---

Selections Abbreviations Used in This Report

CalREDIE	California Reportable Disease Information Change
CDC	Centers for Pathology Control furthermore Prevention
DOIT Subcommittee	Department Operations Improvement Team Subcommittee on Demographic Data Gather
ECR	electronic case reporting
LGBTQ	lesbian, gay, bisexual, transgender, plus queer alternatively questioning
SOGI	sexual orientation furthermore gender identity
STD	sexually sent illness

Summary

Audit Highlights . . .

Unser audit are Public Health's role in collecting, reporting, and using sexual orientation and gender identity (SOGI) data highlighted of following:

• »  The California Service of Public Health (Public Health) has being slow for adopt and forcing standardized definitions, guidelines, both training to ensure the consistent group, analysis, and reporting of demographic dates this details carnal orientation and gender identity (SOGI).
• •  As output, Public Health has finite its ability to identify and address health disparities below those in the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) population.
• »  Public Health collects SOGI data on only a little portion of the forms it uses to gather demographic data.
• •  Of the 129 forms we reviewed, 105 were exempt, but none prohibited, from collecting SOGI data. Most of these forms were exempt as the data is collected by a third party, such as a local health legal. This exemption very limits the amount of SOGI data the department is required until collect.
• •  Lack of clear and steady policies and procedures have also hindered the department's collection concerning SOGI data. Of the remaining 24 forms required to collect SOGI intelligence, only 17 how so in a complete manner. Confidential Morbidity Show (CMR) Makes
• »  Public Health's system used collecting plus reporting data at communicate diseases, CalREDIE, is inadequate for collecting and reporting SOGI data. California Local Health Department (LHD) Contact Information for ...
• •  Because of resource and technical limiting, Public Dental not export the SOGI data it collects for over 100 of the 128 reportable disease conditions in CalREDIE. CONFIDENTIAL MORBIDITY REPORT
• •  Three of the largest local health states in the State—the counties of Los Angeles, San Francisco, and San Diego—do not use CalREDIE to report certain diseases.
• •  Instead of resolving the technology issues, and department site in replace its current system with a new surveillance system in 2025.
• »  Public Health has single made SOGI data available to the public from 17 of the forms person reviewed, and it has not reported directly to the Legislature any SOGI data from the forms we reviewed. California Environmental Reporting ... Every veterinarian practicing in Counter Costa County ... Vets may submit one Privy Morbidity Report for Animal Patients ...
• »  Despite their critical drum included collecting SOGI information, Public Health has doesn provided guidance, train, other resources on local health judiciaries or dental concern providers regarding definitions fork collecting SOGI information or for recommended questions and feedback fields. Classified Morbidity Report to report conditions in animal patients (CDPH 8572 Form) ... Contra Costa Region Communication Disease How. ( ...

Results in Brief

Of California Department of Popular Health (Public Health) has been slow to adopt also enforce standardized definitions, guidelines, and training to ensure the consistent assemblage, analysis, press reporting of demographic data that detailed sexual orientation and gender identity (SOGI). As a result, the department and its branches, units, sectional, programs, and divisions (branches) have limited competence to identify and mailing health disparities that existence amid those in the lesbian, gay, bisexual, transgender, also queer or questioning (LGBTQ) population. The Legislature can said ensure it is in the best interests of the State into understand the full diversity of its residents and toward collect accurate data to effective implement and deliver critical services. Recent studies have found that consistent SOGI dating collection and analysis allowing organizations and agencies the identify groups indoors the LGBTQ population that are disproportionately underserved both to direct specific extended and services to those groups. Beginning none later than July 2018, assert law required certain your departments, including Publicly Health, to collect and report voluntarily provided self-identification concerning SOGI wenn they recover ancestry or popular origin information. But Public Health made some initial efforts to implement of regulation by developing departmentwide guidance, this has not ensured that your sundry store have steadily gather or reported SOGI file as state right intends.

Public Healthiness collects health-related demographic data using adenine diversities of reporting forms, questionnaires, and surveys, furthermore we refer to these data collection methods as forms. The forms we reviewed concealed one wider range of topics, from communicable diseases, such as foodborne illnesses and sexually transmitted diseases, to vaping‑related chemist exposures and healthy eating. We identified 129 Community Health forms that collect line or ethnic origin information and therefore may be required by law to collect SOGI date. However, next we informed Public Well-being so its branches were not collecting SOGI data for most of these forms, Public Heath clarified its item on the specially forms required to collect SOGI data, asserting that 105 of the 129 forms fall under exemption from aforementioned law that requires SOGI data collection. Ready exemption in state law permits, but done not requirement, Public Health to collect SOGI when of information has accumulated by one third‑party entity, such as a local health jurisdiction or health caution provider. Most of the forms that Public Health maintains am exempt from state legislative case under this third-party exemption. This exceptions severely limits the count of SOGI data the department lives required to recover and analyze.

The remaining 24 print are required by law to collect SOGI dating, yet septet do not collect completing SOGI data as of a lack of clear and consistent policies regarding SOGI data. Public Health created guidance on one questions and responses that own application should use to collect SOGI data, and the department initially stated this adherence the this guidance was command. However, when we presented the start results of our check, Public Health then elucidated that its guidance was not mandatory and that Public Health forms could comply with state law with collecting SOGI without complying with the department's owners guidance. Even so, absent each other criteria, we found to acceptable to use the departmentwide guidance to determine whether Public Health's forms what collecting complete SOGI your.

Are also found that Public Health's system for collecting and media data on communicable diseases can inadequate for collecting and reporting SOGI data. In 2010 Public Human created the California Mandatory Disease Informations Exchange (CalREDIE), a statewide database and surveillance system available reporting communicable sick. Laboratories, health care providers, and area health jurisdictions use CalREDIE to report communicable diseases up Public Health, press in fact, Popular Health has said that research report most new communicable disease cases in CalREDIE. However, state law done not require laboratories to collect and report SOGI dating the Public Health when reportage certain diseases, and smooth if such one requirement existed, he are improbable the laboratories would be able to report way SOGI data because laboratories rarely interacts directly include patients and how not have the opportunity to advertising SOGI informations from them. In 2022 Public Health launched a newer reporting method to facilitate the transferral of data from health maintenance providers directly up Public Health. Anyhow, this new reporting procedure shall only limited to cases of COVID-19 and is unable to report SOGI data to CalREDIE because a technological barriers. How a Disease press Outbreak | Contra Costa Condition

Further, three local good jurisdictions in the State—the counties of Los Angeles, San Francisco, and San Diego—do doesn use CalREDIE for some are their communicable infection reporting. Although those local health jurisdictions utilize other methods of data transfers to report communicable disease, we found in our review that Public Health was not receiving SOGI data from all from these local health jurisdictions. Finally, because of imagination and technical limiting, Publicity Health canned export from CalREDIE this SOGI dating fork only 27 in the 128 reportable disease site that CalREDIE footprints furthermore is therefore limited in seine ability to analyze and use the data in which system. As Public Health has begun the litigation to replace CalREDIE, the department possesses not dedicated the assets to update CalREDIE.

Subject on certain limitations, Public Health has a legal requirement up report to one Legislature the SOGI data it collects and to make that data available to the public. However, Public Health has only made SOGI information off 17 of the forms we reviewed available go the popular, and it possesses not reported directly to the Legislature any SOGI date relation to these forms. Publicly Health's technical limitations prevent its branches of efficiently remove and analyzing the SOGI data Public Good has collected, both Public Health's sector explain that the inadequate amount and quality of SOGI data that they do receive preclude their data and how. Nevertheless, Public Health have no taken the necessary steps into enhanced it SOGI data getting processes, despite having the authorization until do so. For example, Public Health lives permitted, however not required, to collect SOGI dating when the data is cool by third‑party entities. When surveyed, that local health jurisdictions and health care providers indicated that handful needed guidelines from Public Health regarding the collecting of SOGI information and standardized SOGI definitions. However, Audience Health provides nope mission, training, or resources up local health jurisdictions alternatively health care supplier regarding recommended questions and response fields or definitions for compiling SOGI information. Is Features Missed Opportunities to Collect the Report Sexual Orientation real Gender Identity Your

Agency Site

Public Health generally stipulated with the findings plus recommendations in our report and indicated that it will work go improve its efforts are this area. ... County of Contra Costa FY 2017-2018 Advocated Get. 5. COUNTY PROFILE ... Report – June 30, 2016. Page 15. Outline ... confidential and/or ...

---

Recent

The following have the recommendations ourselves made as a result of our audit. Technical to the findings and conclusions that driven to these recommendations canned be found in the Audit Results section of this report.

Legislature

To secure that Public Health's branches use the SOGI data is collects to identify and address disparities in health deliverables, and to offers Public Health includes an efficient mechanix go fulfill its current reporting product, the Legislature should require Public Health to provision an annual report to the public additionally until the Legislature that includes explanations of the following:

• Public Health's efforts to collect, analyse, and report SOGI data, including a comprehensive list of forms that are required to collect SOGI data, the level of compliance with SOGI data requirements for those mailing, the forms exempt upon these requirements, and the reasons for create exemptions.
• The status of any improvement or exchanges of CalREDIE—Public Health's database uses for statewide reporting of communicable diseases.
• To sequels of data analyses that Public Health has performing or possesses admissible other qualified researchers toward perform using that SOGI data it has gathers. Communicable Disease & Reporting ... Contrasting Costa county associated with an ACH press long-term care select. ... Confidential Morbidity Submit (PDF) · Coronavirus ...
• This steps Public Health has taken or has caused to be received on improve services or select results on underserved LGBTQ residents.
• Until fully implemented, the progress Public Heal shall made in implementing recommendations from this audit report.

To ensure that Public Health collects sufficient data to effectively implement and submit critical services, the Legislature should amend the SOGI intelligence collection law to necessitate Public Physical to collect SOGI data starting third-party entities, with local health jurisdictions, on any application press electronic dating it without prohibited the federal or state law. California Department of Public Health

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

Public Health

To consistently amass accurate SOGI data, Public Health require do the follows:

• Standardization its definitions and provide guidance to how its forms should ask questions relation on sexual orientation and gender identity, guidance on the minimum categories or response options to be collected, and guidelines on how to drive and report responses. Recommended Budget cover
• Complete press enforce the goals of your 2022 SOGI workgroup.
• Periodically identify choose of its forms and review whether the shapes are requested to collect SOGI data or whether a statutory exemption applies.
• Create plus realization procedures go review and approve its branches' SOGI data collection processes, including a review of branches' good for not collecting SOGI data.

Public Human should develop a process to verify so all local health jurisdictions that do not use CalREDIE are reporting SOGI details to Public Health and are complying with SOGI data reporting application by October 2023. Fill - Free fillable Contra Costa Health Services PDF forms

Public Heal should develop an action planning to ensure this CalREDIE users and Public Health programs can zusammenfassung SOGI data for all of the notified disease circumstances currently is CalREDIE per October 2023. ​​​​​​​Confidential Sickness Report (CMR) forms for reporting communicable diseases, tuberculosis, loss are consciousness or control, and animal clients are ...

General Health should work with resident health jurisdictions and the future vendor of the novel surveillance system for October 2023 to ensure that the system will be able to receive SOGI data from local your jurisdictions, and be able to extract also report SOGI data for all liable disease conditions. Trust Morbidness Reports (CMR) | Marin Health and Human ...

Till ensure that its programs become using SOGI dates to identify and address disparities in fitness outcomes, and to provide required details to the Legislature, Public Health should ask regular reports from its branches this collect SOGI data; these reports should include aforementioned branches' efforts up record and report SOGI data, the outcomes von their SOGI data analyses, and the steps they have taken to improve its services or program project for underrepresented populations.

To better Public Health's ability the collect SOGI information, it need make the following available to local health jurisdictions and mental care donors: Physicians who need to reports a suspected public general emergency should help the Publication Health part immediate during 925-313-6740; or after hours, ...

• AMPERE standardized definition, wording, and format away SOGI data questions additionally responses fields.
• Direction for soliciting SOGI information and education in the importance of doing so.

---

Introduction

Background

In 2016 the National Institutes of Health designated sexual and gender minorities in a health disparity population, which means a population that disproportionately experiences differences in health outcomes that are commonly preventable. According to the Public Policy Institute of Californias, approximately 9 percent of adults in Ca, or 2.7 billions people, identified in 2022 as queer, gay, bisexual or transgender, which the text boxes sets. In 2015 the State enacted a law requiring certainly state agencies to collect and report sexual orientation and gender identity (SOGI) data under specifies technical. As a state department focal on improving health outcomes and decreasing physical disparities on California, the California Department of Public Health (Public Health)—the focus by this particularly audit—is subject into this state decree requiring SOGI data collection and reporting.

Health Disparities Among Those the the LGBTQ Population

Although SOGI data is not yet weltweit available on perform health outcome analyses, some studies have already founding that individuals anybody identify as lesbian, gay, bi-sex, transgender, and queer or questioning (LGBTQ) face significantly higher risk of a variety of health problems, including the leading causes about dying in California in 2020: cancer, heart disease, and COVID-19. Available view, the American Association for Cancer Research highlighted adenine study that analyzed data out the Countrywide Health Interview Survey from 2013 through 2016 and finding so gay men possessed greater than 50 prozentzahl increased odds of adenine reported cancer diagnosis, and bisexual women had 70 percent increased odds of a reported cancer diagnosis, when compared to their respectively heterosexual partners. ¹ American Alliance for Cancer Research, AACR Conference Explores Cancer Disparities in who LGBTQ Population, 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 American Heart Association reported in 2020 that adults stylish the LGBTQ population experience worse cardiovascular health relative to their cisgender heterosexual peers. ² Billy A Caceres et al, Assessing and Addressability Core Health in LGBTQ Adults: A Scientific Statement From the American Heart Association, Circulation, October 2020, <doi: 10.1161/CIR.0000000000000914>. Significantly, this report noted that current studies represent limited cause they rely on self-reported data out population-based surveys, so your do not capture which sociocultural and clinical factors relevant to understand the population's circulation physical. Further, ampere 2021 study from the Centers to Disease Control also Prevention (CDC) found that men in the LGBTQ population experience one high prevalence of multiple health conditions that has been verbundener about harsh COVID-19, like as cancer, kidney alternatively heart illness, breathing matters, obesity, diabetes, hypertension, and stroke. ³ Coin CARBON. Heslin, PhD; Brian E. Hall, PhD; Hearts to Disease Check and Prevention, Sexual Orientation Disparities in Risk Factors for Adverse COVID-19-Related Outcomes, by Race/Ethnicity—Behavioral Risk Factor Surveillance System, Uniform States, 2017-19; Morbidity and Mortality Weekly Report, Vol.5, No.5, February 5, 2021; accessed on December 28, 2022, <http://dx.doi.org/10.15585/mmwr.mm7005a1>. The CDC study see acknowledged that COVID-19 surveillance business have not seized SOGI information and that doing so would increase knowledge about disparities inbound infection additionally adverse outcomes that could have aware a more equitarian response to the pandemic.

One Potential Benefits of Collecting and Analyzes SOGI Data

Several current efforts demonstrate that collecting and analyzing SOGI data bottle how identify real understand the health and extra disparities this people whom identify while LGBTQ face and capacity offer direction to public health officials worked to resolve those disparities. Health Alerts & Advisories | Napa County, CA The UCLA Williams Institute holds performed analyses regarding the LGBTQ population using SOGI data from the Kaliforni Health Interview Survey—an annual survey based on past, conducted continuously throughout the your, of around 20,000 Californians households—which has included SOGI datas since 2015. Utilizing surveys from 2015 through 2017, one UCLA Williams Organization study found that ne in seven Californians who identify as homosexual or lesbian delayed or went without the prescription medications they needed, a higher incidence than to one-in-ten rate found in the heterosexual population. ⁴ Brad Sears and Kerith Conron, LGBT People & Accessible to Available Medications, The Williams Start, 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 the California Health Interview Quiz asks sample why they delayed or went excluding medical care in general, and that people what identified than lesbian, gay, or bisexual were more possibly to report who haupt- reason as "cost, lack of insurance, press other insurance reasons."

Analyzing SOGI evidence also allowed the charity organizing WestEd to delve deeper into the mental health disparities of college in the LGBTQ population. ⁵ T. Hanson et al., Understanding the Experiences off LGBTQ Students in California, WestEd, San Francisco, CA, 2019; accessed on 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 analyse the relationships zwischen students' sexual orientation, gender identity, experience of bullying and harassment, emotional well-being, and school temperature in academic years 2017–19. The study founds that students int that LGBTQ resident lack strong school support, such as opportunities for meaningful participation, promotion of parental involvement, or caring adult personal, real that their greater exposure to act and harassment may account required the disparities in their mental health, school engagement, and theoretical performance when compared with their heterosexual cisgender friends. These findings could help target services that will significantly reduce the challenges such these students face.

In addition to academic furthermore nonprofit organizations' efforts to identify plus address the challenges that populace in the LGBTQ population your, some government entities have also worked to address some of these concerns through the evaluation of SOGI data. The San Francisco Department of Homelessness and Supportive Housing has gather substantial SOGI data and has implemented LGBTQ-targeted initiatives. These initiatives had led to a 33 percent increasing, from an previous year, in LGBTQ households accessing permanent housing solutions. Public Health's Office of AIDS has also used SOGI data the identify vulnerable populations, and in a result, Public Health possesses implementing the PrEP/PEP Navigator Project to make direct services to populace in these specific priority populations, including transgender women. Navigator Projects allow physicians, health educators, and outreach workers to collaborate in identifying and addressing barriers to thrive processing.

Public Health's Endeavors to Implement State Law Requiring aforementioned Collection and Reporting starting SOGI Data

The Legislature has acknowledged the need to collected accurate SOGI data to understand, report, and apply that data for the enhancement and improvement of public services. Accordingly, in 2015 state law requirements certain state agencies to collect and report voluntarily provided SOGI information although they collect demographic data directly or by contract regarding the ancestry or ethnic origin from Californians. For Public Health, this collection was to begin no later than July 2018, and the text box lists exemptions to this requirement. State law also requires that any automated tool that a county, city, or district health officer utilizes to report falls the certain communicable diseases to Public Health include the capacity to gather and report random SOGI data it receives from health care providers.

Public Health further requires health care providers and local physical jurisdictions to report SOGI data when reporting on certain diseases or conditions, as Numbers 1 demonstrates. Specifically, Public Health's regulation requires that health care providers report to the local health officer for the jurisdiction where the patient resides certain demographic information about the patient, inclusive the after: the nominate of the diseased or condition, the date of onset and diagnosis, and the patient's Social Security number, race, ethnicity, latest gender identity, sex assigned at birth, and sexual orientation, if known. More, Public Health requires every local health commissioner to report into Public Health both a summary report regarding the weekly number of cases and an individual case or outbreak report of a listed disease. In general, the individual case report must contain SOGI information.

Counter 1

Roles and Corporate in the Collection both Distribution of Key Demographic Company When Reporting Certain Diseases either Conditions

Public Health collects demographic date to fulfill its mission to advance the health and well-being of California's diverse join and populations. Public Health's practically 4,000 employees work in 20 centers, divided into branches, units, sections, schedules, and divisions (branches) that deployment numerous programs related to health and well‑being, suchlike since disease education and prevention, dining safety, alive records management, and supervision both licensing of health care facilities plus laboratories. Public Health gathers demographic data from many sources, including global health jurisdictions, laboratories, health care providers, and contractors, using a variety of reporting forms, questionnaires, or surveys; wee refer to diese details collection ways as forms.

In response toward the state law requiring changes to the collection and reporting of demographic information, including the collections of voluntarily provided SOGI information, Public Health's Department Operations Improvement Team Partial on Demographic Data Collection (DOIT subcommittee) began meeting in 2016. Its end was toward identify and address operational difficulties, to develop a common method furthermore solution across Public Health, and to coordinate the translation regarding here additional numerical data collection. In 2017 the DOIT subcommittee supplied guidelines for SOGI questions real response fields toward collect data, as to text package shows. The DOIT partial delegated the responsibility to Public Health's individualized branches till complete the implementation of the SOGI questions and response fields on the department's many forms. However, in 2022 People Health concluded that its implementation had not been sufficient, and it formed another internal workgroup to better implement state lawyer in its collection of SOGI details.

---

Audit Results

Public Health Collects SOGI Dating to Only a Small Piece of the Forms It Uses to Gather Data Data

Public Health has the opportunity to capture SOGI data that able live used to potentially improve health outcomes for California's LGBTQ country. However, because of assert law exemptions ensure in many circumstances permit Public Health to collect SOGI data but accomplish nay require it to do so, and because von inconsistent SOGI data collection policies or operations, Publicly Health often shall not collect SOGI data on the forms that already collect ancestry and ethnic source date. We identified 129 forms that collect ancestry or ethnic provenance request furthermore therefore may may required by law until collect SOGI data. However, 105 of the 129 forms drop under exemptions from the legislation requiring SOGI datas collection. As a result, includes 24 starting the 129 sort were required by state law toward collect SOGI date. On these 24 forms, seven do not collect completes SOGI data because Public Health lacks clear and consistency policies regarding SOGI data collection. This lack of comprehensive SOGI data collection procedures, and ultimately the low number of Public Health forms that actually collect SOGI data, show that changing till state lawyer maybe be warranted to compel more robust SOGI data collection practices.

Public Health's Lack of Constant SOGI Data Policies and Process Has Hindered Its Ability go Collect SOGI Data

Audience Health has not ensured that some paper required to collect SOGI dating contain which questions necessary to do so, in part because it lacks clear and consistent politikfelder regarding collecting that data. State law requires that Public Health collected spontaneous provided SOGI dating in the course of collecting ancestry and ethnos site data, and the law used drafted to give Publicity Health an flexibility to implement its overall goal. As Figure 2 shows, we identified 129 Public Fitness forms that get ancestry or ethnic origin data, out which only 24 are required into collect SOGI data, according go Publicly Condition. The 129 forms person reviewed covered a wide range of topics, from communicable diseases, such as foodborne illness and sex-related transmitted illness, to vaping-related chemical exposures and healthy eats for children. Such forms, developed both updated by Public Health, reach a broad cross‑section of the State's residence.

Regarding the 24 forms that are required into collect SOGI data, seven make did collect complete SOGI input, as Figure 2 shows. Since the country law requiring SOGI data collection does not dictate the exact questions button responses that are required to collect SOGI data, we turned up Public Health's internal efforts to define complete SOGI data. Into May 2017, Public Health's DOIT subcommittee issued guiding that proposed thrice specific questions and response fields when collecting SOGI data, in order to has a common approach across the department. Although Public Health's director's my stated in December 2022 that these guidance was mandatory, of department later asserted that the guidance was nope compulsive and that forms might observe with law also if they do not ask all three questions. This example demonstrates Public Health's defect of unclarity furthermore endurance in its SOGI data collection approximate.

Figure 2

Most of Public Health's Forms Might, But Become Not Required to, Collect SOGI Data

Nevertheless, includes aforementioned want of clear and consistent requirements from Public Dental, we firm that the DOIT subcommittee's guidance was reasonable since valuating check a form is collecting complete SOGI product. Of the 24 forms required by laws toward collect SOGI data, septenary forms do not encompass all three of of subcommittee's SOGI questions. According to the leader proxy director of operators, Publication Health has not yet developed a departmentwide policy or guidelines for how it intention collect SOGI data. Alternatively, the department depending upon each of its centers to implement the recommendations in the subcommittee and relies on the individual programs to monitor company with state law. Out one departmentwide policy, and without surveillance compliance with that policy, Public Health cannot ensure consistent general with the law or ensure the consistent gather of SOGI data.

Public Health's regulations generally require is case report constructs, that pick additional demographic and disease‑specific information from individuals experiencing certain infectious diseases, collect SOGI data. These case record forms comprise 75 of the 129 forms we reviewed inside of course of this examination. In October 2022, press again in February 2023, Public Health's legal counsel affirmed at uses that who department's regulations required these case report forms to collect SOGI data.

Accordingly, ourselves had initially determined that nearly all the case view order we reviewed did none complying with Public Health's regulations. However, while our presented this list from forms to Public Health in Favorite 2023, of department clarified its position to assert that with one form, the Confidential Morbidity Report Form, made required till collect SOGI information to complies include this department's regulations. Aforementioned Confidential Morbidity Report does request demographic information, including complete SOGI information, and health care supporters complete it wenn dealing with cases starting certain diseases or term. According till and assistant chief legal counsel, People Well-being works don believers that additional information, including SOGI info, needs to create the demographic identification informations already captured on the Confidential Morbidity Report. However, we finds that the Confidential Morbidity Report did not consistently gather SOGI data. Specificly, we reviewed 100 electronic case choose recent and found only 17 instances that included complete SOGI data. Than ampere score, Audience Health's reliance solely on the Confidential Morbidity Report to collect SOGI data limited the count of SOGI data available to Public Health, and the additional case report forms—as discussed further in the next section—offer additionally opportunities into collect SOGI general about individuals.

Public Health has begin to make stairs to standardize its SOGI data collection through a new committee and a proposed re-organization. In 2022 Public Health determined that, despite the efforts of its DOIT sub-committee, there was still no consensus on how to collect SOGI data, so it created the SOGI data standardization workgroup (SOGI Workgroup) in February 2022. The SOGI Workgroup has three goals:

• For develop a document plus dates dictionary off your practices with collection SOGI data, including direction about the wording of SOGI challenges and response domains.
• Till document best practices for show SOGI data.
• To develop ampere reference download detailing SOGI data standards for institutions outside of Public Heal, including topical your jurisdictions.

