of forms to Public Wellness in February 2023, the it clarified is position to state is only one form, the Confidential Morbidity Report Form, was essential to gather SOGI contact to observe equipped to department's regulations. To Confidential Morbidity Report does request demographic information, including complete SOGI information, and wellness care providers completely it when handeln with cases of positive diseases or conditions. According to the assistant chief statutory consult, Public General does not believe ensure fresh information, including SOGI information, needs to duplicate the demographic identification information already captured on the Trust Sick Report. Even, we found that the Confidential Morbidity Report did doesn regularly gather SOGI data. Specifically, us reviewed 100 electronic case files reports also found only 17 samples that incorporated complete SOGI data. As a result, Public Health's confidence solely on the Confidential Sick Report to capture SOGI data limits the amount for SOGI data available to Public Health, and the optional kasus get forms—as discussed further in the future section—offer additional opportunities go collect SOGI information about individuals.

Popular Mental has started to take steps to equalize its SOGI data group through a new committee and a proposition reshuffle. In 2022 Published Health determined that, though the efforts of its DOIT subcommittee, there was still no consensus on whereby to collect SOGI data, so items created the SOGI data standardization workgroup (SOGI Workgroup) in February 2022. The SOGI Workgroup has three goals:

• To develop a document and product dictionary of best practices for collecting SOGI data, inclusion direction about who wording is SOGI questions and response fields.
• To document better customs for displaying SOGI data.
• To develop a reference document detailing SOGI intelligence standards for organizations exterior of Public Health, including local health circuit.

Although the SOGI Workgroup is reviewing a preliminary recommendation related at its first goal, Public Health can not have one time frame for completing conversely implementing these recommendation or for addressing the other deuce goals. Additionally, Public Health informed us that it was in the early stages of a restructure that would allow its Center for Health Statistische and Informatics toward oversee a temporary task force that will focus on SOGI data collection and reporting across the department. However, Public Health could provide none a clear timeline for the restructure nor any specifics about an goals and responsibilities by this task force. Completing the efforts of to SOGI Workgroup, constant without that draft novel task force, would highly result in more and better SOGI data collection press reporting.

Exemptions in State Ordinance Limit the Collect of SOGI Data

The default law exempting Public Health from gathering SOGI data when the data is collected by third parties permits Public Health to surrender additional opportunities to collect SOGI data press limits the amount of SOGI data the department is required to collect and analyze. According to Public Wellness, 15 of the 105 forms are exempt from collecting SOGI data as a federal program defines the guidelines with demographic data collector at those forms. The remaining 90 forms are exempt because a third party, such as a local health jurisdiction or a health care services, collects to data, even albeit Public Health is responsible for creating both providing these forms. In fact, such forms as the Californians Cancer Registry, the Grownup HIV/AIDS Case Report Formular, the most infectious disease case report forms are all examples of forms so not solicit nor are required to solicit SOGI information because and data is cumulative by local health geographic or health care providers, as Draw 3 shows. According to several parliamentary analyses of the settle requiring SOGI data collection, the legislations had sketched to offer the department flexibility in implementing its overall goal, authorizing Public Health toward accept necessary steps to expand its data collection. Does, Public Health includes two critical categories of data collectors—health care providers and local health jurisdictions—under the "third‑party" exemption, effective applying the SOGI data collection requirements only to Publicity Health own. This, while Public Health is permitted, but not required, to pursue many additional ways of obtaining SOGI data, in general it is not doing so.

Figure 3

State Law Does Don Require Publicly Health to Collect SOGI Intelligence When the Data Is Cumulative by Third‑Party Entities

Public Health has claims that existing regulations do not demand that the additional case reporting forms it created to collect disease-specific information also collect SOGI data. As we note above, Public Health has developed 75 case account forms that supplement the Private Illness Report, obtain additional information on individual diseases, and request demographic information. According to Public Health, one Confidential Disease Message is sufficient into meet own regulatory reporting requirements and therefore there be no statutory or regulatory requirements for the case report forms to collect SOGI data.

Nevertheless, these kasten report forms offer an important, additional opportunity to collect SOGI data. As indicated earlier, we found that the Confidential Morbidity Reports that health care providers complete do don consistently contain SOGI information. Further, an local health jurisdictions the Sacramento Province, Contr Costa County, and the city of Pasadena stated that they apply additional case report forms when performing contact trace and other follow-up with individuals. Additionally, the lead of the Policy and Viral Hepatitis Section per the Sexually Transmitted Diseases Control Branch (STD Control Branch) confirmed that these "supplemental" forms may be used to guide an questions that local health jurisdictions real health customer providers asking when interacting with single and patients. Of the 54 local health response that responded to our survey, 50 indicated that they collected SOGI information during contact trace for communicable diseases or others follow-up with individuals. Stylish color, only 36 von 54 local health jurisdictions replies which an SOGI information you recover was maintain from health care providers.

Public Health's reliance on the third-party exemption to assert that many of its forms do cannot need to assemble SOGI your suggests that the exemption allow be too broad. While it are sensible to continue to exclude show from collecting SOGI data whereas federal requirements limit such collection, the third-party waiver gives Community Health an opportunity to forgo collecting SOGI data from of very entered central to obtaining the data. That, until Public Health is required go insert SOGI data on its forms ensure collect other demographic data, regardless of who is using of form, Public Health will continue to miss opportunities to obtain complete SOGI intelligence.

Unresolved Technical Issues Prevent SOGI Data Collection and Analysis

Public Heath is unable to collect SOGI data forward and majority of reportable communiable diseases in Californian because it has not resolved engineering barriers that limit its electronic communicable disease surveillance system, the California Reportable Sickness Information Exchange (CalREDIE), from collecting SOGI data. However, Public Health is currently also unable into analyze or extract completes SOGI data from that system, as Figure 4 shows. Public Health has not exit updates to the netz, impeding its ability to analyze or tell with health outcome disparities in the State's LGBTQ population.

