NAPHSIS Provides Written Testimony to the US Senate Committee on Homeland Security & Governmenta
Mr. Chairman and Members of the Committee—
The National Association for Public Health Statistics and Information Systems (NAPHSIS) welcomes the opportunity to provide the Senate Committee on Homeland Security and Governmental Affairs this written statement for the record on vital records and specifically, the reporting and electronic verification of deaths. Established in 1933, NAPHSIS is a non-profit membership organization representing the 57 vital records jurisdictions that collect, process, and issue vital records in the United States, including the 50 states, New York City, the District of Columbia and the five territories. NAPHSIS coordinates and enhances the activities of the vital records jurisdictions by developing standards, promoting consistent policies, working with federal partners, and providing technical assistance.
Vital Records Serve Important Civil Registration Function
Vital records are permanent legal records of life events, including live births, deaths, fetal deaths, marriages, and divorces. Their history in the United States dates back to the first American settlers in the mid-1600s, and in England as early as 1538.1 More than 8 million vital events were recorded in the United State in 2009.2
Many organizations and millions of Americans use these records—or certified copies of them—for myriad legal, health, personal, and other purposes.
Birth certificates provide proof of birth, age, parentage, birthplace, and citizenship, and are used extensively for employment purposes, school entrance, voter registration, and obtaining federal and state benefits (e.g., Social Security). Birth certificates are the cornerstone for proving identity, and as breeder documents are thus used to obtain other official identification documents, such as driver licenses, Social Security cards, and passports.
Death certificates provide proof of date of death, date and place of internment, cause and manner of death, and are used to obtain insurance benefits and cease direct benefit payments, transfer property, and generally settle estates.
Data providers—for example, hospitals for birth information and funeral homes, physicians, and coroners for death information—submit birth and death data to the vital records jurisdictions so that the vital event can be reviewed, edited, processed and officially registered. The jurisdictions are then responsible for maintaining registries of such vital events and for issuing certified copies of birth and death records.
The federal government does not maintain a national database that contains all of this information. Consistent with the constitutional framework set forth by our founding fathers in 1785, states were assigned certain powers. The 57 vital records jurisdictions, not the federal government, have legal authority for the registration of these records, which are thus governed under state laws. The laws governing what information may be shared, with whom, and under what circumstances varies by jurisdiction. In most jurisdictions, access to death records is restricted to family members for personal or property rights, to government agencies in pursuit of their official duties, or for research purposes. In other jurisdictions, release of death record information may be subject to less restrictive limitations; and in a few states identifiable information from death certificates is publicly available.
In an example of effective federalism, the vital records jurisdictions provide the federal government with data collected through birth and death records to compile national health statistics, facilitate secure Social Security number (SSN) issuance to newborns through the Enumeration at Birth (EAB) Program, and report individual's deaths.3,4 For example, the National Center for Health Statistics obtains de-identified vital events data from the jurisdictions to compile national data on births, deaths, marriages, divorces, and fetal deaths. These data are used to monitor leading causes of death and our nation's overall health status, develop programs to improve public health, and evaluate the effectiveness of those interventions. In addition, the jurisdictions provide the Social Security Administration (SSA) with fact of death information—including the decedent's name, date of birth, date of death, and SSN as filed with the jurisdiction—for use in the administration of the programs established under the Social Security Act to reduce erroneous payments to deceased persons receiving Social Security benefits.
State Vital Records are the Gold Standard
Vital records collected and maintained by the 57 jurisdictions are the only original and official record of someone's death. They are the "gold standard," providing the most accurate, reliable, and complete information about death.
SSA also sometimes receives reports of deaths from family members and funeral directors separate from the official death records that come from the vital records jurisdictions. This unofficial and incomplete death information is then released to the public through the Death Master File (DMF). Once public, it's used by banks, benefit plans, credit agencies, and some federal agencies to clear various lists and stop payments for those believed dead. Unfortunately, this DMF does not include all deaths. And, sometimes important information like SSN and even the name of decedent is incorrect when family members and funeral directors unofficially report directly to SSA. The result is that some of the information in the DMF is right, but some of it is wrong and the file itself is definitely incomplete. When banks, benefit plans, federal agencies, and others use this incomplete and inaccurate file to terminate accounts, it can have severe consequences for people who are in fact, still alive. It also has serious implications for identity theft and fraud when individuals are in fact deceased but not represented in the DMF.
It is important to note that the death records that the vital records jurisdictions share with SSA are not released publicly in the DMF because—while an individual does not have a federal right to privacy after death—in many states individuals do maintain that right to privacy. Official death records are governed by state and not federal laws, thus these records cannot be released publicly by the federal government.