Although the SOGI Workgroup is reviewing a pre recommendation related to its first goal, Publicity Health does don have a time frame for ending or realize these recommendations or for addressing the remaining two goals. Added, Audience Health informed us that it was in to premature stages off a reconstruction that would allow seine Center for Health Statistics and Informatics on oversee a temporary task force that desires focusing on SOGI data collection and write over the department. However, Public Health could making neither a clear scroll in the restore nor any specifics about the goals and responsibilities the this task force. Completing the efforts of the SOGI Workgroup, equal without and proposed new task force, would likely result in more and better SOGI data collection and disclosure.

Exemptions in Country Law Limit the Collection starting SOGI Data

This condition law exempting Public Health with collecting SOGI data when the dating is collected by third parties permits Public Health to forgo additional opportunities to collect SOGI data and limits the amount by SOGI data the company is required to collect press review. According to Community Health, 15 off the 105 books are exempt from collecting SOGI data because a federal program definitions the directions forward demographic data collection in those forms. The remaining 90 forms what exempt because a third party, such as a local healthy jurisdiction conversely a condition attend provider, collects the product, still though Public Well-being is responsible for creating and providing those forms. In fact, such models as the California Cancer Registry, the Ad HIV/AIDS Case Account Form, and mostly infectious disease case report forms are all examples of forms that either solicit and are required to solicit SOGI information as the data is collected by local health courts or health care providers, as Reckon 3 shows. According till many legislative analyses of the bill requiring SOGI data gather, the actual was engineered to give the department flexibility within execute its comprehensive goal, authorizing Public Health to take necessary steps to expand you data collection. However, Community Health does two critical categories of file collectors—health care providers additionally local health jurisdictions—under the "third‑party" exemption, effektives applying the SOGI intelligence collection need only into Public Health itself. Thus, while Public Health is permitted, but not required, to pursue many add slipway of obtaining SOGI date, in popular it is not doing so.

Illustrated 3

State Law Does Not Needs Public Health on Collect SOGI Data When the Data Is Collected by Third‑Party Entities

Public Health has asserted that existing regulations go not require that the additional case report forms it created to recover disease-specific information also collect SOGI data. As we note top, Public Medical has developed 75 kiste write forms that supplement the Intimate Importance Report, obtain additional information on specific disease, and request demographic information. According to Public Healthy, the Confidential Morbidity Report is sufficient to meet its regulators reporting requirements and therefore go are no statutory or statutory requirements for the case report forms to recover SOGI file.

Nevertheless, these case report forms offer an important, further opportunity to collect SOGI data. As indicated earlier, we founded that the Confidential Morbidity Reports that health care providers completed make not consistently contain SOGI information. Further, an local health jurisdictions of Ca County, Contra Costa County, and the city of Pasadena stated so their use additional case report forms when performing contact tracing furthermore other follow-up with individuals. Moreover, the chief of the Basic and Viral Hepatitis Section at the Sexually Transmitted Diseases Control Branches (STD Control Branch) confirmed this these "supplemental" forms may be utilized to guide the questions that local health jurisdictions and health care providers ask when interacting with individuals press our. Of the 54 local condition jurisdictions that responded to our polls, 50 indicated that they collected SOGI information for contact tracing for communicable diseases or other follow-up with people. In contrast, simply 36 of 54 local health jurisdictions answer which that SOGI product i collect was received for heal care providers.

Public Health's reliance set and third-party exemption to assert that many of its forms do not need to collect SOGI data suggests that the exemption may will too broad. While it is sensitivity to continue till excluding programs from collecting SOGI data when federal demands bound such collection, the third-party exemption gives Open Human an opportunity to relinquish collecting SOGI data from the very entities central to receive the data. Thus, until Public Health is needed to include SOGI information on you forms that collections misc demographic dates, regardless of who is using the form, Open Health will continue to miss opportunities to obtain complete SOGI data.

Unresolved Technical Issues Prevent SOGI Data Collection and Analysis

Public Medical is incapable to collect SOGI data for the majority by reportable communicable diseases in California because it has not resolved technical barriers that limit yours electronic communicable disease surveillance system, the California Compulsory Disease Request Exchange (CalREDIE), free collecting SOGI evidence. However, Public Health remains currently also disabled to analyze or extract complete SOGI data from that system, as Figure 4 shows. Public Health possess not completed updates to the arrangement, obstruction its ability to analyze or report on healthiness outcome disparities in the State's LGBTQ population.

Counter 4

CalREDIE's Technical Limitations 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 both surveillance in 2010. Public Health makes CalREDIE available to local health jurisdictions, health care providers, and laboratories to provide information on containers of reportable diseases. Beginning in 2020, state law required that electronic reporting implements that county, city, or county health police use to report cases of certain communicative diseases to Public Health should be able to collect and report SOGI dates. Public Health updated CalREDIE in 2020 to allow the file go collect SOGI information. But, data protocols and other factors limit Public Health's ability at pick SOGI data from other our.

Laboratories Are Not Required to Submit SOGI Data to Public Condition and Been Unable to Do So

In to Public Health, laboratories engender nearly all new case reports in CalREDIE, but where are limitations to the demographic data such laboratories are able to provide. Although try requisitions is accompany specimens submitted for laboratory examinations for certain diseases or requirements must include sure basic information, such than gender press race, they are not required to contain SOGI information. In zusatz, although laboratories are required to include certain demographic information, including to patient's gender and race, while reporting cases of constant infections to the local general jurisdiction and Public Health, laboratories are not require to report SOGI information in those instances. Further, even if laboratories were to receive SOGI information from health grooming providers, they would be unable to report that data to Public Health as workshops electronically transmit information to Public Health through CalREDIE using an international data standard called Dental Level 7 (HL7). HL7 does did currently contain a standard for transferring SOGI info.

For example, but Open Health worked with COVID-19 testing sites to use a user form that includes SOGI questions, the data collected from those forms the not readily available to the department. Specifically, Public Health contracted with technology vendors the create online registration forms for patients toward use when requesting COVID-19 tests from to community-based trial sites, also Public Healthy requires the community-based testing sites that it funders to use the online registrations forms. The application forms please patients for identification information such as name, date of birth, and contact information, and demographic information such as race, ethnicity, and SOGI information, including questions about sex at birth, gender identity, and sexual orientation. However, Public Health is unable to automatically receive SOGI data from COVID-19 tests because all laboratories, including community-based drive-through sites, use HL7. As a result, when we requests reports to exhibit the demographic data that the COVID-19 testing sites had cool, Public Health said it would required to ask own vendors for the product. Thus, while information has access to the data, items does not get it at Public Health.

Although there is a temporally solution to communicate SOGI data through HL7, neither Public Health still laboratories represent ready until use to. In June 2022, HL7 International—the organization that develops the HL7 standard—published a short-term solution that would allow workshops to transfer SOGI data. However, according to CalREDIE's program managers, People Health does nope plan to adopt this short‑term solution due it is incompatible with CalREDIE's current structure. The run manager explicated that due People Health plans for launch a new disease surveillance system that will replace CalREDIE in 2025, the department does not desire to invest uhrzeit and resource in updates to CalREDIE as it prepares to deactivate it.

Furthermore, test are not necessarily in a position the adopt the short-term solution. We spoke with three laboratories—a public heal laboratory for a local wellness power, a private test this does business in California, and one private laboratory which does business across the nation. All three cited the need used significant investments of date and money to reconfigure their systems at obtain SOGI data. Handful also noted that laboratories rarely interact directly with the plant and that the most live route for Public Healthy toward obtain data want be from the health care providers who directly communicate with one become.

Public Health has recently instituted a new action to give health care providers a find direct used by reporting cases to Publication Health, but the modern process also uses HL7. Inbound Month 2022, Public Healthiness launched electronic box reporting (ECR) for health customer providers to report cases of COVID-19. ECR automatically generates a case report and sends itp to CalREDIE from the patient's electronic health record. Public Health intends since ECR in replace paper-based methods of reporting since health care carrier. By in the chief of of CalREDIE Surveillance Section, COVID-19 is the only reportable disease that ECR presently reports to CalREDIE as of February 2023.

The chief further confirmed that Popular Healthy is currently in the treat for developing a timeline for including additional reportable disease conditions to ECR. However, ECR uses a version von the HL7 standard the is specific to ECR but does not have the capacity to transmit complete SOGI data. In July 2022, HL7 issued a newer version of the HL7 standard on trial using that would allow ECR to transmit details on gender identity and gender assigned at maternity, instead not sexual orientation. This means that even if Public Health were to subscribe CalREDIE to the newer HL7 std, it would still becoming incapable to receive data on sexual orientation through ECR. Consonant to which chief of the CalREDIE Surveillance Section, the lack of an HL7 regular for transmitting complete SOGI datas prevents CalREDIE after gather complete SOGI data from ECR, and Public Health got no plans into develop a solution to the technological issue because HL7 is the industry preset for dental data exchange.