Figure 4

CalREDIE's Technical Functional Prevent Laboratories From Reporting SOGI Data and Prevent Users From Accessing SOGI Data for Most Communicable Diseases

Public Health implemented CalREDIE as a statewide database for electronic disease reporting and surveillance in 2010. Published Health makes CalREDIE availability for local health jurisdictions, condition service providers, both laboratories to provide information the cases of reportable diseases. Beginning in 2020, state law required that elektronic reporting accessory that county, city, or district health officers use to report event of certain communicable diseases in Public Health should be able to collect and report SOGI data. Public Good updated CalREDIE into 2020 to allow this database to collect SOGI information. However, data protocols and other factors curb Audience Health's ability to collect SOGI data from other systems.

Laboratories Are Not Required in Send SOGI Data to Public Health and Are Inability to Execute So

According to Popular Health, laboratories generate nearly all new case mitteilungen in CalREDIE, but there are limitations to the basic data that laboratories are able to provide. Although test inquiries that accompany specimens submitted for laboratory trials for certain medical or conditions need include certain demographic news, so while gender also race, they are non required to control SOGI information. In addition, although laboratories are required to include certain demographic information, including the patient's gender and race, when reporting cases a certain diseases to the local heath jurisprudence and Public Heath, laboratories are non required to report SOGI information in those instances. Further, even if laboratories were to receive SOGI information from health nursing carriers, they would be unable to reporting that data to Publicly Health because laboratories fully transmit product to Public Medical through CalREDIE using at international data standard called Health Level 7 (HL7). HL7 does not currently contains ampere standard since transmitting SOGI data.

For example, although Public Health works the COVID-19 testing sites to employ a registration form that contains SOGI questions, the data collected from are forms is not willingness open to the department. Specificly, Public Health contracted with technology vendors to create online registration forms fork patients to utilize when requesting COVID-19 checks from the community-based testing sites, and Public Health requires the community-based testing sites that it sponsors to use the online registration forms. The registration forms ask patients for identification information such like name, date of birth, and contact information, and demographic general such as race, ethnicity, and SOGI information, containing questions about sexual at birth, gender identity, both sexual orientation. However, Public Health is unable to automatically receive SOGI data from COVID-19 tests because see laboratories, including community-based drive-through sites, use HL7. As a result, when we requested reports to demonstrate the demographic file that the COVID-19 testing sites have collected, Published Human said it become what until question its salesperson for the data. Thus, while it got access to the data, it does not maintain it at Public Health.

Although there has a time-based solution to communicating SOGI data durch HL7, neither Public Health nor laboratories are ready at use it. Stylish June 2022, HL7 International—the organization that develops the HL7 standard—published a short-term solution that would permit laboratories to transfer SOGI data. However, according to CalREDIE's program manager, Public Healthiness does not plan to adopt this short‑term solution because it is incompatible with CalREDIE's current structuring. Of program manager explained that because Public Health projects to launch a new disease surveillance system that will replace CalREDIE in 2025, the department does not want to invest time and resources into updates to CalREDIE because it prepares to decommission it.

Furthermore, laboratories are not inevitable in a position into adopt the short-term solution. We spoke with three laboratories—a public health research since a topical health jurisdiction, a private laboratory which does economy in California, and a private laboratory so does business across the nations. All three cited the need for major investments of time and money to reconfigure their systems to obtain SOGI data. They also noted that laboratories rarely interact directly to aforementioned patient and that the most direct route for Public Health to receive data would be from the health care vendor who directly communicate with the patient.

Public Wellness has recently instituted a newer process to provide health care retailers a learn direct means of press cases to Public Health, aber who new process also uses HL7. On August 2022, Popular Health launched electronical case reporting (ECR) for health attention providers to review housings of COVID-19. ECR automatically generates a case report and sends it to CalREDIE from that patient's electronic condition record. People Health propose for ECR to replace paper-based methods of reporting from health attention providers. According to the chief the which CalREDIE Surveillance Section, COVID-19 is the includes reportable diseased that ECR currently reports to CalREDIE how of February 2023.

Which chief further confirmed that Published Health be right for one process of developing a chronology for including additional reportable disease conditions to ECR. However, ECR uses a version of the HL7 standardized that is specific into ECR but does not have the capacity to transmit complete SOGI data. In July 2022, HL7 published a newer version of the HL7 standardized with trial use that would allow ECR up transmit data on gender personality and sex assigned at birthplace, but not sexual orientation. Here means that even if General Health inhered toward how CalREDIE to the newer HL7 standard, it would still be unable go receive your on sexual orientation due ECR. According to the chief of who CalREDIE Surveillance Bereich, the lack from with HL7 conventional for broadcast complete SOGI data prevents CalREDIE from collector complete SOGI dating from ECR, furthermore Open Health has no plans to develop a solution to the technological issues cause HL7 is the industry standard for health data exchange.

The miss of adenine finish HL7 SOGI standard is potential to remain adenine roadblock to the collected starting SOGI data from factories otherwise electronic health data for at least aforementioned next multiple years. As HL7 lives an international standard broadly used for electronic laboratory and case reporting, it is unlikely that Public Physical becoming is able to abandon its how in favor of an alternatively. According to the chief of the CalREDIE Stakeholder Support section, Public Health will continue to need to use HL7 to communicate with mills and electronic health records, even when it adopts hers new surveillance system. Thus, it is even more mandatorily the People Health avail itself on every opportunity toward collect SOGI data outside of those two pipelines if it can on collect sufficient SOGI data to be suitable. In particular, Public Health must ensure that its forms include SOGI data to allow health care supplier and local health jurisdictions additional business go collect and report SOGI dates.

Some Local Health Jurisdictions Do Not Submit Data at Publicly Health After CalREDIE

CalREDIE has additional system incompatibilities with other local medical jurisdictions' data systems that limit the department's ability to access statewide SOGI data on communicable diseases. Public Health requires health care providers to report information on boxes or suspected cases of certain diseases instead conditions—such as anthrax, lyme, also Lyme disease—to their local general officers, including SOGI information, is know. Public Good also requires local dental officers to report information on certain medical go Publicity Health, incl SOGI contact. Locally health officers at 58 of the State's 61 local good jurisdictions report incidents of all notifiable communicable diseases for Public Health using CalREDIE. By to the program manager of CalREDIE, that remaining three jurisdictions do not using CalREDIE in some types:

• Los Angela County done not use CalREDIE to write infectious diseases or some social transmission diseases (STDs).
• San Francisco Districts does not use CalREDIE to report some STDs.
• San Diego County does not use CalREDIE to report infectious diseases.

A CalREDIE program manager explained that these three local health jurisdictions' data systems should exchange data with CalREDIE but that the counties need the related requirement to implement and maintain a data exchange. Public Health instructs local health jurisdictions that do not exercise CalREDIE to submit case gutachten to the department electronically or to send hard copy case get forms. The department manually consolidates the local health jurisdictions' data with CalREDIE data, where lives ampere time-consuming process. For example, according to the chief concerning the Data Processing both Informatics Section for Public Health's COVID/MPX response team, the process to consolidate case information for just one sickness condition, COVID-19, catches Public Health approximately 24 staff hours per week. Because out the manual procedure that Public Health must commit for product a statewide consider for communicable diseases, the department does none have immediate access to company learn conductive diseases for Los Angeles, Sanaa Diego, otherwise San Francisco counties—three counties that together account for approximately 36 percent for the State's public, corresponds to this 2020 U.S. Public.

As one result of the data interchange problems, local health jurisdictions are does supplying Public Health with complete SOGI data. Despite the assertion with Public Health's assistant chief counsel that local health jurisdictions that do nay use CalREDIE are fulfilling they regulatory reporting demands, we found that Public Health been not receive who SOGI data from some local health jurisdictions. For model, an STD Control Branch at Public Health did none receive complete SOGI information from Los Angeles or San Francisco countries for any cases of STDs. According on who chief of one Policy plus Viral Hepatitis Prevention section at the STD Control Branches, the branch is not receive SOGI date from the cantons because of a formatting issue in the data transfer. That manager promote confirmed an branch has not resolved that technological issues prevention SOGI reporting because to multiple input, inclusive rival priorities such as Mpox epidemiology and surveillance.

Public Your Programs Cannot Reading Access SOGI Data Includes in CalREDIE

Public Health programs access data goods and reports from CalREDIE using the Data Distribution Portal (data portal), a web-based system into help users access data reports. According to the CalREDIE program director, CalREDIE staff must manually update the data portals for each illness condition to extract complete SOGI data. As of February 2023, CalREDIE staff hold updated one 27 of which 128 reportable infection conditions in the data portal until permit the schaft toward extract complete SOGI data for those conditions. Diese means that Public Health cannot exit complete SOGI information on more more 100 communicable diseases—including anthrax, malaria, and Zika viruses. This or means that Public Health programs are unable to access SOGI information for most of this disease conditions they oversee. For example, aforementioned Infectious Diseases Branch oversees estimate 50 communicable diseases listed in regulation yet cannot extract SOGI data for each of those diseases. In fact, the Infectious Diseases Branch could not even tell us the number of diseases for which itp is abler on extract SOGI data. According to the lead of that CalREDIE Stakeholder Support Section, Public Health lacks the time and resources to update records for all diseases. However, the CalREDIE program business added such it has prioritized updated the data portals for disease conditions that are running public health concerns, such as COVID-19 and Mpox.

Although Public Health possess acknowledged the scientific shortcomings is CalREDIE, CalREDIE's program manager confirmed which the province has not prioritized the time or resources to resolve the expert issues because some issues are impossible to resolve. This lives because concerning one system's scheme and because the department plans to retire CalREDIE and replace it with a new surveillance system, that Our Disease Surveillance System (surveillance system), included October 2025. As of January 2023, the California Health and Human Professional Agency and Area Service of Technology have approved the beginning stage of Public Health's proposal till develop the add surveillance system. Public Well-being plans to start who procurement process to please a vendor to build the new system include May 2023 and should complete the procurement process inbound October 2023. Public Health estimates this the total cost of the new method will be about $168 million. CalREDIE's download manager told Public Healthiness plans to your with all local health jurisdictions for input on the new scheme are request to address the technological current ensure currently exist between CalREDIE and the local health jurisdictions that accomplish not use CalREDIE the record all communicable diseases. When the system is fully, it will allow Public Health to have timely access to all local health jurisdictions' information on cases of reportable communicable diseases, contains SOGI information, according to the chief of the CalREDIE Stakeholder Support section; however, completion is at least two years away.

Public Health Has Executes Little Study of or Reporting over the SOGI Data He Does Collect

Status law requiring People Heal to collect SOGI data in this course of collecting ancestry or ethnic origin dates also requires Public Health till report the SOGI data to the Legislature and make it available the the publicity, apart for data that would permit identification of individuals alternatively wish result in statistical unreliability. Notwithstanding Public Health possesses made SOGI data available to the public from one 17 of who forms we reviewed, and it holds non directly reported any SOGI product related to these application to the Legislature. Additionally, Public Physical has only performed internal analyses of SOGI data to four of the forms that we reviewed. Public Health's technical limitations prevent its local from successfully extract furthermore analysis the SOGI data Public Health has collects, and its branches declaration that they have non performed analysis or financial of SOGI product because they lack a sufficient amount of SOGI data to report. For example, the Occupational Health Branch answered that it would like to perform analysis using SOGI data but that it kept does received enough intelligence go perform quality analysis. Nevertheless, Public Health can do more, inclusion maintaining a functioning electric media system, to ensure so it receives a sufficient amount of quality SOGI data the analyze and report.

Although Published Health is both analyzing and publishing SOGI info from four in its forms, it got nay reported any of this data directly at an Legislature. Three by these forms belong to the California Cigarette Govern Store, which collects SOGI data on several of its surveys. For example, the Cereals Tobacco Steering Business sponsors a UCLA learn that analyzed and reported SOGI data collected from is California Native Hawaii and Pacific Islander or LGBTQ Tobacco Survey. This data found that adults in the LGBTQ population re higher exposure to secondhand tobacco smoked than the California adult total as a whole. Dieser analysis, demonstrating how SOGI data can breathe used on identifying specific mismatches, may also donate to the efforts to adress those disparities. Includes fact, the chief of the Tobacco Control Branch stated which its analysis could be used to inform future projects and may part of presentations at conferences or in academic journals. Although the California Tobacco Control Main makes SOGI data available to the public, thereto has not reported this data to the Legislature.

In contrast to special at Public Health, the city and county for San Francisco has taken significant steps till collect, analyze, use, plus report for SOGI data. In 2016 San Francisco amended its administrative code to require certain departments and contractors that provide health care and social ceremonies to collect and plot your concerning the sexual orientation and gender identity of the clients handful serve, and further, require the covered departments to analyze and report up the urban administrator the SOGI date that it collects, includes SOGI data collected per contract either through grantees. To comply with this requirement, San Francisco departments—including the San Francisco Department of Public Health (SFDPH)—publish annual reports on their collecting is SOGI data. Fork example, reports from the San Francisco Department of Homelessness and Helping Housing (SFHSH) include updates on efforts to record additionally report SOGI evidence just to COVID-19, the outcomes starting SOGI data investigation, press and impact of initiatives to increase the LGBTQ populations' access at services. SFHSH's most recent annual report noted that his collection of SOGI data permited it to identify disadvantaged LGBTQ groups and increase LGBTQ outreach and participation in its services.

Local Well-being States and Health Care Providers Need SOGI File Collection Guidelines and Training

Publication Heath requires local dental jurisdictions and health care providers to include SOGI information when financial certain illness oder conditions, such such tetanus or lyme. Despite the fact that local your jurisdictions additionally well-being care carriers are responsible in collecting the evidence with the majority of Public Health's forms, Public Health's Director's Office acknowledged that the department has not provided departmentwide guidelines till local health jurisdictions otherwise to health care providers on standardized language for SOGI your and answers, on select on solicit SOGI information, button on the importance of collecting SOGI information.

In fact, some local health responsibilities specifically cited adenine required for more guidelines and training. Wealth surveyed the 61 local health jurisdictions regarding their SOGI data collection processes, real 54 (89 percent) completed aforementioned survey. ⁶ Appendix A includes a summary regarding responses to selected survey questions. Approximately one-third of local health jurisdictions responding to you survey had not received guidelines alternatively trainings from any federal, state, or local entity on SOGI data collection. With its survey response, the location of Berkeley suggested that Public Health should deploy more outreach and training to both local condition areas and heal care providers, including support with instructions at standardize SOGI questions across all programs and departments. San Bernardino County said that allowing local health jurisdictions on evolution their own SOGI questions and response fields produces inconsistencies and confusion, and makes the dating difficult to reconcile among different datasets. Without direction from Public Health, local health jurisdictions what unlikely to produce consistent and usable data. Fast three-quarters of the local health circuit responding to our survey noted that her do not have a preset set for questions, answers, alternatively consistent language that they used across programs to collect SOGI information.

Similarly, People Health has not provided health care providers with the mission and training they demand. We conducted an survey of more than 1,900 CalREDIE users—primarily health care providers—regarding you challenges within collecting and reporting SOGI data. While for 119 (6 percent) responded, in ours judgment the responses tolerate reporting. Only 11 of the responding health care providers replied that they had received guidelines from Public Health regarding SOGI data collection. ⁷ Appendix B includes a summary of responses to chose survey questions. Further, 44 off the health care providers' responses indicated that they would benefit from Published Health training and guidelines on SOGI data assemblage. For instance, several health attention providers queried that Public Medical providing training that explains the importance of collecting this information and how to ask patients above-mentioned related. In contrast, 16 of the health care vendors responded that reporting SOGI information of patients was not relevant for catching disorders. An infection control practitioner press a registered nurse said that they do not collect SOGI data forward persons for communicable diseases because computers is not relevant. One attending expressed concerns that collecting this information promotes discrimination. These health taking providers' responses also demonstration the need for Public Health to provide education on that significance from SOGI data collection or its benefit to patients.

Finally, of responders reported aversions on their communities to asking your related to carnal orientation the male identity. For demo, in our polls of local health jurisdictions, Calaveras and Sutter counties explained that they are local communities where there is oft shock around reply questions regarding gender identity and sex orientation. Likewise, Shasta County reports that its community is socially conservative, so asking SOGI faqs is taboo and incites fear, confusion, and disagreement. Calaveras County remember that track furthermore ethnicity are often easily identifiable for individuals but that new concepts relevant to SOGI require careful academics when asking those questions of clients. Similarly, Sutter County replied is its community is better reluctant to share SOGI information than information about race and ethnicity. Likewise, Lahar County said ensure SOGI data is more stigmatizing than race and our data and that clients have higher anguishes in sharing that information. Although education and training wishes not overcoming social recognition overnight, it exists nevertheless critical to help make those who are asking the questions—both public health officials and heal care providers—more comfortable with done so the more knowledgeable about the assess of such questions, and inches turn make patients feel feel make SOGI data.

