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Health and Human Services

Health and Human Services

by , / October 31, 1997
Martha L. Fajardo
Interim manager and project director for California Statewide Automated Welfare System Consortium IV.

Terrence A. Maxwell
Executive director of the New York State Forum for Information Resource Management and co-chair of the Devolution Commission for NASIRE.

Carolyn Purcell
Executive director of the Texas Department of Information
Resources (DIR) and the current President for NASIRE.

Larry Singer
President of Public Interest Breakthroughs Inc. and a Research Fellow at Harvard University's John F. Kennedy School of Government.





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By Wayne Hanson
and Maria Fusilero

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QUESTION ONE:
Since welfare reform was enacted, what progress
has been made by states and localities in meeting
the information system requirements?

Martha L. Fajardo
[I]t is clear that tremendous efforts are underway to meet the information system requirements of welfare reform and progress is being made. Will our information systems be fully modified or replaced within the time frames laid out by welfare reform? It is unlikely. But, with prioritization of efforts to meet business needs and requirements, strategic planning and cooperative team work, we will continue to work towards that goal.

Terrence A. Maxwell
State and local governments are attempting to modify their systems to meet the new requirements, but many of the policy decisions which will drive the design of local systems have not been completed.

Carolyn Purcell
I am confident that states and localities will strive to meet the information system requirements in order to minimize disruptions to their clients and taxpayers.

Larry Singer
Human service agencies, as well as the other agencies that will be impacted by new policies, are in the process of understanding, some even re-engineering their programs, in response to new policies. Until the new programs have been fully defined, states and localities are not yet even sure of the information system requirements that the programs will have, and therefore little progress in actually delivering systems has been made to date.
QUESTION TWO:
Welfare reform has time limits on benefits, and various restrictions on eligibility. How will agencies obtain the data necessary to enforce these requirements?

Martha L. Fajardo
Ideally, the infrastructure, functionality and ability to match information with other systems on a nationwide basis would be in place. Because this is not the current status of our systems, we are making use of existing or reasonably obtainable automation and considering alternative methods, such as client self-declaration, to meet the need for information that is not available through automation.

Terrence A. Maxwell
The design of data exchange for nationwide time limits has not been completed. There is disagreement both about design and locus of information systems to support this effort. Decisions about the level of verification regarding many other eligibility restrictions have not been completed, clouding decisions about the level and type of information necessary to determine eligibility.

Carolyn Purcell
It seems clear to me that interstate data exchanges will be required. I hope that new technologies modeled after the Internet emerge as the right way to do this. Rather than building the big database in the sky, we have the technology available to dynamically link to existing databases all over the world. By promulgating some standards for data elements, we can create an ad hoc data exchange that will be flexible and scalable.

Larry Singer
It is still very unclear how states will get the data necessary to meet time lines or to validate eligibility for benefits under new requirements. Since each state, and in some states each county, has the flexibility to define how it will use its TANF block grants, there is no national definition of what welfare is for the purpose of the 5-year lifetime limitation.

QUESTION THREE:
Many large welfare systems appear to be failing.
What's the prognosis?

Martha L. Fajardo
We must focus not only on our short-term automated information system needs, but also consider the age, technical capabilities and maintainability of existing systems so that cost-effective solutions to providing continuing automated support in welfare can be achieved. The potential for system failure is a major driving force in moving forward with the efforts required to do long-range planning and implementation of cost-effective solutions.

Terrence A. Maxwell
Welfare reform requires a new business design, and therefore new welfare systems. While parts of the old systems can be used, they must be integrated with the new business, and become more integrated with each other. This is a huge undertaking, particularly when IS professionals are struggling with issues like Y2K and the shortage of staffing with key competencies.

Carolyn Purcell
Large systems implementations of all types are failing, not just large welfare systems. New methodologies for the development of large systems in manageable modules may provide a partial solution. IT project success is further dependent on mastery of several disciplines -- contract management, project management, cost benefit analysis, negotiation skills, change and risk management. CIO's around the country are working to inculcate these management skills in their IT staff.

Larry Singer
I believe that the prognosis for large welfare systems is not good. The large systems development and deployment efforts are a direct result of federal incentives, [which] ... had all 50 states trying to build the same types of systems at the same time, stretching the vendor communities resources so thin that they were unable to meet demand. Perhaps the good news is that states are now more cautious, and there are many fewer "large systems" being planned.

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QUESTIONS
Follow the questions for the panels responses.

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1. Since welfare reform was enacted, what progress has been made by states and localities in meeting the information system requirements?

2. Welfare reform has time limits on benefits, and various restrictions on eligibility. How will agencies obtain the data necessary to enforce these requirements?

3. Many large welfare systems appear to be failing. What's the prognosis?

4. Will Internet employment listings, such as America's Job Bank, have a significant effect on moving welfare recipients into jobs?

5. How soon will we know if welfare reform is succeeding and what indicators should we look for?

6. Does the cross-matching of databases under welfare reform pose a real threat to privacy and safety, or is it mostly just hysteria?

7. Do you agree with the posting of physician malpractice information on the Internet? Why or why not?

8. Will Americans one day carry a smart card containing their complete medical history, or have that data on their driver's license or ID card?


BACK TO MAIN



QUESTION FOUR:
Will Internet employment listings, such as America's Job Bank, have a significant effect on moving welfare recipients into jobs?

Martha L. Fajardo
Local job listings on the Internet are a valuable tool in assisting clients to obtain work. Nationwide listings raise issues such as a client's ability to relocate in order to obtain jobs. In combination with other resources, these listings enhance the opportunity to expand the job search as required and feasible. Obviously it is important to ensure that access to the information is available and that the listings are current.

Terrence A. Maxwell
Any system which can assist in providing information to support employment will help in the effort to find work. It will not help in the effort to remain employed.

Carolyn Purcell
It should be noted that America's Job Bank attributes itself to the efforts of the states to maximize the exposure of job openings to job applicants. Internet access at various public places including welfare and public employment offices, libraries, schools, and kiosks will provide opportunities for the unemployed to connect with job openings through these kinds of tools. However, America's Job Bank won't provide training, skills, or the education necessary to meet job requirements.

Larry Singer
The easier it is to access job opportunities, the better it is for those seeking jobs. But, and this is a major issue, for many welfare recipients there are complex obstacles keeping them from productive work including: access to transportation, child care, mental health and substance-abuse counseling and others. The listings will help those who are ready to work, but moving many welfare recipients off the roles will require more than just pointing them to job openings.
QUESTION FIVE:
How soon will we know if welfare reform is succeeding
and what indicators should we look for?

Martha L. Fajardo
[W]e must first be clear about what we are expecting to achieve with reform. A cornerstone of reform is to assist clients in obtaining work. The expected outcome has been described as achievement of self-sufficiency. We must determine what that will look like. In assessing the success of welfare reform, we must be cautious in attributing success to reform when other factors, such as a growing economy and increased job availability, may also be contributing factors.

Terrence A. Maxwell
We will know if welfare reform is working when welfare roles stay down and former welfare recipients remain employed in jobs which pay enough to support their families without subsidies. Key indicators to watch are lengths of employment after welfare, changes of income levels among former welfare recipients, and levels of recidivism back to welfare roles.

Carolyn Purcell
I think the answer to this question falls into the policy realm. A prosperous economy is responsible for some of the relief we currently see. I hope the policy makers think long and hard about this, and that the indicators are well defined but not numerous. The ability to link data across states will provide longitudinal data that may be helpful in measuring welfare program performance.

Larry Singer
There are some indicators that it is working already. Reduced caseload levels is one indicator that is already shining through. There are of course many factors affecting caseload levels, including the health of the economy, but some of the reason is certainly the change in attitudes by welfare recipients and case workers both.
QUESTION SIX:
Does the cross-matching of databases under welfare reform pose a real threat to privacy and safety, or is it mostly just hysteria?

Martha L. Fajardo
When cross-matching databases, every effort must be made to ensure that correct matches are made and that the information obtained is correct and used only within the context intended. There have always been issues around privacy in relation to automated information systems. These concerns become valid if we do not use the utmost care to ensure security and appropriate use of the data and provide a process whereby discrepancies or information disputed by the client may be resolved.

Terrence A. Maxwell
Any time we integrate information from formerly disconnected databases we increase the possibility of security problems and privacy invasions. This is not, however, fundamentally a technical problem, but rather a management and policy issue. People breach security and invade privacy, using technology tools, so we must place the proper management and policy safeguards in place to make such intrusions very costly to the intruder.

