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February 6, 2022
Looking for Out-of-County Discharge Data in the Underwear-and-Socks Drawer
Health Department Busted for Violating FOIA Laws
by Patrick Monette-Shaw
“Help, I lost my patient!”
That painful cry from a certified nursing assistant frantically searching for a patient she had lost track of when I worked at Laguna Honda Hospital for a decade is still painful to remember, even though it would have been somewhat comical to witness at the time had it not involved patient safety.
But what happens when a Public Health Department loses track of its patients who have been dumped (discharged) out-of-county?
That’s nowhere near “comical.” In my eyes, it borders on criminal neglect, intentional obstruction, or governmental incompetence.
San Francisco’s Department of Public Health claimed way back on September 16, 2020 that its new replacement Electronic Healthcare Records (EHR) database — named Epic — that was rolled out and went live on August 3, 2019 and has cost the City at least $167.4 million, does not track patients discharged out-of-county. Wait! What?
I suspected then DPH’s claim was probably an outright lie, however unintentional. Ironically, it was an epic-sized lie. The Westside Observer first reported on this in June 2021.
It was a brazen, bizarre claim, because DPH had been extracting out-of-county discharge data from its SFGetCare database and its previous EHR database — the Invision/LCR system from Siemen’s Corporation — for at least eight years since 2013, and had provided me with retrospective data dating all the way back to July 1, 2006. DPH responses to subsequent records requests I have placed over the years revealed that at a minimum 1,746 San Franciscans have been dumped out-of-county from SFGH and Laguna Honda Hospital and a handful of other private-sector hospitals in San Francisco.
It took me over a year before I could prove it was a lie, until I finally won a Sunshine complaint before San Francisco’s Sunshine Ordinance Task Force (SOTF) on October 6, 2021, which ruled in my favor that the records are public records and must be released under California Public Records Act (CPRA) §6253.9(a)(2) that specifically requires local agencies to extract aggregate data from databases they maintain.
According to testimony that noted geriatrician Teresa Palmer, MD has provided to San Francisco’s Board of Supervisors, obtaining out-of-county discharge data statistics is an integral part of evidence-based processes of looking at the gaps in healthcare services, and various types of severe healthcare facility shortages in San Francisco, in order to help improve citywide healthcare planning.
DPH’ “Big Lie” Led to Sunshince Complaint
As I periodically have, I placed a new records request with SFDPH on July 6, 2020 to obtain out-of-county discharge data for the period of January 1, 2020 to June 30, 2020. After fighting with DPH for months over the delayed response to my records request, DPH suddenly claimed on September 16, 2020 that its “Epic” database “doesn’t track out-of-county discharges.”
On May 4, 2021 I finally and belatedly filed a formal Sunshine Ordinance Task Force complaint over DPH’s failure to provide aggregate out-of-county discharge data as it had previously extracted and provided for years. On May 7, 2021 the Task Force’s Administrator notified DPH that it was required to respond in writing within five days to the allegations I had raised in the Complaint. DPH never responded in writing, let alone within five days.
On June 16, 2021 Epic Systems Corporation’s Media Relations Department responded to a media inquiry I had placed in my role as a long-time columnist for the Westside Observer newspaper. Epic’s Media Relations Department revealed out-of-county discharge data I had requested from DPH is, in fact, contained in structured database fields in Epic’s “Patient Flow” module.
Epic’s Media Relations Department informed me that Epic’s standard configuration (i.e., its “base” enterprise package) includes discharge destinations/dispositions, including the name of the City discharged to in Epic’s “Patient Flow” module. (If the city discharged to ≠ “San Francisco,” it’s an out-of-county discharge.)
After consulting with its in-house subject-matter experts, Epic’s Media Relations Department also confirmed that the Patient Flow module includes database fields for Discharge Disposition — the broad category of where a patient is discharged to, e.g., returned to home vs. discharged to a skilled nursing facility, a rehabilitation facility, a Long-Term Care Acute Hospital (LTCAH), or perhaps a Residential Care Facility for the Elderly (RCFE) — and the actual discharge location (including the name, address and City, phone number, and type of facility). A facsimile of a sample Epic screen I created (shown here) illustrates what an Epic Discharge Note screen looks like.
On July 21, 2021 I placed a records request to DPH seeking information on who at DPH had determined Epic doesn’t track out-of-county discharges. On August 2, 2021 I received a thread of 29 e-mails from DPH, but the e-mail exchanges reveal DPH’s information systems staff were stuck on — barking up the wrong tree — quibbling about the technical difficulties they might face trying to track the zip codes patients were discharged to. That, too, was patently ridiculous because the discharge note screen in Epic clearly shows Epic contains a structured database field that captures the name of the City any given patient is discharged to, including the facility name, type of facility, and level of care (medical or skilled nursing level of care) that the new facility would need to provide.
Rather than struggling with zip codes, DPH’s I.T. staff should only need to look at the name of the City any given patient is discharged to. Because if the name of the City is not “San Francisco,” then ergo, the patient was discharged out-of-county. It couldn’t be any simpler. Why DPH staff chose to focus on the zip code database field, when they should have been looking for the name of the city in the City database field in the Patient Flow discharge notes module, isn’t known. It’s kind of like looking for a cashmere sweater in your socks and underwear drawer. Or like looking for your checking account balance in your Instagram or TikTok account. (Looking for information in the wrong place rarely yields results!)
On July 20, 2021 SOTF’s Complaint Committee held a preliminary jurisdictional hearing on my complaint. The Complaint Committee ruled: 1) That the records requested were and are, in fact, public records and the complaint was within the Task Force’s jurisdiction, 2) That DPH provide to the Complaint Committee answers to three remaining questions the Committee had about the complaint within a two-week period dating from July 20 from a knowledgeable subject-matter expert familiar with DPH’s databases, and 3) That my complaint be referred to the full Sunshine Task Force for a hearing on the merits of the complaint.
Once again, DPH did not respond within two weeks (or ever, as of February 6, 2022) to the Complaint Committee’s request a knowledgeable subject-matter expert provide additional information the Complaint Committee had requested on July 20.
Sunshine Task Force Rules SFDPH Violated Two Laws
On October 6, 2021 the full Task Force held a hearing on the merits of my Complaint. Again, DPH did not send a knowledgeable person familiar with the Epic database as a subject matter expert, and instead sent Public Information Officer Cristina Padilla, who was unable to answer three remaining questions Task Force members still had about the complaint; Padilla claimed she would ask DPH subject matter experts and would provide answers to the full Task Force. Padilla was also unable to answer whether DPH staff had requested technical assistance from Epic Corporation on how to locate and extract the requested data. It’s thought Ms. Padilla also never provided any follow-up answers she may have gotten (if any) from DPH’s subject matter experts to the Task Force, before she, too, suddenly left her position at SFDPH.
Prior to taking a roll call vote on October 6 on the motion a SOTF member had introduced finding DPH had violated four provisions in the Sunshine Ordinance, the Task Force took public comment on the motion on the floor. Teresa Palmer, MD testified in support of the motion. Palmer, a noted geriatrician, testified that she has worked with and is very familiar with Epic, having used it at Kaiser, at UCSF, and at Sutter. She further stated she’s aware Epic contains discharge disposition locations, there is data entry in Epic about discharges and locations of discharge, and the data can be found by writing a proper database query.
Given my own experience writing ad hoc database queries while employed at Laguna Honda Hospital assisting with developing its Rehabilitation Services Department’s home-grown Microsoft Access database tracking patient’s scheduled and required physical assessment forms, scheduling patient’s functional maintenance exercise sessions to prevent their potential physical decline, scheduling patients for other rehab clinician therapy appointments, and track Medi-Cal billing and reimbursement information to generate revenue for the hospital, I know this doesn’t involve rocket science. Now 20 years later, I distinctly remember having written a database query and formatted a “Discharge Outcomes Report” way back in 2001 for the LHH Rehab Department’s Community Re-integration Program, a report that included details on the destinations patients were discharged to, the types and level social services they would need given their specific circumstances to support them post-discharge, and which cities patients were discharged to.
I believe a proper database query to extract data from Epic would be very simple and take very little time for an experienced DPH information systems professional to write. If I could do it at LHH 20 years ago, then Epic I.T. professionals at DPH can surely write such ad-hoc queries now, given advances in computer technology during the past two decades.