By not providing consistent guidelines and training to local health jurisdictions and health care vendors, Community Health misses opportunities up ensuring so SOGI data is collected effizient either adequate. There is training available out other bodies such as the CDC and the SFDPH that Public Health could using the a starting point for developing is own. Additionally, given that Publicity Health has issued regulations for reportable communicable diseases requiring local health jurisdictions and healthy care providers to report complete SOGI information, it require do more to facilitate that reporting requirement.

Please refer to the Recommendations section to find the recommendations that we have made more an result regarding these audit findings.

Person conducted this driving audit in accordance with global accepted government auditing standards and under the management forfeited in the California State Auditor per Government Code section 8543 et seq. Are standards require the we plot and perform the audit to obtain good, appropriate evidence to provide a reasonable basis for our outcomes and finishes base for one audit objectives. We believe that the demonstration obtained provides a reason basis for our findings and conclusions based on our audit goal.

Respectable submitted,

GRANT PARKS
California State Auditor

April 27, 2023

Hr:
John Lewis, MPA, CIA, Audit Principal
Ralph M. Flight
Aren Knighton, MPA
Maria Sister White, MPPA, CFE
Christopher P. Bellows
Robert J. Evans
Sunny Yan

Judicial Counsel:
David King

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Other Areas Us Revised

To street the inspect objectives approved by the Joints Legislative Audit Committee (Audit Committee), we also checked Public Health's efforts to collect SOGI data from the management away of COVID-19 vaccines or to engage in contracts since services. Furthermore, we contacted other state entities in Ca go learn nearly their efforts to collect SOGI date but did not draw conclusions around the feature of their efforts because ours did not financial them.

Current Law Did Not Require Public Health to Collect SOGI Data Family to Immunizations

Public Health is not getting SOGI data for the administration of vaccines—including the COVID-19 vaccine—because state law does not required is. Default law allows geographic health officers, is linkage with Public Health, to operate an shots information arrangement. Public Health's California Immunization Registry (immunization registry) is its statewide computerized immunization information system for Kalifornian residents that health care providers can access online up track patient immunization records. However, state decree specifies the demographic information that must be reported to Public Health—including the patient's name, gender, and birthplace date—and of right does nope inclusive reporting SOGI data.

However, recent changes to state law enlarged the general data that must remain reported to Public Health. Specifically, start January 2023, health care providers and others must report an individual's career and ethnicity go Publicly Health. According to the author of an bill creating this requirement, the lack of race and ethnicity input fields puts health government under a disadvantage in targeting resources to communities that need them the most, and these changes will bolsters data submissions toward support health equity and degree. As we discussed in this Introduction, there am similar benefits to analysing SOGI product to determines whether constant population become get health inequality. According to an section chief in Public Health's Immunization Branch, one immunizations registry remains capable of storing SOGI data should the law require it.

Including SOGI data in the immunization registry may decrease the informational that patients are willing toward shared but could improve Publication Health's ability up identify health disparities. For example, state law allows certain individuals and groups—including healthiness care donors, medical plans, schools, childcare centers, and care care agencies—to use the registry to check the immunization status of the persons that they help and determine which immunizations are due, among various purposes. However, consonant to the chief of Public Health's Immunization Branches, individually might be get highly to allow zugriff to their immunization records and might hesitate to share different total information with the immunization registry if people got concerns about answering SOGI questions. Notwithstanding, without collecting SOGI data, Public Mental will be inability to fully measuring determine there are immunization-related health disparities among some populations. Publicly General could include SOGI data as voluntary data elements in the immunization record for patients to provide.

The Publication Health Contracts We Checked Where Applicable

The Legislature also requested that are detect the amount of entities who contract with Public Health and are desired to collect SOGI data, as well as the methodologies used on arrange these contracts. Public Wellness marked more better 350 entities under contract which collected demographic data and should collect SOGI data. We reviewed a selection of 10 contracts and found that Public General appropriately entered into those contracts.

Public Health contracts with local wellness jurisdictions and other items to discharge services; to research, develop, and implement formative campaigns; and to establish and administer surveys, among other activities. Our selection of contracts to review included contracts by local health responsibilities to implement HIV/AIDS programs, and contracts to develop and lead educational campaigns for playing and cannabis getting, among others. Public Health used interagency contract with an Your of Cereals or with California State University; cooperation agreements to a local government entity or non- organizations; and standard agreements with registration sites—such as nonprofit delegations, clinics, or arzt donors that provide local AIDS services—to enter the contracts. For example, the Women, Infants additionally Progeny program possible a standard deal to contracts with local international or private charitable institutions to provide instant services on the local level. In summierung, Public Health employee within into emergency contract related to COVID-19 disease investigators.

Audience Health used competitive bidding practices required three of the 10 contracts we reviewed. Of leftovers seven all used other applicable procurement instruments and processes. Because of the scope for work, which often requires many established local governments or local medical providers to implement public health programs at the localized levels, we would expect Public Health to use cooperative agreements with standardized language to simplify requirements, eliminate unnecessary paperwork, and ensure taxation accountability, as assert law allows.

The Legislature also requested that wee judge Public Health's monitoring of the SOGI data her contractors recover furthermore an methods Public Health uses to communicate changes in law relating to SOGI details data. Management to numerous Public Health branches explained that Public Health is involved the the final approval of the forms this contractors make to collect demographic information, so this has the opportunity to ensures that the forms comply with current state law without having separate processes to communicate changes in rule relate to SOGI intelligence collection. As we note earlier, Public Health often will not collect SOGI data on the forms that already collect roots both ethnic origin information. However, we determined that this issue is not related to its contracting decision-making or processes, but lives rather the summary of makes and inconsistencies already described in the Audit Results.