Electronic Systems Enhance Death Reporting Accuracy, Timeliness, and Security
A death certificate contains both demographic (personal) information and medical (cause of death) information about the decedent. Over the last century in the United States, death certificate completion has mostly been the responsibility of funeral directors, with physicians, medical examiners, and coroners providing cause and manner of death information. Once the demographic data and medical data are complete, the death certificate is then filed with the vital records office. In some states, the death certificate is filed at the local vital records office, and then sent to the state office; in other states the death certificate is filed directly with the state office. The data are then reported to state and federal entities for public health and administrative purposes.
Manual certificate preparation, including the personal delivery of records to physicians for signature, extensive and costly travel by funeral director staff to file certificates, and labor-intensive processing of paper records locally and at the state vital records offices, all contribute to slowing registration and delaying the availability of death data.
Furthermore, even though each state has laws requiring the registration of death records within a specific time period, a significant number of certificates are not appropriately filed, may contain incorrect or inconsistent entries, or are not finalized until many weeks after the death occurred. In addition, incomplete death certificates and coroner cases may take weeks or even months to resolve. These late-filed and/or partially completed death certificates are not generally acceptable for use by family members, nor do they meet federal administrative needs or satisfy the information demands of local, state and federal agencies.
In January 1997, the report, Toward an Electronic Death Registration System in the United States: Report of the Steering Committee to Reengineer the Death Registration Process was prepared by a task force of representatives from federal agencies—the National Center for Health Statistics and SSA—as well as NAPHSIS and other professional organizations representing funeral directors, physicians, medical examiners, coroners, hospitals, and medical records professionals. The Committee examined in detail the feasibility of developing electronic death registration in the United States. The conclusion of the report was that the introduction of automated registration processes in the states is a viable means to resolve several historical and continuing problems in the process of death registration.
The advent of technology has facilitated the automation of death registration and reporting, which is the key to addressing these long-standing issues related to accuracy, security, and timeliness of data. To date, 44 vital records jurisdictions have implemented electronic death registration systems (EDRS) to better meet the public health and administrative death information needs. There are thirteen jurisdictions (eight states and the five territories) without an operational EDRS, but four of the states are expected to be online in 2015. Three states have not started any planning, and one state has completed its planning phase but does not have adequate funds to proceed with development of an EDRS system (see Appendix 1).
For jurisdictions using an EDRS, death reporting is:
More Accurate and Complete. An EDRS ensures that all required fields are completed before the death certificate is filed using built-in, real-time edits and crosschecks on the data entered. For example, it can ensure that the individual recording the data does not inadvertently indicate that a two-year old decedent has a college education. For purposes of SSA, an EDRS incorporates a real-time check of the decedent's SSN against the SSA data files to ensure accuracy of the SSN recorded before the death certificate is registered and filed.5
More Timely. An EDRS allows different death data providers, e.g. the funeral director and physician, to complete the death record concurrently from their computers. It eliminates the need for a paper death certificate to be hand-delivered by funeral home staff to the physician's office for completion. Automatic reminders and workflow prompts are built into an EDRS so a physician is notified via e-mail when a death certificate is awaiting completion. Once the electronic death record is complete, state vital records offices may submit fact-of-death records to SSA daily (Monday-Friday).
More Secure. An EDRS requires a distinct username and password for each death data provider to access the death records. An EDRS also has built-in audit trails to monitor the users' activity.
While vital records jurisdictions have made great strides in implementing EDRS, there is still much to be done. In most of the 44 vital records jurisdictions that have implemented EDRS, not all physicians and funeral directors submit death records electronically. Implementation of the EDRS in the vital records office is just one piece of the puzzle. To be effective, all data providers—funeral homes, hospitals, physician offices, nursing homes, hospices, coroners and medical examiners —also must use the system. These users must then adjust their workflow processes and make themselves available for training. From start to finish, the full rollout of an EDRS may take years and a significant financial commitment on the part of the state health departments and the death data providers themselves. The lack of adequate resources—both financial and human capital—are the biggest barriers to more widespread EDRS adoption. This is particularly true for death data providers who do not report a significant number of deaths each year, and therefore do not see the value of the required investments.
Between 2001 and 2006, SSA provided funding to many vital records jurisdictions to help support their EDRS implementation efforts. Based on a late-2008 survey of the vital records jurisdiction, NAPHSIS estimates that at least $20 million is needed to complete EDRS implementation in all 57 vital records jurisdictions, to increase use of EDRS among death data providers, and to modernize the systems of early adopters that lack the resources to upgrade their systems to keep pace with new technology. Some additional funding may be required on an annual basis to facilitate death data provider training.
