Vital records jurisdictions have made significant progress in improving the timeliness and quality of vital statistics through the implementation of electronic systems. For example, the National Center for Health Statistics (NCHS) has completed funding of remaining jurisdictions seeking support for the development and implementation of electronic birth registration systems (EBRS), and the last remaining states are expected to adopt the 2003 Standard Certificate of Birth, which is a much more robust source of public health data than the older 1989 certificate, by the end of 2015.
For death registration, 45 jurisdictions have implemented electronic death registration systems (EDRS) to date. The implementation of EDRS is in progress in four vital records jurisdictions, and another is in the planning stages. Nevertheless, even in states with an EDRS, most states continue to rely to some extent on hybrid drop to paper records, a practice that compromises the accuracy, timeliness, interoperability, and security of these data and the records themselves. For example, a recent assessment by NAPHSIS with data reported by the jurisdictions finds that only a handful of states are "fully electronic," that is, more than 75 percent of deaths reported through EDRS by funeral directors and medical certifiers—physicians, coroners, and medical examiners. And of course, 75 percent is still not 100 percent. Within jurisdictions with electronic systems, many haven't the resources to expand technical assistance to, and maximize electronic death reporting by, funeral directors and physicians, and some early adopters lack the resources to modernize their systems to keep pace with new technology.
A recent article from Pew Charitable Trust's publication "Stateline" explores the challenges states face in assuring complete and accurate reporting of cause of death and their efforts to help health data providers do better. I spoke at length on background with reporter Michael Ollove as he prepared his story, "To Make Better Policy, States Seek Better Death Certificates." Special thanks to jurisdictions who helped along the way, as well.
In the article, Ollove notes that incomplete cause of death information has important implications for public health:
On the best certificates, the information is accurate and complete. That would mean, for example, that the death certificate would say not only that someone had died of a drug overdose, but that the drug had been heroin. If the departed had died of cardiac arrest, the certificate would say that death resulted from a heart attack and it would disclose that the person had been a lifelong smoker and overweight.
Unfortunately, many death certificates are incomplete or inaccurate. When multiplied across thousands and thousands of cases, such gaps can translate into a faulty understanding of mortality in the United States, and affect how money is spent on research and prevention.
Ollove spends time describing the complexities of death data reporting, including the reporters. He also drills down into where the problems arise in the data flow from medical certifiers to vital records jurisdictions:
For people who die a "natural" or illness-related death (the vast majority), the last medical provider attending the deceased—usually a physician, a physician's assistant or a nurse—fills out the death certificate. But most physicians aren't trained how to fill out the certificates correctly and comprehensively…
It doesn't help that in most cases, they must fill them out without the benefit of an autopsy, which is the most definitive method of determining the cause of death, but costs several thousand dollars.
As a result, many death certificates do not supply the level of specificity that would help medical researchers in their investigations into the prevalence and causes of deaths.
The details matter.
Complete and correct statistics on death are essential for understanding fatal diseases and injuries, said Marcus Nashelsky, president of the National Association of Medical Examiners and a professor of pathology at the University of Iowa. "Research using local, regional, state or national death statistics is a vital component of public health activities—ranging from education and prevention strategies for heart disease, diabetes, infectious diseases, injuries, and so on."
Ollove concludes that electronic systems—and their consistent use among medical certifiers—is the key to timelier and higher quality cause of death data, and highlights the efforts of NCHS and Iowa, Alabama, and Utah in improving EDRS usage among physicians, coroners, and medical examiners.
With progress near complete on the implementation of EDRS nationwide, NAPHSIS is turning its attention to encouraging lawmakers to invest in efforts that will improve system usage among medical certifiers. The systems themselves cannot produce more, better, and faster data if there is not widespread adoption among funeral directors, physicians, medical examiners, and coroners. An important part of improving EDRS uptake among these stakeholders is answering the question, "what's in it for me?" And an important part of answering that question is understanding their needs and barriers for adoption. Articles such as Ollove's are a positive first step in building awareness about the value of quality death data and why medical certifiers should care.
For more information about vital statistics and efforts to improve them, please click here.