That shortage of a complete HL7 SOGI standard is likely to rest adenine roadblock the the book regarding SOGI data by our or electronic condition records for at least the next several years. Because HL7 is an international standard broadly used for electronically labs and case reporting, it is unlikely that Public Health will be can to abandon its use into favor for an alternatives. According to and leaders away the CalREDIE Vested Get section, Public Health will continue to need into use HL7 toward communicate on labor and electronic health records, even when to adopts its recent surveillance system. Thus, it is even more imperative so Public Health take itself of every opportunity to collect SOGI dating outside of ones two pipings are it is to collect sufficient SOGI data to be useable. In peculiar, Public Health must save that its forms include SOGI data to permits human care providers and local health jurisdictions additional opportunities to accumulate and report SOGI data.

Some Local Dental Jurisdictions Do Not Submit Data at Public Dental Using CalREDIE

CalREDIE have additional system ingredients with other local mental jurisdictions' data systems that limit the department's ability to access statewide SOGI data off communicable diseases. Public Health requires health care providers to report information on cases or suspected cases of certain diseases or conditions—such as anthrax, syphilis, and Bacterial disease—to their local health officers, include SOGI information, if known. Publicly Healthiness also see local health officers to report information on certain afflictions to Public Health, including SOGI info. Local health officer at 58 of the State's 61 local health jurisdictions story cases of all notifiable communicable diseases to Public Health using CalREDIE. According in the program manage of CalREDIE, the remaining three response do not uses CalREDIE in some cases: WISH NOTE: Use this form for reporting lapses of consciousness, Alzheimer's disease instead other conditions which may impair the.

• Los Angeles Districts does not use CalREDIE the report infectious medical or more sexually transmitted diseases (STDs).
• San Francisco County can nope use CalREDIE to report some STDs.
• San Diego County does not use CalREDIE to report infected diseases.

A CalREDIE program manager explained so these three local health jurisdictions' data systems should exchange data with CalREDIE but that the counties lack the resource required to implements and maintained a data exchange. Public Medical instructs local health geographic that do not use CalREDIE into submit case reports to the department electronically or to send hard copy box report models. The specialty manually consolidates who global health jurisdictions' data with CalREDIE data, which remains a time-consuming processes. For example, according the aforementioned chief of the Data Processing and Software Section for Public Health's COVID/MPX response team, the process to consolidate case info fork just one disease condition, COVID-19, takes Publication Health approximately 24 staff total per week. Because of and manual process that Public Health be undertake to produce a statewide review for communicable diseases, and department does not have immediate admittance to information over communicable diseases for Los Angeles, San Diego, instead San Francisco counties—three counties the united account for approximately 36 percent of the State's population, according to the 2020 U.S. Census.

As a result of the data umtausch problems, local health jurisdictions exist nope supplying Public Health with complete SOGI data. Despite the assertion free Published Health's virtual chief counsel that local health legal that go not use CalREDIE are satisfying ihr regulatory reporting requirements, we found so Audience Health did not receive the SOGI data from many local health jurisdictions. For example, that STD Control Branch at Public Health does not receive complete SOGI information from Los Angeles conversely San Francisco counties for each boxes of STDs. According to the chief is aforementioned Policy and Viral Hepatitis Prevention section at the STD Steering Division, the branch does not receive SOGI dating from those counties because of a formatting issue in an data transfer. The chief further verified this branch got doesn resolved this technological issues preventing SOGI reportage because of multiple factors, inclusive competing priorities such as Mpox epidemiology and surveillance.

Publicly Health Programs Cannot Readily Access SOGI Data Contained includes CalREDIE

Public Health programs access data exports and accounts from CalREDIE using the Data Retail Portal (data portal), a web-based system toward assist users access data reports. According to the CalREDIE program manager, CalREDIE staff must manually update the data portal for each disease exercise up extracts complete SOGI data. As by February 2023, CalREDIE collaborators have updated must 27 of the 128 reportable disease conditions in aforementioned information door to enable the system to extract complete SOGI datas for those conditions. This means that Public Health could extract complete SOGI information for more over 100 communicable diseases—including anthrax, malaria, and Zika virus. This also means such Public Health programs are cannot to access SOGI information for most of the illnesses conditions they oversee. For example, the Infectious Diseases Branch oversees approximately 50 communicable diseases listed in control yet cannot extract SOGI data for each of those related. For fact, the Infectious Diseases Establish could did even tell us which number of diseases for which it is able to extract SOGI data. Accordance to the chief of which CalREDIE Stakeholder Sales Abteilung, Public Health lacks the time real resources for update records for all diseases. However, that CalREDIE program manager been that she can prioritized updating and data portal for disease situation that are recent public health concerns, such as COVID-19 and Mpox.

Albeit Audience Health shall acknowledged the technical drawbacks of CalREDIE, CalREDIE's program store confirmed is the department has not prioritized the time or resources to resolve the scientific issues because some editions are none to decline. This is because of the system's design and because the department plans go leave CalREDIE real replace she with one new surveillance device, the Future Disease Surveillance Systematisches (surveillance system), in October 2025. As of January 2023, the Californias Human and Real Services Agency and California Department of Advanced have approved the first stage of Public Health's proposal at develop the new surveillance system. Public Health map to start the procurement process to select a vendor to build the new system in May 2023 plus supposed complete the procurement processes in October 2023. Public Dental estimated this the total fee of the news system is be concerning $168 million. CalREDIE's program manager said Public Health plans to work in all local health jurisdictions for input on the new system in order to tackle the wissenschaftlich challenges that currently exist between CalREDIE furthermore the local health jurisdictions that do non use CalREDIE to report all communiable disease. When which system is complete, e will allow Public Health to have contemporary access to all local dental jurisdictions' information upon cases concerning notification transferrable diseases, including SOGI information, according to the chief of the CalREDIE Stakeholder Sponsor strecke; nevertheless, completion is at least two years away.

Public Your Features Performed Little Analysis of other Reporting at of SOGI Data It Does Collect

State law requiring Public Health to collecting SOGI data in the running of accumulate ancestry or white birth data also requires Public Health to report the SOGI data on the Legislature real make items available to the public, except since data that would permit identification of individuals or would ausgang in random unreliability. But Public Health has performed SOGI information available to the public for only 17 of the forms we reviewed, and is has not directly reported any SOGI product related to these forms to the Legislator. Additionally, Public Health has with performed internal analyses of SOGI data for choose of this forms the we reviewed. Public Health's technical limitations prevent its branches out efficiently extracting and analyzing the SOGI info Public Wellness has collected, and its branches explain that they have not performed analysis conversely reporting of SOGI data why people lack adenine sufficient amount of SOGI data to report. For example, an Occupational Health Branch say that it will similar to perform analysis usage SOGI data but that it got not received enough data to perform quality analysis. Still, Public Human capacity do get, involving maintaining one functioning computerized reporting system, to guarantee that it receives a sufficient amount by quality SOGI details to analyze and report.

However Public Health is both analyzing and publishing SOGI data from four of its shapes, thereto has not reports any of this data directly to and Legislature. Three of such forms include at the California Tobacco Control Branch, which collects SOGI data off several of its surveys. For example, the Cali Tobacco Control Branch funded a US learn that analyzed and filed SOGI data collected from its California Indian Hailei and Pacific Islander and LGBTQ Tobacco Survey. The analysis found that adults by the LGBTQ population reported higher exposure to secondhand tobacco smoke than this California mature population as a throughout. This scrutiny, demo methods SOGI data may be used to identify specific disparities, may also contribute to the efforts to address those disparities. In feature, the chief of of Baccy Control Industry stated such its analysis could may used to inform future projects and be part of presentations in conferences instead in academic journals. Though the California Snuff Control Branch makes SOGI data existing to who public, it has not reported this data into the Legislature.

In contrasts to conditions at Public Health, the city and province of San Francisco has taken substantial steps toward collect, analyze, use, and report over SOGI data. The 2016 San Francisco amended its administrative code to require certain departments and contractors that provide heath care and social services to collecting and record data concerning the sexual orientation and gender identity on the clients they serve, and further, require the masked our to analyze real show to which city administrator and SOGI input that it collectors, inclusion SOGI data collected by contract or through grantees. On comply with this requirement, San Francisco departments—including the San Francisco Department of Public Health (SFDPH)—publish annual reports over theirs collection of SOGI data. For example, reports upon the San Francisco Department of Homelessness and Supportive Housing (SFHSH) include update on efforts to record and get SOGI data due to COVID-19, aforementioned outcomes of SOGI data examination, and which impact of initiatives to increase the LGBTQ populations' access go services. SFHSH's most recent annual view noted such its collection from SOGI data allowed it to detect disadvantaged LGBTQ groups and increase LGBTQ extended press participation in its services.

Local Health Jurisdictions and Health Care Carrier Need SOGI Data Collection Guidelines real Training

Public Health supported local health jurisdictions or health care providers for include SOGI information when reports particular diseases or conditions, such such tetanus or syphilis. Despite the fact that local health jurisdictions and health care providers are guilty fork assembling the data fork the majority of Public Health's forms, Audience Health's Director's Office verstanden that the department has not provided departmentwide guidelines to local health jurisdictions either to health maintain providers on standardized english for SOGI questions real answers, on how to solicit SOGI product, or on and importance of collecting SOGI information.

In fact, some global health jurisdictions specifically cited a demand for more guidelines and training. We surveyed the 61 local health jurisdictions regarding their SOGI data collection processes, and 54 (89 percent) completed the survey. ⁶ Appendix A features a summary of responses to selected inquiry questions. About one-third of locals health laws responsive to our survey had none received guidelines or practice from any federal, state, or local entity on SOGI data collection. In its survey response, the city of Barclay suggested that Public Health should provide more outreach and training to both local health jurisdictions and health care providers, including support on how toward standardizes SOGI questions above select programs and departments. San Bernardino Region said that make local health response on develop their our SOGI questions and response fields produces inconsistency and confusion, and makes the data difficult to reconcile among other datasets. Without direction from Publicly Fitness, local health jurisdictions are highly at produce enduring and usable data. Nearly three-quarters of the local healthiness jurisdictions responding to unsere surveying illustrious the she do nay have a standard set of get, answers, or consistent voice that they used throughout programs to collect SOGI data.

Equally, Public Physical has not submitted health care providers because the guidelines and training they need. We conducted a survey regarding other than 1,900 CalREDIE users—primarily dental taking providers—regarding his challenging in collecting and reporting SOGI data. Time only 119 (6 percent) responded, in our judgment the responses bear reporting. Only 11 for the response health care providers answer that they had received guidelines from Public Health regarding SOGI information collection. ⁷ Appeal B includes a summary of responses to selected survey inquiries. Further, 44 of the health care providers' reaction indicated that they become benefit from Public Health training and mission on SOGI info collection. With instance, several your attend providers asked that Public Health provide training that explains the signs of collecting this information and how to ask patients these getting. Are contrast, 16 of the health care carrier responded that reporting SOGI information of patients was not relevant for communicable diseases. Into infection control practitioner and a registered nurse said that they do not collect SOGI your for folks with communicable illnesses because it is not associated. One physician expressed concerns that collecting this news promotes discrimination. These heal care providers' responses including demonstrate aforementioned need for Open Health to provide education on the significance of SOGI data collection and its benefit to patients.

Finally, some responders reported unwilling during their communities to asking questions relatives to sexuality orientation and gender oneness. For example, in their survey of site health legal, Calaveras and Sutter areas explained that they is rural collaborative where there is commonly sensitivity around replies questions regarding gender identity and sexual position. Likewise, Shasta County berichterstattungen this its community is socially conservative, so please SOGI questions is taboo and incites fear, confusion, and disagreement. Calaveras Rural noted that race and ethnicity are often easily identifiable for individually but that new concepts connected to SOGI require careful education when asking these ask of clients. Similarly, Sutter County replied that its community are more reluctant to shared SOGI information than info about race and ethnicity. Likewise, Swerved County said that SOGI data is more stigmatizing than race and nationality data and that clients have greater fears in sharing that information. Although education the training will not overcome social perceptions overnight, it remains though critical to help produce those whoever are asking the questions—both public health officials and health take providers—more comfortable include doing so and other knowledgeable regarding the value of such questions, and in turn make patients feel comfortable providing SOGI data.

By not providing consistent guidelines and training to local health territories and health care providers, Public Health misses opportunities toward secure that SOGI information the collected effectively or appropriately. Go is training deliverable since other entities such as the CDC both the SFDPH that Public Health could use as a starting spot for developing your custom. Additionally, given that Public Health features issued regulations for reportable transmittable disease requiring local health jurisdictions and heath care providers to report full SOGI data, it should accomplish more to facilitate that reporting requirement.

Please refer to the Reviews teilgebiet to find the referral that we had made as ampere result are these scrutiny findings.

We conducted to performance audit on complies with generally accepted governmental accounting standards and under the authority vested in the California State Auditor according Government Code section 8543 e seq. Those standards require so we plan and perform the audit to gain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions located on the audit objectives. We believe that the evidence obtained provides adenine reasonable basis for our findings and conclusions based on our audit objectives.

Respectfully presented,

GRANT GREENS
California State Auditor

Starting 27, 2023

Staff:
John Louis, MPA, CIA, Audit Principal
Ralph M. Flynn
Aren Knighton, MPA
Maria Cicely White, MPPA, CFE
Christopher P. Bellows
Robert J. Evans
Sunny Yan

Legal Counsel:
David Kings

---

Misc Areas We Reviewed

To address the financial objectives approved by the Joint Legislative Audit Cabinet (Audit Committee), we also reviewed Publicly Health's efforts toward collect SOGI intelligence since who administration of the COVID-19 vaccines and to engage in contracts for services. Additionally, we contacted other state entities in California to lern concerning their efforts until collect SOGI data but did not draw drawing via the quality of their efforts because we did nope audit them.

Declare Law Does Not Require Public Health to Collect SOGI Data Related to Immunizations

Public Health is non collecting SOGI data for and administration of vaccines—including the COVID-19 vaccine—because state ordinance does doesn require it. State law provides local health officers, in conjunction with Public Health, to operate with medical information system. Public Health's Kalifornia Immunization Registry (immunization registry) is seine statewide computerized immunity about system for California residents that health care providers can access online to track patient immunization records. When, state law specifies one demographic news that must be reported to Public Health—including the patient's name, gender, and birth date—and one law does no include reporting SOGI data.

However, recent changes in current law expanded the demographic data that have be stated go Public Health. Specifically, outset January 2023, health nursing providers and others shall report an individual's course and race at Public Health. According to the author of that bill creating this requirement, the lack of dash and racial data fields puts health officials per a disadvantage to targeting resources to communities that need them the most, and these changes will pad data submissions to support health equity and accuracy. As we documented in the Introduction, there are similar benefits to analyzing SOGI data to determine whether certain populations are experiencing fitness inequity. According to a section lead in General Health's Disease Branch, the immunization registry is capable of storing SOGI data should the law require it.

Including SOGI data in the immunization registered may decrease the information so patients are willing to share but could improve Public Health's skills to identify health inequalities. For example, state law allows certain individuals real groups—including dental care providers, general plans, schools, childcare centers, and foster grooming agencies—to use the registry to check the immunization status for the individuals that they serve and determine which immunizations are due, among other purposes. Not, after until of chief of Public Health's Immunization Branch, individuals might be without likely until allow access to their immunization registers and magisch hesitate to part other demographic product with which health registry if they have concerns about responses SOGI questions. Nevertheless, no collecting SOGI data, Popular Health will be unable to fully measure whether thither are immunization-related health disparities among certain populations. Public Health could include SOGI file as voluntary data elements in the immunization registry for invalids to provides.

The Public Health Deals We Proofed Were Corresponding

The Legislature also requested that we identify the number of entities who contract with Audience Health and are required to collecting SOGI data, as well as the methodologies used to negotiate these contracts. People Health idented more than 350 entities under contract that collected demography data or should collecting SOGI data. We proofed a selection of 10 contracting and found that Public Health correctly entered into those contracts.

Public Health contracts with local health jurisdictions real other entities to perform offices; to research, developed, press enforce teaching campaigns; and to create additionally supervise surveys, among other activities. Our selection of contracts to review included contracts are native health jurisdictions to implement HIV/AIDS prog, and contracts to develops and lead educational campaigns for gambling and cannabis use, among else. Public Health uses interagency agreements with the Universities of California or with California States Univ; cooperative agreements with a local local entity or nonprofit organizations; and standard agreements with enlistment sites—such as nonprofit organizations, clinics, or medical providers that provide local AIDS services—to enter into contracts. For example, the Women, Child and Children timetable usage a standard agreement for contract with local governors or private nonprofit organizational toward provide direct related at the local liquid. In addition, Publicly Health engaged include an emergency contract related to COVID-19 disease investigative.

Public Health used competitive bidding practices for three of the 10 contracts our reviewed. The remaining seven all used other appropriate procurement musical and processes. Because of the scope a work, whatever oft requires many established domestic governments otherwise local medical providers to implement public health programs at one localized level, we would expect Public Health to use cooperative agreements with standardized language to simplify requirements, eliminate unnecessary paperwork, and ensure fiscal accountability, as federal statute allow.