Carolyn Purcell
I think the recent experience of the Social Security Administration is instructive here. Although they exercised due diligence in pursuit of data security, they missed an important consideration that made the data accessible to more people than its intended audience. Privacy should be a premier concern for all of us who develop systems to implement welfare reform. It is not trivial, and it does not come without planning and deliberate execution.

Larry Singer
There is real potential that by uniting health, criminal records, education and other personal information in one location that the system could be abused. But I believe that so long as we guard against misuse of those files, audit their use and prosecute those who misuse the records, there is not any unreasonable risk.
QUESTION SEVEN:
Does the cross-matching of databases under welfare reform pose a real threat to privacy and safety, or is it mostly just hysteria?

Martha L. Fajardo
As with many other decisions that we make in obtaining services, it is important to have a complete picture of the quality of the services in order to make informed decisions. Making this information available on the Internet is one method of providing access to the consumer. Be it on the Internet, or within any medium, issues of validity, scope and clarity are critical.

Terrence A. Maxwell
Physicians provide life and death services to the public, and as such would be open to public scrutiny via such services as the Internet. However, we should only publish malpractice information that has been proved, rather than alleged, since physicians should have the same due process rights as the rest of us.

Carolyn Purcell
If malpractice is alleged it should not be made available in any case. If it is proven, I think it is already accessible through the court systems. Regardless, there is a lot of interest in providing information to health-care consumers to enable them to make informed judgements about their health care.

Larry Singer
Yes. What better protection for consumers of medical care than information about providers? I think there should be some analysis of the information by an informed third party, so that a consumer can understand its impact on their own choices better. I also believe that it is important that the physician can post with that information, statements about his/her capabilities and strengths. The more good information the better.
QUESTION SEVEN:
Will Americans one day carry a smart card containing
their complete medical history, or have that data on
their driver's license or ID card?

Martha L. Fajardo
The technology to use a smart card to record and retrieve medical history or other information will allow this to be accomplished. The real question is not can we, but will we. Serious consideration of cost and achievable benefits is required. What need will this ability meet or problem will this resolve and is this the best solution? If the answer is yes, than we must also consider and resolve issues around the use and abuse of this information.

Terrence A. Maxwell
I don't know, it depends on whether you envision such a system as mandatory, part of a national health-care initiative, or as part of the services and requirements of particular health-care organizations. The latter scenario is more likely than the former. This will be decided in the marketplace.

Carolyn Purcell
I think there are two possible scenarios here. One, where a smart card and the necessary infrastructure are sufficiently ubiquitous to warrant a mobile medical record. The other is the emergence of a network sufficiently robust to offer an aggregate medical record on demand, regardless of where the patent has been treated in the past. Both technologies are advancing rapidly. The smart card is already used in applications like you describe, but in a limited scope.

Larry Singer
No, I don't think so. There will be more reliable ways to access that information than by smart card. Once we have the capability to access information via network resources, and to have strong positive identifiers (such as biometrics) there will be no reason to use smart cards, which will be difficult to keep current, and can be less secure than sophisticated networks.


QUESTIONS
Follow the questions for the panels responses.

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1. Since welfare reform was enacted, what progress has been made by states and localities in meeting the information system requirements?

2. Welfare reform has time limits on benefits, and various restrictions on eligibility. How will agencies obtain the data necessary to enforce these requirements?

3. Many large welfare systems appear to be failing. What's the
prognosis?

4. Will Internet employment listings, such as America's Job Bank, have a significant effect on moving welfare recipients into jobs?

5. How soon will we know if welfare reform is succeeding and what indicators should we look for?

6. Does the cross-matching of databases under welfare reform pose a real threat to privacy and safety, or is it mostly just hysteria?

7. Do you agree with the posting of physician malpractice information on the Internet? Why or why not?

8. Will Americans one day carry a smart card containing their complete medical history, or have that data on their driver's license or ID card?



November Table of Contents
Wayne Hanson

Wayne E. Hanson served as a writer and editor with e.Republic from 1989 to 2013, having worked for several business units including Government Technology magazine, the Center for Digital Government, Governing, and Digital Communities. Hanson was a juror from 1999 to 2004 with the Stockholm Challenge and Global Junior Challenge competitions in information technology and education.