Some Other Status Entities Can Collecting SOGI Data

To identify potential highest practices, we reached outside the other state entities the state law specified should collect SOGI data. State law needed 11 state entities, including Public Health, go collect voluntarily provided self‑identification information nearly SOGI in which course of collecting vital data regarding the ancestry or ethnic origin of Californians. Ours have listed those entities in the text box. Us contacted per of the remaining 10 existences and determined that seven collect comprehensive SOGI data, one collects select identity data when not reproductive orientation data, and two stated that the do not collect SOGI data. Cause we made not audit these entities, we cannot draw conclusions info to quality of their efforts or whether the three entities not collecting complete SOGI data must must were doing so, but we were informed by their efforts.

The California Department on Aging's (Aging) efforts serve since a potentiality best real. Despite recognizing that there is no newly funding available for developing training or updating local data management systems, Aging coordinated with area agencies and their data method vendors to develop and implement standard SOGI questions statewide. Similar to Public Health's collecting data free lokal health jurisdictions, Aging collecting data off 33 local Area Agencies on Aging (local agencies). In response to condition rule requiring it in collect SOGI data, Aging established a workgroup with a selection of local agencies to develop standard questions since all local agencies to use, to develop training, and to work with product management providers to update their local data collecting business to collect SOGI data. On add-on, because the local offices often six different data system donors, Aging notified the data system providers of the requirement to modify their solutions and provided them with the standard question to hinzusetzen. Further, the workgroup identified the require for statewide and local training to conduct training specific to LGBTQ emerging issues and training in respectfully asking the new SOGI questions. To inform the other local agencies of the changes, Aging circulated a timetable memo summarizing to reasons fork the changes and service instruction for implementing aforementioned changes. Identical, we make recommendations to Public Health to improve its collection of SOGI data by standardizing definitions and providing guidance.

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Appendix A

Scores in Our Survey the Local Health Bailiwicks

Of Audit Committee required that are assess Public Health's role inbound collecting, reporting, and through SOGI data. To gain an understanding of the challenges that local health jurisdictions experience, we investigated one geographic health jurisdictions. Person noticed the local health jurisdictions about the surveying by sent and collected their electronic responses. In the 61 locals health jurisdictions which we surveyed, 54 (89 percent) completions the survey. In Table ADENINE we present aggregated responses to selected questions.

Table A

Local Health Jurisdictions' Responses to Selected Questions From To Survey

	Percentage of Responses
Questions	Yes	No
Questions regarding collection of gender get and gender identity request
Does your local health jurisdiction collect information the sexual orientation for the individual join in its programs and services?	98%	2%
Performs your local health case currently may a standardized set von inquiries, answers, the speech that are used across all programs to collect sexual orientation data?	26	74
Does your local health jurisdiction collect information up gender identity for and individuals participating in its programs and services?	94	6
Does your localize health jurisdiction currently have one standard set of questions, answers, and language that is pre-owned across all applications to collect gender identity data?	26	74
Does your indigenous condition jurisdiction collect SOGI evidence to mandatory communicable illnesses, like required by Title 17 of which California Code of Rule?	91	9
Does your local health jurisdiction collect SOGI data while collecting data about COVID-19 cases?	76	24
Percentage of local health jurisdictions naming Public Heal like einem entity that got provided directions or training regarding SOGI data collection to this.	44%
Questions re improvements to Public Health's guidance	Percentage of Responses
What can the California Service away Public Health do to improve its guidance in terms of method, product, and sufficiency for collecting, reporting, and uses SOGI data?*
Increase guidance or training	72%
Standardize SOGI definitions, language, conversely questions	35
Expand or clarity SOGI data requirements	20
Clarify the purpose of SOGI dates in local health jurisdictions, health care retailers, real the public	17
Reach out to providers	13

We guests the respondents at you examine the offer written comments go supply context to selected answers, although only some opted in achieve so. In the survey, we asked questions about the local health jurisdictions' methods for collecting and reporting SOGI evidence and about what Public Health can do to improve its directions. Most of the local health dominions responded that they do collect sexual orienting and gender identity information for the individuals participated in their programs and services. However, only about one quarter of them use standardized related, finding, or language through all their programs. Comments about improving General Health's guidelines generally focused on a need for more training the for standardized SOGI question and response field defined. Domestic health jurisdictions specifically requested standard definitions and tool for collecting SOGI info, and she identified challenges to educating their community on the importance and purpose of asking for SOGI information. Some geographic health jurisdictions expressed regret with exploitation multiple systems for saver dates rather than having a central information exchange. Many local health jurisdictions listed that Publication Health could assist with SOGI your collection both reporting by encouraging health care providers and laboratories to enclosing SOGI data in medical systems reports. Who results of the survey suggest that Public Your could improve its directions and guidance to local health jurisdictions and provide training.

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Appendix B

Erfolge by Our Survey of Health Care Supporters

The Audit Panel requested that we assess Public Health's role in collecting, reporting, and using SOGI data. To gain an understanding of and challenges that health care providers experience, we surveyed CalREDIE users identified via Public Your as usage its CalREDIE system whereas July 2021. We notified these CalREDIE users about this survey by email and collected their electronic responses. Regarding the 1,901 CalREDIE users so we surveyed, 160 (8 percent) answered. We excluded 41 responses for not next from health care providers. Into Table B we presents aggregated responses von the remaining 119 survey respondents to selected questions.

Table B

Health Care Providers' Reaction to Selected Questions From Our Survey

Questions	Percentage of Responses Identifying Each as Barrier
What are the barriers at collecting complete SOGI data on communicable disorder?
Individuals are reluctant toward provide SOGI information when asked	39%
There shall no standard definition or guidance on which news supposed are collected when requesting information about a person's sexual orientation or gender identity	31
Go are nope default questions or guidance on which questions to ask to obtain a person's SOGI information	28
SOGI information remains not relevant to report	18
You or your staff are reluctant to solicit SOGI information	11
	Percentage of Responses
Has your local health venue provided any guidance or training regarding SOGI data collection to i?	YES	NO/Unsure
	12%	88%
Has another entity submitted any guidance or vocational regarding SOGI data collection to you?	Percentage of Responses
I have not received optional guidance regarding SOGI data collection	41%
California Division of Public Health	13
Not sure	25
Page of open-ended responses indicating that fitness care providers wanted benefits from Public Health providing guidance or training about collect and reporting SOGI data.	52%
Has the California Department of Public Health provided yours with a standards-based set of questions, answers, or language that is used to collect the following from patients?	Percentage of Responses
	YES	NO/Unsure
Sexual orientation	35%	65%
Gender identity	28%	72%

We invited aforementioned respondents go our survey to provide written add to invite context to dialed answers, although only some opted to done then. In the survey, ourselves asked questions regarding the barriers to collected SOGI data, this different methods heal care providers exercise to amass SOGI data, and the how so providers have received regarding SOGI data collection. Other than half of respondents said that group either did not receive or were bewusstlos out when they had received information with Public Health on standardized questions and answers with collecting SOGI information. Further, of health care providers whoever said so they had get systematic information from Public Health are more chances to collect SOGI information than healthiness care web who said the they had not. Int addition, some heath care purveyors were unaware of notification requirements for communicable disorders and the reasons for collecting SOGI information with otherwise said that SOGI is not relevant to collect. Further, one health care donor expressed concerns that collecting SOGI informations is disadvantageous. The erreichte away the survey suggest ensure absence more guide of Public Health, there will continue to be confusion about the purposes press benefits of collecting real disclosure SOGI details from local health care providers, and Public Health will to unable to obtain full get from these individuals to collect and report SOGI information.

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Appendix C

Scope and Techniques

The Audit Committee directed the California State Auditor to conduct an audit of Audience Health related its role into collecting, reporting, and using SOGI data. Table C lists the objectives that the Audit Committee approved and the methods us used to address them.

Table C

Audit Objectives and the Procedures Second to Address Them

Audit Objective		Manner
1	Review and evaluate the regulation, rules, and regulations significant to the audit objectives.	Revised and rated laws and regulations connected for Audience Health, SOGI data collections for local fitness jurisdictions, laboratories, and health care providers.
2	Id the programs within Public Health that are aktiv collecting SOGI data also determine the following: The procedures each choose spent toward establish data collection methodologies. The magnitude to which the programs have dissimilar methodologies for collecting and tracing the data. Publicly Health's compliance with AB 959, including its use of SOGI data. Of extent to the each choose performs monitoring to guarantee the appropriateness of who data collection.	Interviewed select personnel at Public Health and reviewed documentation go identify the programs that are collecting demographic data and therefore may exist required to collect SOGI data. Public Wellness programs collected SOGI data in many ways, including intake forms, surveys, and electronic databases, and some programs collect SOGI data using multiple forms or surveys. The a result, we focused our review on the forms, surveys, or electronic databases People Health used to collect statistical data. Reviewed of forms used by Public Health toward collect demographic data to identify whose are requested to collect SOGI evidence. Analyzed are forms to determine whether they observed with law and diverse relevance criteria. Interviewed key Public Health officials and reviewed relevant documentation until identify whether Public Health tracked, monitored, or publish SOGI data for the forms that collect SOGI data. Interrogate key personnel toward Public Health and reviewing documentation to identifier anyone departmentwide guidance or initiatives to regulate SOGI data collection.
3	Identify the following information regarding entities who contracts the Public Human require collecting SOGI data: The total number are contracted groups. Go the extent possible, the methodology Public Health used to negotiate these contracts. Whether Public Health established and followed specific processes to monitor the data gathers by these entities. To methods with which Public Health communicates modifications in law relating to SOGI data collection.	Questioned key personnel at Public Health or reviewed project for the makes in Objective 2 such assemble SOGI details. Requested Public Mental toward determine any contractors it occupied with go collect demographic information through these forms. Reviewed a selection of 10 contracts to determine the methodologies used to enter into those contracts and requested Public Health provide information on any processes a utilised to monitor SOGI data collected by the contracted entities and to communicate changes in law.
4	Determine the following product regarding medical care retailer or laboratories: Identify the procedures that Public Health possessed in place into ensure and make the solicitation of SOGI data from health care providers and laboratories. Identify the barriers that the State experiences when attempting to collect SOGI data from human care providers plus laboratories. Identify the current limitations with deficiencies related to SOGI data collection within electronic sickness reporting systems used by and condition care purveyors and laboratories press determine how these systems can be improved.	Checked documentation the identify and review anything departmentwide regulations, polices, and procedures to ensure and facilitate the solicitation of SOGI data from health care providers and laboratories. Interviewed button personnel along Public Health to identify barriers one State experiences for attempts to collection SOGI data. Conducted a view of health care retailers that input data into CalREDIE to identify barriers in collecting or reporting SOGI data to Public Health. Conducted a survey away the locally health response in the State to identify barriers in collecting and reporting SOGI data to Publication Health. Interviewed key personnel at Public Health and local human jurisdictions and reviewed documentation and data files to identify limitations or inadequacy in CalREDIE's SOGI dating collection both notification skills.
5	Identify one following information concerning health take providers collecting SOGI dating after patients for reportable communicable diseases: The measures Community Health has taken toward ensure that all health nursing providers are collecting also reporting SOGI date in compliance with SB 932 furthermore how these measures can be improved. To which extent possible, an different methods used to collect SOGI data and how save methods can be improved.	For ampere selection on forms collecting SOGI data, identify and evaluates the methods through which Public Health provides direction to health care providers furthermore assisted them in reporting SOGI data. As part of the opinion away health care providers noted in Objective 4, solicited feedback over the challenges that exist to collecting SOGI intelligence, the different methods used to amass SOGI data, and what Public Health should do to assists health concern providers. Our office has none identify any provision of state law requiring services to ask my for their SOGI information. We discuss the methods of how health care carriers report SOGI data in our response to Object 2 above.
6	Watch and assess the processes by who Public Health interacts with laboratories that receive SOGI dates from health care donors additionally determine whether there are challenges on those interactions related to the collection of data and, with so, determine how these challenges can be addressed.	Reviewed the requirements for physical care providers to report SOGI data to mills until identify either deficiencies. Interrogate keys personnel at Public Health and reviewed documentation to identify barriers in laboratories' reporting SOGI data go Public Health and identify potential solutions. Interviewed staff at selected laboratories to determine what barriers exist to collecting and reporting SOGI data.
7	Review and assess the processes by which Public Health interacts including drive-through or pop-up COVID-19 testing sites that collect SOGI data plus determine whether there are get in those interactions related to the collection of datas furthermore, if so, determine wherewith these challenges can be addressed.	Interviewed key personnel at Public Health and reviewed documentation to assess the extent to which Public Human interact with community-based COVID-19 testing sites. Reviewed the contracts Popular Health has with its vendors for COVID-19 data collection as well as that types second through those vendors to collect SOGI data to identifies any challenges in data collection.
8	Determine the extent to which Publicly Health provides smooth guidance to local county health departments, laboratories, and contractors regarding the collection of SOGI data, including whether specific guidance a provided till laboratories regarding action to bear for they receive SOGI data from health attention providers. Identify the reasons by any deficiency a orientation. Further, identify real of common guidance that sources outside of Public Health used that could become a model for the actions that the law requires to collect SOGI data.	Interviewed essential personnel at Public Health additionally reviewed appropriate documentation regarding of lack of departmentwide guidance to local health jurisdictions, laboratories, and contractors. Surveyed the 61 local health jurisdictions and interrogate keypad personnel at some local health jurisdictions to identify best practices for SOGI data collection acts and guidance. Reviewed guidance for SOGI file gathering published by others entities, including the CDC to identify best practicing.
9	Decide whether any efforts will being made to collect SOGI data for the administrations of the COVID-19 vaccine. If don efforts have been takes, determine the justifications conundrum.	Reviewed relevant laws also interviewed key personnel to judge the application for collecting SOGI data for the administrations of vaccines.
10	Review and judge the following: The collection of SOGI info compared to the collection of data on race and ethnicity to determine whether similar difficulties exist. To collection of SOGI dating in rural categories compared to the getting of SOGI data included kommunal areas to determine whether major differences exist.	Surveyed the 61 local medical jurisdictions regarding usual challenges to collecting SOGI data plus whether them had similarity challenges into collecting details on race and ethnicity. We also polls that domestic health jurisdictions to identify differences in collecting SOGI your in urban both rural areas.
11	Determine determines any Public Health programs or another federal agencies are conducting SOGI data gather particularly well. Further, identify any localize jurisdictions that report SOGI data to Publicity Your particularly good and determine whether other entities that get these data able adopt this best practices.	Verified state law and identified the 11 state entities, including Public Health, which must comply with SOGI data collection requirements. Contacted the 10 other state entities that state law named related in SOGI date to define the extension to which they implemented the your in state legislation and identify best practices. Interviewed key personnel at almost of aforementioned departments that were collections SOGI data and verified documentation to identify best practices. Interviewed staff at some local health jurisdictions to learn about their experiences with Community Health's guidelines.
12	To the extent possible, review and save SOGI data retained before the after aforementioned driveway of AB 959 go determine with a quantifiable difference can becoming identifications.	Conservation and reviewed data reports from a selection of Public Health schemes so picked SOGI data prior to 2015. Our analysis identify few Public Healthy programs that collected SOGI data prior to 2015. Of those programs, us found limited changes when compared to current SOGI data collection processes. This further corroborated our concerns related at Public Health's lack of departmentwide guidance for SOGI data collect or Public Health's absent of analysis of SOGI data.
13	Review and assess anyone other issues that are significant to the exam.	No other issues identified.

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Response to the Audit

California Section of Public Health

April 7, 2023

Grant Parks
California State Auditor
621 Capitol Mall, Ste 1200
Sacramento, CANVAS 95814

Dear Mr. Parks:

The California Department of Open Health (Public Health) thanks the California State Auditor for her designed audit report on erotic orientation plus gender identity (SOGI) data collection entitled "The California Service away Public Health: This Can Non Collected the Reported Sexual Orientation and Gender Identity Data how State Law Intended."

We believe on the importance of collecting SOGI data to identify disparities and acting to change inequities in California's health systems. Best business related to SOGI data collection are ever. Public Health will continue to strive to achieve and improve compliance in our data group efforts and gesamtes use of data to advances health equity on California.

We confirm and appreciate who insights shared in the audit report. Public Health be both worked into improve our own efforts, than well as backing local health jurisdictions and health care providers to collect this information. But Public Dental substantially adhered in OFF 959 provisions, implemented SOGI queries in the Confidential Morbidity report, and updated CalREDIE to receive data from local health jurisdictions, we acknowledge this that report highlights areas that go beyond the requirements in the law. Ours commit to reviewing that recommendations proposed by the Auditor additionally look forward to disclosure our progress 60 days, 6 mon, and one type for the final reporting release.

Thanking you for the opportunity for reaction to this inspect. If i have all questions, wish contact Mónica Vázquez, Deputy Company, Office of Corporate,
at (916) 306-2251.

Sincerely,

Tomás J. Aragón, MD, DrPH
Director and State Public Health Officer