Preventing Fraud, Identity Theft through Electronic Verification of Vital Events (EVVE)
Because vital records are essential legal documents linked to identity, and because criminals need new identities, vital records are sought out and used to commit fraud, identity theft, and even terrorist activities.6, 7,8 It is therefore essential that birth and death records be protected, and that federal and state agencies have the ability to verify the source data contained therein. In addition, the ability to quickly catch and stop the fraudulent use of Social Security and other public benefits would reduce wasteful spending, and restore public trust in government.
Recognizing the need to verify benefit eligibility in a timely and secure fashion, SSA awarded NAPHSIS funding in 2001 to develop and implement the Electronic Verification of Vital Events (EVVE) system. EVVE is an online system that verifies birth and death certificate information. It provides authorized users at participating agencies with a single interface to quickly, reliably, and securely validate birth and death information at any vital records jurisdiction in the country, circumventing the need for a national database of such information. In so doing, no additional personal information is divulged to the person verifying information—EVVE simply relays a message that there was, or was not a match, with the birth and death records maintained by the state, city, or territory. In addition, EVVE has the capability to provide an indication that an individual is deceased if the birth record has been flagged. This eliminates a key loophole whereby thieves use a valid birth certificate of a deceased individual to create a new identity.
Today, SSA uses EVVE to verify proof of age and place of birth as a program policy requirement before issuing Social Security benefits. Other federal and state agencies—Department of State Passport Fraud Managers and Diplomatic Security, the Office of Personnel Management (OPM), Federal Bureau of Investigation regional offices, Department of Homeland Security U.S. Citizenship and Immigration Services, and some state Medicaid offices and Departments of Motor Vehicles—are currently using EVVE to verify or certify identification and authenticity of birth certificates. These users are enthusiastic about the EVVE system, citing its ability to:
Provide protection against the potential use of birth certificates for fraudulent activities.
Improve customer service by facilitating rapid access to accurate and verifiable vital record data in real-time.9
Safeguard the confidentiality of birth and death data.
Offer a secure mechanism for communication between agencies and vital records offices via the Internet.
Easily integrate with current legacy systems that the federal or state agencies may already be using, and for serving as a user-friendly interface for agencies that seek a stand-alone query system.
While EVVE is currently being used to verify deaths in only a few jurisdictions, NAPHSIS continues conversations with interested public and private sector users about their death information needs and the system's capability as a viable DMF alternative. NAPHSIS and the jurisdictions have made significant progress in enhancing EVVE to address these users' need for more accurate, reliable, timely, and complete death record information. Specifically, as of March 2015, EVVE is installed and ready to accept birth queries in 54 jurisdictions—a process that has taken nearly 15 years with support from both SSA and the Department of Homeland Security. NAPHSIS is working to install EVVE in the remaining three jurisdictions, with one jurisdiction currently in progress. 10 Today, EVVE has been upgraded to accept death queries in 40 of these jurisdictions—a process that has taken only three years without any financial support for the jurisdictions or NAPHSIS from potential public or private sector users (see Appendix 1).
Despite EVVE's security, speed, and ease of use, the system is only as good as the underlying data infrastructure upon which it relies. Digitizing paper-based birth and death records, then cleaning and linking those records, will provide for secure, reliable, real-time identity verification using EVVE. For example, there are cases where an individual has assumed a false identity by obtaining a birth certificate of a person who has died. Therefore, it is important that all jurisdictions' death and birth records be linked to flag individuals who are deceased and identify fraudulent birth documentation.
The vital records jurisdictions' efforts to digitize, clean, and link vital records have been hindered by state budget shortfalls. In short, the jurisdictions need help to complete building a secure data infrastructure. Specifically, resources are needed to help vital records jurisdictions digitize their birth records back to 1945, include death records back to 2000, clean these data to support electronic queries, and link birth and death records. Additional resources would also significantly enhance the ability of NAPHSIS and the jurisdictions to expedite progress in the implementation of EVVE nationwide, and in building system capacity to accept death queries from public and private sector users.
NAPHSIS appreciates the opportunity to submit this statement for the record and looks forward to working with the Committee. If you have questions about this statement, please do not hesitate to contact NAPHSIS Executive Director, Patricia Potrzebowski, Ph.D., at email@example.com or (301) 563-6001. You may also contact our Washington representative, Emily Holubowich, at firstname.lastname@example.org or (202) 484-1100.
U.S. Vital Statistics System: Major Activities and Developments, 1950 – 1995. Centers for Disease Control and Prevention, National Center for Health Statistics. Feb 1997. Available online at: http://www.cdc.gov/nchs/data/misc/usvss.pdf
National Center for Health Statistics, Centers for Disease Control and Prevention. