BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 2541
A
AUTHOR: Portantino, Fletcher
B
AMENDED: June 24, 2010
HEARING DATE: June 30, 2010
2
CONSULTANT:
5
Orr
4
1
SUBJECT
Reporting of certain communicable diseases
SUMMARY
Deletes the HIV exemption from authorized electronic
reporting in order to increase federal funding provided to
California for HIV and AIDS services.
CHANGES TO EXISTING LAW
Existing law:
Permits certain laboratory test results to be posted on the
Internet or other electronic method if requested by the
patient and deemed appropriate by the health care provider
who ordered the test. Prohibits the electronic delivery of
clinical laboratory test results or any other related
results for HIV antibody tests, regardless of
authorization.
Requires health care providers and clinical laboratories to
report HIV infection by patient name to the local health
officer, and mandates local health officers to report
Continued---
STAFF ANALYSIS OF ASSEMBLY BILL 2541 (Portantino,
Fletcher)Page 2
unduplicated HIV cases by patient name to the California
Department of Public Health (CDPH).
Stipulates that public health records relating to HIV or
AIDS, containing personally identifying information,
developed or acquired by state or local public health
agencies or an agent of such an agency, shall be
confidential and shall not be disclosed, except as provided
by law for public health purposes or in accordance with a
written authorization by the person who is the subject of
the record or by his or her guardian or conservator.
Allows state or local public health agencies, or an agent
of such an agency, to disclose personally identifying
information in public health records to other local, state,
or federal public health agencies or to corroborating
medical researchers, when the confidential information is
necessary to carry out the duties of the agency or
researcher in the investigation, control, or surveillance
of disease, as determined by the state or local public
health agency.
Requires CDPH to establish a list of communicable and
noncommunicable diseases and conditions which local health
officers are required to report to CDPH. Exempts from
civil and criminal penalties any person or facility that
fails to provide notification of a reportable disease or
condition, unless the disease or condition that is required
to be reported has been printed in the California Code of
Regulations (CCR) for at least six months.
Existing regulations:
Require that all reports containing personal information,
including HIV/AIDS Case Reports, shall be sent to the local
health officer (LHO) or his or her designee by courier
service, U.S. Postal Service Express or registered mail, or
other traceable mail, or by person-to-person transfer with
the LHO or his or her designee.
Prohibit the health care provider and laboratory from
submitting reports containing personal information to the
LHO or his or her designee by electronic facsimile
transmission or by electronic mail or by non-traceable
mail.
STAFF ANALYSIS OF ASSEMBLY BILL 2541 (Portantino,
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Require all local health department (LHD) employees and
contractors to sign a HIV/AIDS Confidentiality Agreement
prior to accessing confidential HIV-related public health
records, required to be renewed annually. Stipulates that
information reported pursuant to these regulations is
acquired in confidence and shall not be disclosed by the
LHO or his or her authorized designee except as authorized.
This bill:
Deletes the provision in existing law that that excludes
HIV infections from being reported electronically.
Describes the methods health care providers and LHOs may
submit cases of HIV infection, including facsimile and
electronically by a secure and confidential electronic
reporting system established by the department, to be
implemented using the existing resources of the department.
FISCAL IMPACT
According to a recent report by the Legislative Analyst's
Office (LAO) on HIV surveillance and federal funding, by
increasing the number of HIV infections reported,
California could potentially increase receipt of federal
Ryan White Act funding by several million to low tens of
millions of dollars annually. These increased federal funds
would be used to reduce GF spending for HIV/AIDS.
Unknown costs to CDPH to modify an effort already underway
to develop a web-based electronic laboratory reporting
(ELR) system.
BACKGROUND AND DISCUSSION
According to the author, this bill would enable
laboratories to report HIV test results through CDPH's
electronic laboratory reporting system (ELR), in order to
enhance the completeness of HIV/AIDS data reported by CDPH,
Office of AIDS (CDPH/OA) to the federal Centers for Disease
Control and Prevention (CDC). This bill implements a
STAFF ANALYSIS OF ASSEMBLY BILL 2541 (Portantino,
Fletcher)Page 4
recommendation from a February 2010 Legislative Analysts
Office (LAO) report on California's HIV/AIDS reporting
system, 'Maximizing Federal Funds for HIV/AIDS: Improving
Surveillance and Reporting." The recommendation was to
enact legislation requiring laboratories to electronically
report HIV test results, in order to ensure that California
receives the maximum amount possible of federal funding
from the Ryan White Treatment Extension Act of 2009 (Ryan
White Act) for HIV/AIDS care and treatment services.
HIV/AIDS reporting
AIDS has been reportable in California for more than 20
years. Since AIDS cases represent later stages of the
disease, AIDS data are less useful than HIV data for public
health professionals to monitor the epidemic, and target
and evaluate prevention programs. Historically, HIV has
been treated differently than many other diseases, due in
part to the misperceptions and stigmas associated with its
transmission. Under current law, HIV cannot be reported
electronically and must be reported using methods such as
hand delivery or registered mail. This handling of HIV
reporting is administratively burdensome and does not
maximize data matching opportunities to increase the
identification of HIV-positive patients. Public health
professionals found they needed accurate HIV case data in
addition to AIDS data to assess the spread and impact of
the HIV/AIDS epidemic.
To address this, in 1997, the CDC called for all states to
conduct HIV surveillance as an extension of their on-going
AIDS surveillance programs. CDC published draft guidelines
outlining criteria for ensuring the quality and
confidentiality of HIV data, which set forth the standard
data that needs to be collected from each patient (date of
diagnosis, demographics, risk exposure, etc.), and also set
performance standards that reporting systems must meet.
California responded to this need by implementing
code-based HIV reporting in July 2002. The code contains
information about the patient's gender, date of birth, and
a code derived from the last name and the last four digits
of their social security. Since then, local health
departments have reported over 33,000 cases of HIV,
representing more than 35 percent of reported cases of
individuals living with HIV/AIDS in California. However,
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the CDC has since acknowledged that they consider HIV data
from code-based systems to be less reliable than name-based
systems, and would not accept the data and will not confirm
them for use in allocating Ryan White funds, putting some
of the state's federal grant money at risk. It is noted
that, at the time, the state used name-based reporting for
AIDS, and that California had had no documented or reported
cases of illegal or inappropriate disclosure of case
information from the state's AIDS Case Registry. To address
this, SB 699 (Soto) was passed in 2006 to report HIV cases
by patient's name rather than code in order to comply with
federal funding requirements.
Communicable disease reporting and surveillance
California has a dual reporting system for communicable
diseases. Both health care providers (physicians) and
laboratories are required to report a case, or suspected
case, of notifiable diseases to public health officials.
They are both responsible for reporting dozens of named
conditions, as well as any outbreaks of unusual diseases,
within a specified timeframe of identifying the disease.
Laboratories report these specific conditions to the LHD,
based on the location of the physician's office. The
laboratory report may be submitted to the appropriate LHD
by various means including a phone call, facsimile, mail,
or electronically. Once the LHD receives a laboratory
disease report for a suspected or confirmed case, it
notifies the appropriate public health staff to manage and
track the case. LHDs then report disease case information
directly to the state.
Public health officials use disease reporting to monitor
public health, develop prevention strategies, set
priorities and evaluate programs, allocate resources and
facilitate research. While there are many surveillance
strategies, disease reporting originating from health care
providers and laboratories is at the core of surveillance.
Disease reporting is mandated by the California Code of
Regulations, and California requires health care providers
to confidentially report more than 80 diseases and
conditions to local health officers.
Electronic disease surveillance
At the national level, the Centers for Disease Control and
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Prevention (CDC) initiated an effort to streamline the
collection, management, and reporting of data - primarily
for the surveillance of communicable diseases. In 1999, the
CDC introduced the National Electronic Disease Surveillance
System (NEDSS), designed to:(1) facilitate the electronic
transfer of appropriate information from clinical
information systems used in the delivery of health services
to public health departments; (2) reduce the burden on
health service providers of collecting and reporting such
information; and, (3) enhance the timeliness and quality of
public health information.
In late 2002, the CDC introduced the concept of the Public
Health Information Network (PHIN), to provide a network of
information that functionally and organizationally
integrates public health partners across the country. Other
CDC initiatives promoting the integration of technology in
public health, in addition to NEDSS, include the Health
Alert Network (HAN), the Laboratory Response Network (LRN),
the Epidemic Information Exchange (EPI-X) and the redesign
of the CDC website for public information and public health
education. CDC began providing funds to those public health
jurisdictions reporting public health data to CDC and who
are working to develop or procure applications that comply
with the specified requirements of their public health
information technology initiatives.
The California Department of Health Services (now under the
California Department of Public Health) initiated the
California Public Health Information Network (CalPHIN)
initiative to support the CDC efforts and promote the
public health goals of the state. Applications included
within the CalPHIN framework include the California
Electronic Laboratory Reporting (CA-ELR), and the
California Web Based Morbidity Reporting (WebCMR), among
others. The overall objective of the Electronic Laboratory
Reporting application is to enhance and strengthen state
and local disease surveillance capacity and promote public
health. This type of application will improve the ability
to collect more complete and timely surveillance
information from laboratories on a statewide basis, and is
used to increase the efficiency of existing surveillance
activities and the early detection of public health events
(e.g. bioterrorism). This will be accomplished through
automating manual processes such as data importing and
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Fletcher)Page 7
accuracy verification, decreasing paper-based data
submittals, eliminating data redundancy and duplicate data
entry, and providing easy accessibility to data for
planning, analysis, and decision making.
Chapter 278 of Statutes of 2008 (AB 2658, Horton) requires
laboratories to submit all cases of reportable diseases and
conditions electronically within one year of the
establishment of the new state ELR system, which is slated
for completion in 2010. According to the LAO, HIV reports
were specifically excluded from this requirement in order
to allow CDPH sufficient time to ensure the new system's
data architecture is not at variance with the HIV-specific
reporting requirements and that the system would meet
federal standards for HIV reporting.
HIV/AIDS funding
California switched to name-based reporting in 2006 in
order to not risk major losses of federal Ryan White Act
funding. The state has since been in a transition period
between code-based reporting and full name-based reporting.
According to CDPH estimates, California's failure to be
fully name-based in HIV reporting, meant the lost of $3
million to $7 million in federal funding in 2009.
According to the LAO, only about 36,000 cases of HIV have
been reported by name to local health jurisdictions. This
number likely represents only one-third to one-half of HIV
cases statewide. According to the LAO, California could
potentially increase receipt of federal Ryan White Act
funding by several million to low tens of millions of
dollars annually simply by increasing the number of HIV
infections reported. California spends roughly $1.2 billion
a year (40 percent GF) on medical treatment and HIV/AIDS
programs. The Ryan White Act provides $125 million in
federal funding per year to California. Increased federal
funds would likely be used to reduce GF spending for the
treatment of the disease.
Related bills
AB 2786 (Committee on Health) of 2010 would require CDPH to
establish a list
of communicable diseases and conditions for which clinical
laboratories are required to submit a culture or specimen
to local and state public health laboratories, as
STAFF ANALYSIS OF ASSEMBLY BILL 2541 (Portantino,
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specified.
Prior legislation
AB 2658 (Horton), Chapter 449, Statutes of 2008, required
laboratories to submit all cases of "reportable diseases
and conditions" electronically, within one year of the
establishment of the new state electronic laboratory
reporting system, with the exception of HIV reports.
SB 356 (Negrete McLeod) of 2007 was nearly identical to AB
2786. SB 356 was vetoed by Governor Schwarzenegger because
the delay in passing the 2008-2009 state budget forced him
to prioritize the bills sent to his desk. According to the
Governor, SB 356 did not meet his standard as priority
legislation.
AB 682 (Berg), Chapter 550, Statutes of 2007, revised the
written and informed consent standards associated with
testing blood for the human immunodeficiency virus (HIV),
including prenatal HIV testing, to no longer require
affirmative approval prior to administering an HIV test.
Established the new HIV testing consent standard as the
right to decline the test.
SB 699 (Soto), Chapter 20, Statutes of 2006,required health
care providers and laboratories to report HIV cases by the
patient's name rather than code in order to comply with
federal funding requirements.
Arguments in support
AIDS Project Los Angeles supports this measure because they
believe it will bring us closer to a full and accurate
database of people living with HIV/AIDS in the state. They
believe the existing prohibition on electronic reporting
has inhibited the speedy and accurate reporting of HIV
cases. The AIDS Healthcare Foundation believes this bill
will provide additional tools for the state to improve its
HIV surveillance and better ensure our competitiveness for
federal Ryan White CARE Act dollars beginning in the 2012
award cycle. They claim that the state's plan has been to
implement SB 699 and strive for as mature a database as
possible by the 2012 funding award cycle, thereby
minimizing the loss of federal funding.
PRIOR ACTIONS
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Assembly Health: 18-0
Assembly Appropriations: 16-0
Assembly Floor 72-0
POSITIONS
Support: AIDS Project Los Angeles
AIDS Healthcare Foundation
Oppose: None received
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