There you have it: Both clinicians like Dr. Palmer who have worked with Epic, and Epic Corporation’s own Media Relations Department, have acknowledged Epic clearly contains the locations of cities patients are discharged to, despite DPH’s lie that Epic is incapable of tracking out-of-county discharges. Why DPH’s staff are barking up the wrong tree and confounding the issue by trying to figure out zip codes is simply comical. It’s clear DPH staff are looking in the underwear and-socks drawer to find that elusive cashmere sweater — along with the out-of-county discharge data!
The Task Force ruled seven-to-zero in my favor on October 6, 2021 ruling that DPH had violated Administrative Code Sections §67.21(b), for incomplete records production (and essentially the “timeliness of response” issue); §67.21(c), for failing to provide me with assistance; §67.27, for failing to provide justification for redactions; and §67.22(b), for not sending a knowledgeable (subject-matter expert) representative to either of SOTF’s two hearings on my complaint.
The Task Force also ordered DPH to produce the remaining outstanding records that haven’t been produced since first requested on July 6, 2020 within five days after the Order of Determination would be issued, and referred the complaint to the Task Force’s Compliance and Amendments Committee for further monitoring.
Unfortunately, it took months before the SOTF issued its long delayed Order of Determination (O.D.) published January 31, 2022 — four months after I won my Sunshine complaint on October 6, 2021 — finally ordering DPH to produce the improperly withheld records within five days, ostensibly no later than February 8, 2022.
We’ll have to wait to see if DPH complies with the O.D. and resumes producing the records it had long provided, but has now long withheld improperly. As a “pink” person, I’m not going to hold my breath because I’m afraid of turning blue in the face while waiting.
SOTF’s O.D. essentially found that DPH had violated two laws: Both California’s FOIA law — the California Public Records Act (CPRA) — and San Francisco’s Sunshine Ordinance. As noted above, CPRA §6253.9(a)(2) requires local government agencies across the State to extract aggregate data from electronic databases they maintain, like Epic, since they are essentially public records. The SOTF has authority under San Francisco’s Sunshine Ordinance to cite violations of our local Ordinance, California’s Public Records Act, and California’s Brown Act — the latter two of which Mayor London Breed can’t suspend, even during a COVID-style or other local emergency.
Legislation Requiring Hospitals Report Out-of-County Discharge Data
On November 9, 2021 Supervisor Ahsha Safai’s introduced a draft Ordinance to require public- and private-sector hospitals operating in San Francisco report a limited amount of data about out-of-county discharges, but only for patients being discharged out-of-county who need sub-acute level of care. Safai’s Ordinance was assigned to the Board of Supervisor’s Public Safety and Neighborhood Services (PSNS) Committee.
The first PSNS hearing on Safai’s Ordinance is scheduled for February 10, 2022 at 10:00 a.m.
Medical sub-acute level of care is for medically complex, high-maintenance patients, including those who are ventilator- or tracheostomy-dependent and who need close observation and nursing care long-term. It’s best that a sub-acute SNF unit be located in a hospital-based setting to provide rapid access to an ICU if a patient’s health deteriorates rapidly. These facilities are separate and distinct from patients who need sub-acute level of care in psychiatric facilities.
While Safai’s draft legislation may be a commendable and long-overdue first effort, it’s woefully inadequate as initially written and introduced. And his legislation totally ignored previous testimony from community- and healthcare-advocates about what the legislation should include.
Along with other health care advocates including Dr. Palmer and others, I have been requesting this legislation since at least 2018. Indeed, for the Board of Supervisors PSNS Committee hearing on September 26, 2019, testimony was presented for agenda item #4 titled “Hearing – Sub-Acute Care in San Francisco” [File #190725].
For instance, San Franciscans for Healthcare, Housing, Jobs and Justice (SFHHJJ, or alternatively H2J2) submitted written testimony to the PSNS Committee dated June 18, 2019 urging that the Health Commission and Board of Supervisors:
“Direct the Department of Public Health to collect to the maximum extent feasible from all acute care hospitals and SNF facilities located within San Francisco comprehensive and specific data and information, for the past three years and prospectively, about all San Francisco residents who have been discharged to out-of-county facilities to receive SNF, Subacute SNF care, or RCFE care; to support the enactment of legislation by the Board of Supervisors to mandate all acute care hospitals and SNF facilities in San Francisco to provide such data and information; to prepare and publicly publish, within four months a written report covering all such data and information collected …”.
Of note, H2J2 specifically requested that SFDPH collect from all acute care hospitals and all SNF’s, and obtain data for the previous three to five years to provide historical context about just how severe the out-of-county discharge problem is.
We need an ordinance assuring that SFBOS will receive regular reports about how many San Francisco residents are discharged out of county from acute hospitals and acute psychiatric facilities due to the lack of services and severe lack of appropriate facilities in San Francisco.
The importance of collecting out-of-county discharge data goes way beyond Safai’s single focus on the issue of just requiring data reporting about the number of patients discharged out-of-county who need sub-acute SNF level of care. How can we know if we are properly planning to care for the longer term physical and mental health issues of our senior citizens and people with disabilities if we have no idea who — and how many people —are getting dumped out of county for sub-acute SNF, psychiatric, and all other types of long term care? This is an interest that seniors, disability, and mental health advocates all agree on.
This much-needed legislation would go a long way toward helping collect evidence-based data for looking at the gaps in services, improving citywide healthcare planning, and help identify the types of in-county facilities that are in severely short supply to assist in finding sources of funding to build out additional in-county capacity. It would also go a long way towards helping City officials craft San Francisco’s Health Care Master Services Plan, which identifies current and projected needs for health careservices for San Franciscans, with a focus on vulnerable populations.
Dr. Palmer has testified this information is easy to collect with modern hospital electronic healthcare records systems. She notes SFDPH’s past attempts were unable to get voluntary cooperation on reporting out-of-county discharge data from private-sector hospitals, even though those hospitals have state-of-the-art EHR systems that could be easily mined to collect and report the data. Indeed, SOTF’s ruling DPH has refused to provide out-of-county discharge data for now two full years for records dating back to January 2020 illustrates that SFDPH, itself, has been less than cooperative providing FOIA-requested information on a regular basis about SFGH’s own out-of-county discharge data.
CPMC/Sutter closed the last remaining sub-acute SNF facility in the city at St. Luke’s Hospital in 2018 after stopping all new admissions from only its affiliate CPMC hospital chain for at least a year before then, so all new patients — even from CPMC’s affiliate hospitals who need sub-acute SNF level of care — were forced to leave the City and County of San Francisco for at least the past four years. But it’s much worse than that, because CPMC stopped admitting patients from any other San Francisco hospital way back in 2012.
That means it has now been a full decade since patients needing sub-acute SNF level of care have endured being dumped out-of-county. No other county in California has zero in-county sub-acute facility capacity in their jurisdictions, as San Francisco now has.
And four years after CPMC shut down any new admissions to it’s temporary replacement sub-acute SNF moved to CPMC’s Davies Hospital campus, San Francisco has still not identified and opened yet any of the 70- to 90-projected sub-acute SNF beds anywhere else in the City that DPH has documented to the Board of Supervisors the City desperately needs. Efforts to open any new sub-acute SNF beds in San Francisco have stalled for four years, since former-Director of Public Health Barbara Garcia — who had been working to solve the problem — was unceremoniously fired.
Recommended Amendments to Legislation
As Dr. Palmer recently testified to the PSNS Committee, hospital discharges to sub-acute SNF facilities “are less than 1% of total hospital discharges.” Clearly, Safai’s first draft of a proposed Ordinance requiring hospitals to report data only on the number of discharges to out-of-county facilities to receive sub-acute level of care is going to miss the vast universe of discharges to facilities that provide levels of healthcare other than sub-acute SNF level of care. The legislation should not apply only to patients needing sub-acute care.
Safai’s legislation must be vastly amended — or replaced entirely with a revised Ordinance containing a much broader scope — while the Board of Supervisors has this long-overdue opportunity to do so.
Particular recommendations include, but are not limited to:
Please contact the full Board of Supervisors and members of its PSNS Committee and urge them to rapidly expand, support, and pass this urgently needed legislation.
Monette-Shaw is a columnist for San Francisco’s Westside Observer newspaper, and a member of the California First Amendment Coalition (FAC) and the ACLU. He operates stopLHHdownsize.com. Contact him at email@example.com.