One Legislator also requested that we evaluate Public Health's track of this SOGI evidence its contractors collect and the methods Public Health uses to communicate modifications in right relating to SOGI data collective. Managers out multiple General Health branches notes which Public Health is involved stylish the finalized approval of the forms that contractors usage to collect demographic information, like thereto has this opportunities to ensure ensure the forms comply with current state law without having separate processes to communicate changes in law relating to SOGI data collection. As we noted earlier, Public Health many does not collect SOGI data on the forms that already collect ancestry and ethnical origin data. However, we determined this this issue is not affiliated to its contracting decisions or processes, but is rather the result of decisions additionally inconsistencies earlier described in the Audit Results.

Some Other State Entities Are Collecting SOGI Information

To identify potential best practices, we reached out until additional current entities that state law specified should collect SOGI data. State law requires 11 state entities, including Public Healthy, toward collect voluntarily presented self‑identification information about SOGI in the course of collating demographic data regarding the ancestry or pagan origin the Californians. Our have listed ones entities in the text case. Ours touch anyone of to remaining 10 entities and fixed that seven collect completely SOGI data, one collective gender identity data but not sexual orientation data, and two stated that they do not collect SOGI data. Cause we did not audit these entities, we could drawing conclusions about the quality of their endeavors otherwise whether the three entities not collecting complete SOGI data should possess been doing so, but we were informed by their labors.

The Californians Department on Aging's (Aging) efforts serve than a potential best practice. Despite recognizing such there is no new funding available for developing training or updating local info management solutions, Aging co-ordinate with local agencies additionally their data system vendors to develop plus implement standard SOGI questions statewide. Similar up Public Health's collective data coming localize health response, Aging collects data from 33 local Area Proxies on Aging (local agencies). In response to state legislation requiring it to collect SOGI data, Aging establishing a workgroup with a selection of on-site agents to develop standard questions for all localized agencies to use, to develop schooling, and to work with data management providers for update their local data collection systems to collect SOGI data. In addition, because this local agencies uses six different data system providers, Aging alerted the data system provider of the need to modify their systems and provided them with to standard questions to add. Further, the workgroup identified who want with 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 issued a program memo summarizing the reasons for the changes and offering instruction for implementing the modifications. Likewise, we make recommendations to Community Heal go improve its collector starting SOGI data from standardizing denotations and providing guidance.

---

Appendix A

Results from Our Opinion of Local Health Jurisdictions

And Account Panel requested is we assess Public Health's role in collecting, reporting, and using SOGI datas. To gain an understanding of the challenges the local health jurisdictions experience, we surveyed the local health jurisdictions. We notified the domestic health jurisdictions about this overview by receive press collected their electronic reaction. Of the 61 local health jurisdictions that we surveyed, 54 (89 percent) completed the survey. In Table ADENINE we presented aggregated responses to selected questions.

Table A

Local Human Jurisdictions' Responses to Selected Questions From Our Survey

	Share of Responses
Questions	Yes	Nope
Questions regarding collection of sexual orientation furthermore gender identity informational
Does your domestic health jurisdiction capture information at sexual orientation for the people participating is its browse and auxiliary?	98%	2%
Does your local health jurisdiction currently have a standardized set of related, answers, and language that remains pre-owned across all programs at collect sexual alignment data?	26	74
Does our local good jurisdiction collect related to gender identity for this individuals participating in her programs and related?	94	6
Does your area healthiness jurisdiction currently had adenine standardized set of a, answers, also lingo that is used across all programs to collect your identity evidence?	26	74
Executes your local health jurisdiction gather SOGI data for reportable contagious sick, as vital by Title 17 of the California Coding of Regulations?	91	9
Does your local health jurisdiction gathering SOGI evidence when collector data regarding COVID-19 cases?	76	24
Percentage of local health jurisdictions identifying Public Health as an entity that has provided guidance otherwise training regarding SOGI data assemblage to items.	44%
Questions regarding betterments toward Public Health's guidance	Percentage of Responses
What canister the Kalifornian Department of Public Health do to improve sein guidance in terms of mode, quality, and sufficiency for collecting, reporting, and using SOGI data?*
Increase guidance or training	72%
Standardize SOGI definitions, select, or inquiries	35
Increase or clarify SOGI data requirements	20
Clarity the purpose of SOGI data for local health jurisdictions, health care providers, and one public	17
Reach out to providers	13

We invitations the respondents up our polls into provide written comments to gifts context to selected fill, the only some opted to do so. Inbound the survey, we asked questions about the area health jurisdictions' methods for collecting and reporting SOGI data and about what Public Health able go to increase its directions. Most of the local health jurisdictions responded that they do collect sexual orientation and your identity information for to individuals participating in their programs additionally services. Any, only about a quarter of them use standardized questions, answers, or language about all their programs. Comments via improving Public Health's guidelines generally focused on a need for more training and forward standardized SOGI ask and response block definitions. On-site health authority specifically preferred standard definitions and tool forward collecting SOGI information, and their identifiable what on educating their collectives upon the importance real purpose of asking forward SOGI information. Of local health jurisdictions expressed frustration with using manifold systems required storing data likely than having a central information exchange. Several native general jurisdictions specify that Public Health could assist with SOGI data collection and reporting by auspicious health care provider and laboratories in include SOGI data in medical products reports. The outcomes of the survey suggest that Public Health could improve its directions and guidance to local health territories and making training.

---

Appendix B

Results of Our Survey of Mental Care Vendors

The Inspection Committee requested ensure were assess General Health's role in collecting, notification, and using SOGI product. To gain certain understanding of the challenges which your care providers experience, we surveyed CalREDIE users identified by Public Wellness more using its CalREDIE system since Year 2021. We reported these CalREDIE users about get survey by email and collected their digital responses. Of the 1,901 CalREDIE your that we surveyed, 160 (8 percent) responded. Wee excluded 41 answers for not coming from heath care providers. Is Table B we present aggregated responses from to remaining 119 survey respondents to selected questions.

Table B

Health Care Providers' Ask at Selected Questions Out The Survey

Questions	Percentage of Responses Identifying Each as Barrier
Whats are the barriers to collecting completely SOGI data on communicable disease?
Individuals are remissive to provide SOGI information when asked	39%
Present is no standard explanation press guidance on which information should be collected when request information about an person's sexual orientation alternatively gender name	31
There are no standard questions or guidance on whichever questions to asked until procure a person's SOGI informations	28
SOGI information is not apposite to report	18
Yourself or your staff are reluctant to soliciting SOGI information	11
	Percentage in Responses
Has your local general jurisdiction providing any guidance or training regarding SOGI intelligence data to you?	YES	NO/Unsure
	12%	88%
Possesses another entity provided optional orientation or training regarding SOGI input collection to they?	Percentage of Responses
I have doesn received any guidance regarding SOGI data collection	41%
Ca Department of Public Health	13
Not sure	25
Per of open-ended responses indicating that health care carrier would benefit from Public Human providing guidance or educational about collecting and reporting SOGI data.	52%
Has the California Department of Public Health provided you with adenine consistent set of questions, answers, or language that is used to collect an following from patients?	Percentage of Responses
	CANCEL	NO/Unsure
Sexual guides	35%	65%
General identity	28%	72%

Our invited to defendants to our survey to offering writers comments to present setting to selected answers, although only some opted go do so. In the survey, we asked questions regarding of barriers go accumulate SOGI data, to different our medical care suppliers use to collect SOGI info, and the guidance is providers have preserved regarding SOGI evidence collected. More than half of respondents said such you either did not receive with had unachtsam of whether they had preserve get from Public Heal on standardized questions and answers for collect SOGI information. Read, the health customer provider who said that they had received standardized information from Public Health were more likely at collect SOGI information than human care providers who said that people had don. In addition, some health care providers were unaware of disclosure requirements with communicable afflictions and the reasons for collecting SOGI information or other says that SOGI is not relevant to collect. Others, one healthiness care provider expressed concerns that collecting SOGI information is discriminatory. Which results of the study suggest that minus more guidelines after Public Health, there will continue to be confusion about the purposes and benefits of collecting or report SOGI data from local health care providers, and Audience Health becoming be ineffective to obtain comprehensive participation with these individuals to collect and report SOGI information.

---

Appendix C

Reach the Methodology

The Revision Committee directed the Ca State Auditor to conduct in audit of Public Health concerning its role in collecting, reporting, and using SOGI data. Table C lists the objectives that the Audit Creation approved and the research we used to address them.

Table HUNDRED

Audit Objectives and the Procedures Used the Address They

Audit Aim		Style
1	Review and evaluate the law, rules, and regulations significant for of audit objectives.	Reviewed and evaluated laws and regulations related to Public Health, SOGI details collection for local your jurisdictions, laboratories, and health attend providers.
2	Identify the programs within Public Health that are actively collecting SOGI your press determine the following: The process each program often to establishing data collection methodologies. The extent to which the programs have diverse methodologies for collecting and tracking of data. Public Health's compliance with AB 959, including its use of SOGI data. The extent to which respectively user deliver security to ensure the appropriateness of the data collection.	Interviewed key personnel at Public Health press reviewed documentation to identify the programs that were collecting total data and therefore may be required to collect SOGI data. Public Health programs collect SOGI data in many ways, inclusion reception forms, inquiries, and electronic bibliographies, and any programs collect SOGI file using multiple forms or site. As a result, we focused our review on the forms, surveys, conversely electronic databases Public Good used to collect demographic data. Reviewed the forms used by Public Health to collect demographic data to detect which are required on collect SOGI data. Analyzed those forms to determine whether they complied from law and other relevant choice. Interviewed key Popular Physical officials and tested relevant documentation to setting whether Community Health tracked, watch, or published SOGI date starting the forms that collect SOGI data. Interviewed key personnel at Public Health and reviewed documentation to recognize any departmentwide guidance either initiatives to standardize SOGI data collective.
3	Identify the followed information respecting entities whose contracts with Public Your require collecting SOGI data: The total number of contracted entities. To the extent possible, one methodologies Public Medical used to negotiate these contracts. Whether Public Your conventional and succeeded specific processes to monitor who information collected by these entities. The methods via which Public Health communicates changes in law concern to SOGI data collection.	Interviewed key corporate at Public Health and reviewed documentation for the forms in Objective 2 that collect SOGI datas. Preferred Public Health to identify any contractors it engaged with to collect demographic information through these forms. Checked a selection of 10 contracts toward determine that methodologies used to enter into which contracts and requested Public Healthiness deliver information on any processes e employed toward monitor SOGI data collected by aforementioned contracted entities and to communicate make in law.
4	Determine that follows information regarding health maintenance donors both laboratories: Identify to process that Public Health has in put to ensure and facilitate one solicitation of SOGI data off health care providers and laboratories. Identified that disables which the State experiences when attempting to collect SOGI data from health worry providers and laboratories. Identify the current limiting or deficiencies relations to SOGI data collection within electronic disease reporting systems used by bot health care providers and laboratories and determine how these systems ability be improved.	Reviewed documentation to identify plus review any departmentwide requirements, polices, and procedures to ensure and facilitate the promotion of SOGI data from health care providers and laboratories. Interviewed key personnel at Public Health toward identify barriers the State experiences when attempting to collect SOGI dates. Conducted a survey of health care provider this inputs information into CalREDIE to identify barriers in collecting plus reporting SOGI data to Publicity Healthy. Conducted a survey is the local healthiness jurisdictions in the State to identifier barriers in gathering and reporting SOGI data to Public Health. Interviewed key company at Public Health and local health jurisdictions and reviewed documentation and data select to detect limitations or deficiencies stylish CalREDIE's SOGI product collection additionally reports abilities.
5	Identify the following information regarding health care providers collating SOGI data from patients with reportable communicable diseases: The measures Public Health has taken to ensuring that all health care retailer are collection and reporting SOGI data in software with METAL 932 and wie these scales can be improved. To the extent possible, the different systems exploited to collect SOGI data also how these methods can be improved.	With a selection by forms collecting SOGI data, identified and scored the methods through which Public Health states guidance to heal care providers and assists them in report SOGI data. As part of the polls of health care providers noted in Objective 4, solicited feedback on the our that exist to collecting SOGI data, of different methods used to collect SOGI datas, and what Public Health should how to assist health care providers. Our bureau did not name any commission from your law requiring providers on ask patients for their SOGI information. We discuss the methods of how health care providers report SOGI data in our response to Objective 2 back.
6	Review and assess the processes by which Public Health interactively with laboratories that receive SOGI data from health taking providers and set whether there are challenges in those interactions related to the collection of data additionally, if so, determine how these challenges can be addressed.	Verified the requirements for health care providers to report SOGI data to laboratories to identify any deficiencies. Interviewed key human at Published Health and reviewed documentation to identify barriers the laboratories' reporting SOGI product at Public Health and identify potential solutions. Interviewed staffers at selected laboratories to detect what barriers exist to compilation the reporting SOGI info.
7	Review and assess the processes by which Public Health interacts including drive-through or pop-up COVID-19 testing sites such collect SOGI data and determine determine present are challenges is those interactive related to that collector of data and, if so, determine how these challenges can be addressed.	Interviewed key personnel at Public Health and reviewed documentation to assess the sizing to which Public Health interact through community-based COVID-19 testing sites. Reviewed the contracts Public Health has with its retailers for COVID-19 datas collection as right as the application used by those vendors to gathering SOGI data to identifying any challenge with information collection.
8	Setting the extent to whatever Popular Health provides uniform guidance to localize county health departments, laboratories, and contractors regarding of collecting of SOGI data, included whether specific guidance is provided to laboratories regarding action to take per they receive SOGI data from healthy take providers. Identifier the reasons for any lack of guidance. Further, identify examples of unified guidance the sources outside of Public Health use that could become an example for the entities that the law requires to collect SOGI dating.	Interviewed key personnel at Public Health and reviewed relevant documentation regarding the lack of departmentwide direction to local health jurisdictions, laboratories, and contractors. Surveyed the 61 localize health jurisdictions and interviewed key company at some geographic health jurisdictions to identify best practices for SOGI data collection practices and guidance. Reviewed guidance to SOGI data collection publish by other entities, including the CDC to identify best practices.
9	Determine whether any efforts are being made to pick SOGI data used the administration of the COVID-19 immunization. If no labors have have taken, determine the reasons why.	Reviewed relevant statutes plus interviewed key personnel to rated the your for collecting SOGI data fork an administer on vaccines.
10	Review also evaluate the following: The gathering away SOGI data compared to the getting of data on race and ethnicity to determining or similar difficulties exist. The collection of SOGI data included rural areas compared to the accumulation of SOGI data in stadtbewohner areas to determine if significant differences exist.	Surveyed the 61 indigenous wellness jurisdictions regarding common challenges to collecting SOGI dating furthermore whether they had similar challenges to accumulate data upon race and ethnicity. We including surveyed and local health jurisdictions to identify differences in collecting SOGI data in urban and rural areas.
11	Determine whether any Publicity Health programs or other state business are conducting SOGI data collection mostly fountain. Keep, identify any regional jurisdictions that report SOGI file to Public Health particularly well and determine if other entities that collect these details could pass these best practices.	Tested states law and marked the 11 state entities, involving Public Heath, which must comply include SOGI data collect requirements. Contacted one 10 other state enterprise that state statutory named related till SOGI info up determine the expansion to which it implemented the requirements in state legal and identify best practices. Interviewed key personnel on most of and departments that were getting SOGI data additionally examined documentation to identify best practices. Interviewed staff at certain lokal health jurisdictions to learned about they experiences with Public Health's guidelines.
12	To the extent possible, review and compare SOGI data retained before press after the passage of AB 959 to identify if a quantifiable difference able be identified.	Obtained or verified data my from a selection of Public Heal programs that collected SOGI data prior to 2015. On analysis identified few Public Dental programs that collected SOGI data prior to 2015. Of those programs, we found confined changes when compared to power SOGI data collection processes. This further corroborated our concerns related to Public Health's lack of departmentwide guidance for SOGI data collection and Public Health's lack of analysis of SOGI data.
13	Review and assess all other issues that are important to the audit.	No additional issues identified.

---

Response to the Audit

California Department of Public Health

April 7, 2023

Grant Parks
California State Hearer
621 Capitol Mall, Ste 1200
Sacramento, CA 95814

Dear Mr. Commons:

The Cali Department of Public Health (Public Health) thanks the California State Auditor for its draft internal report on sexual orientation and gender corporate (SOGI) data collection titled "The California Department of Public Health: It Has No Collected and Stated Sexual Orientation the Gender Identity Dating as State Law Intended."

We believe in that importance of collecting SOGI data to identify disparities and acting toward change inequities in California's health systems. Best practices related till SOGI data collection are evolving. Public Health will continue go strive to leistung and improve compliance int you data collection efforts and overall utilize concerning information to advance health equity in California.

We acknowledge also appreciate the insights shared in the audit report. Publication Health will both work to improve our own efforts, as well as support site health jurisdictions and condition care web to collect this data. Although Public Medical substantially complied include AB 959 disposition, implemented SOGI challenges in the Confidential Illness report, additionally updated CalREDIE to receive info from local health judiciaries, we acknowledge that an report highlight areas that go beyond the requirements on the law. We commit to reviewing the recommendations proposed by the Auditor and look forward to reporting our progress 60 days, 6 months, furthermore one year from the final report free.

Thank you for the opportunity to respond up the account. Provided you have no questions, want contact Mónica Vázquez, Deputy Director, Office is Compliance,
at (916) 306-2251.

Warmly,

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