Overcoming Obstacles

Recommendations 10

• R1

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  8 in Figure 1). 2008-2009 Los Angeles County Civil Grand Jury Report 245
• R2

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  1 – DCFS and DHS As direct electronic links between mHUB and myCSW software programs would violate the Statewide Automated Child Welfare Information System (SACWIS) regulations, DCFS and DHS should set up non-electronic processes for information-sharing (See
• R3

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  1 – DCEO of Children and Families Well-Being Cluster The Deputy Chief Executive Officer (DCEO) of the Children and Families Well-Being Cluster should take immediate action to extend the agency cooperation concept of Magnolia Place.
• R4

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  1 – The County Chief Executive Officer and Chief Information Officer The CEO should mandate that the County CIO be included from the beginning in the development and procurement of all sophisticated IT systems, utilizing the CIO’s professional expertise with extensive cooperation from each user organization. There should only be very limited and specific instances, mandated by the County CIO’s office, in which user organizations may bypass CIO procurement services. The County CIO should work with the user organization at the beginning of the project development cycle to identify the respective roles and responsibilities to be assumed by the CIO and the user department staff. 5. The Comprehensive Case Management System (CCMS) A CCMS team involving representatives of 14 County departments has been formed for the purpose of creating a coordinated program for facilitating greater function and use of IT capabilities within the current legal impediments to cross-departmental information- sharing.
• R5

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  1 – DCEO of Children and Families Well-Being Cluster The DCEO should present the results of the coordinated CCMS effort to the Board of Supervisors as quickly as feasible for approval and implementation. 2008-2009 Los Angeles County Civil Grand Jury Report 251 6. Limitations imposed by legal restrictions A major factor confronting many County agencies that keep extensive computer-based records for youth under their care is that existing Federal and State information handling rules and privacy protection statutes actually are intended to prevent the release of patient information, except in special pre-approved circumstances. Only limited off-line, non-automated exchange and sharing of information through Multi-Disciplinary Teams is available. This is a time-consuming process requiring pre-coordination and significant paperwork. The standards for limiting information sharing have been set by several California and Federal statutes, as occasionally modified in Federal Court legal actions (see section 7.0 Katie A.) The dual purpose and effect of these rules and actions has been to provide guidelines for acquiring, processing, interchanging, and storing healthcare information while protecting the privacy of persons receiving care. The key statutes affecting personal privacy and information-sharing are described below: CAPTA The Federal Child Abuse and Prevention Treatment Act (CAPTA) requires child protective services to refer children aged 0-36 months, who are victims of substantial child abuse or neglect, to Early Intervention Services. In order to provide services to these children, DCFS has coordinated this referral effort between Regional Centers, medical HUBs, and the Department of Mental Health (DMH) to screen these children for developmental or mental health problems, and then refer them as needed to Regional Centers for necessary care. This process, and the necessary coordination between these agencies, is carefully done so as to ensure both the confidentiality of these minors’ personal information and of their care and safety, as required by two other statutes, HIPAA (Health Insurance Portability and Accountability Act, and CMIA (California Confidentiality of Medical information Act). HIPAA HIPAA was enacted by the U.S. Congress in 1996. According to the Centers for Medicare and Medicaid services (CMS) website, HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs and requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. It helps patients keep private the personal health information they have submitted to insurers. Other provisions address the security and privacy of health data. The idea is that, if individuals know that personal health information submitted to their insurers is carefully managed and protected, they will be more willing to submit that information. Thus HIPAA both encourages and supports electronic patient care information-sharing but only if rules for protecting patient information are followed. CMIA The State of California, in 2007 and 2008, implemented AB 1687 and AB 2352. This legislation is intended to deal affirmatively with health record-keeping and processing under HIPAA and CMIA. These statutes state that there are no legal barriers preventing a health or mental health care provider from disclosing medical information 252 2008-2009 Los Angeles County Civil Grand Jury Report to a County social worker, a probation officer, or any other person who is legally authorized to have custody or care of a minor, for the purpose of coordinating the provision of healthcare services to the minor. This form of disclosure, however, must be recognized as being different from giving social workers unlimited, on-line access to a minor’s complete electronically stored medical history files. Such on-line access is still prohibited by law. SACWIS and CWS/CMS DCFS is required to utilize California’s Child Welfare Services/Case Management System (CWS/CMS), an automated database system that contains all case-related information on each DCFS client, as its sole electronic system for child welfare case management. CWS/CMS users are mandated to comply with the rules of the Federal Statewide Automated Child Welfare Information System (SACWIS) because California received Federal funding to create and maintain the CWS/CMS system. Consequently, if the Federal government determined that the County’s management and handling of CWS/CMS records was not in compliance with SACWIS requirements, Federal funding could be disallowed. SACWIS rules include prohibition of many information-handling activities, including, but not limited to, prevention of the utilization of competing data systems, duplicative data entries into more than one system, and duplicative functionality. Consequently, if a County department ,such as DCFS, were to create a centralized database (in addition to CWS/CMS) which housed the same detailed client information as does CWS/CMS, and was accessible at one or more levels of confidentiality to all DCFS employees, it could be deemed a competing system by the Federal government and thus violate SACWIS. One methodology successfully employed by the County which does involve cross- departmental information-sharing (although not on-line sharing) is the use of “Multi- Disciplinary Teams” composed of health and other professionals assembled from several departments to plan health diagnosis and treatment of juveniles under County care. These teams meet and use health information on specific individuals extracted from multiple databases to plan the minor’s care. This kind of information-sharing is legally permitted because it does not require cross-departmental electronic file access by County personnel. Each health professional accesses only his or her own database.
• R6

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  1 – DCFS, DHS, DMH and DPH To the extent permitted by law, DCFS, DHS, DMH, and DPH should provide skilled healthcare professionals access to a youth’s healthcare information regardless of the department in which the information was originally obtained. However, such access should be limited to those personnel who have been provided confidential user names and passwords. Requiring the use of user names and passwords for maintaining 2008-2009 Los Angeles County Civil Grand Jury Report 253 information privacy is a proven tool which makes the control of such access safe and feasible. 7. Katie A. In July 2002, a class-action lawsuit, hereinafter referred to as “Katie A.”, was filed in Federal District Court against the State of California and the County of Los Angeles. The suit alleged that children in contact with the County’s foster care system were not receiving mental health and other foster care services to which they were entitled, potentially creating or aggravating mental health problems for those youth. In 2003, the County entered into a Settlement Agreement under which the Court established an Advisory Panel to monitor, evaluate, and report to the Court on County plans and efforts to fulfill their obligations under the Agreement. On August 16, 2005, the Advisory Panel issued its fifth report concluding that the County had not developed a sufficient plan nor taken sufficiently effective steps to meet the needs of the plaintiff class, and was therefore, not meeting the obligations of the Settlement Agreement. In response, the County first developed the 2005 County Plan and then the 2007 Corrective Action Plan (CAP) and now has developed the targeted enhancements and coordinated vision of the Strategic Plan in consultation with the Advisory Panel. The Strategic Plan, along with the accountability oversight provision, has been developed to fulfill the terms of the Settlement Agreement and provide a viable exit from Court jurisdiction. An important change occurred when the County and plaintiffs joined to obtain a Court order which permitted the two County agencies to conduct data matches and exchange information for planning and service purposes. More specifically, DMH, and DCFS, were allowed by Court order to share specific patient/youth records. Before this order, the ability to share such information was limited because of strict Federal and State confidentiality provisions, which in part led to the initiation of the lawsuit and presented a major barrier preventing compliance with the Settlement Agreement. To understand the financial magnitude of the settlement, it is important to understand that the County is now estimated to spend over $200 million dollars annually to provide intensive and individualized mental health care services in conjunction with qualified staff, and medical HUB services deemed reasonable and necessary by the Court and its Advisory Panel for members of the settlement class. Initial steps have been taken by DMH to facilitate information sharing using the data warehouse/data-mining software. In addition, efforts are underway at the HUBs to assess 100% of newly detained children through the Multidisciplinary Assessment Teams (MAT) Program. The plan is to require that all CSWs similarly screen all children for mental health issues in newly detained open cases as well as children in existing open DCFS cases.
• R7

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  1.1 – The County Chief Executive Officer The CEO should caucus with DCFS and DMH, as well as with the DCEO of the Children and Families Well-being Cluster and the County Counsel, to develop strategies for implementation of standards, remedies, and legislative changes at both County, State and Federal levels that will enable continuing improvement of healthcare delivery to County residents, consistent with the improvements which have been achieved as a result of Katie A. Court and Advisory Panel supervision.
• R8

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  1 – DHS, DMH and Probation DHS, DMH, and Probation should each immediately develop and implement policies based on the May 9, 2007 Board of Supervisors MOU. Information Technology Developments Significant information technology developments identified below are under way in the County at this time. Redesign of LEADER: While the County Department of Public Social Services (DPSS) is not seen as a key health care provider, it does provide key services to the needy, many of whom are also receiving health care from DCFS, DHS, or DMH, and thus needs to share information with these departments on services being provided to these persons.
• R9

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  1 - DHS DHS should direct that SCAN reports (officially entitled “California Office of Emergency Services – Medical Report: Suspected Child Physical Abuse and Neglect Examination – OES 900 form) be entered electronically at HUBs by the end of September 2009 so that: 1. There will be no risk that they become lost. 2. DCFS office personnel are not obliged to decode someone else’s handwriting in taking the data from the SCAN reports. 10. Conclusion Through this CGJ’s “follow-on” investigation, we documented a number of issues related to information-sharing. Of those issues, there are several that the CGJ intends should be given the highest priority on the County’s “to do” list. These are: 1. Implementation of EMPI and expanding its scope to other departmental services. 2. Strategizing for and meeting with State officials to work for legislative amendments to key state statutes itemized in this report which inhibit information-sharing on healthcare issues. 3. Redefining the responsibilities of the County CIO to include, for all major departmental information system acquisitions, active participation in: • implementation planning, • preparation of functional specifications, • definition of contractor skill and experience specifications, and • system selection process and issue resolution; 4. All departments which share responsibilities for providing essential services to County citizens should caucus and appoint cross-departmental coordination 262 2008-2009 Los Angeles County Civil Grand Jury Report committees with principal responsibility for investigating problems in, and facilitating solutions of, information-sharing issues. 2008-2009 Los Angeles County Civil Grand Jury Report 263 HEALTH INFORMATION-SHARING FOR AT-RISK YOUTH Overcoming Obstacles
• R10

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  Conclusion Through this CGJ’s “follow-on” investigation, we documented a number of issues related to information-sharing. Of those issues, there are several that the CGJ intends should be given the highest priority on the County’s “to do” list. These are: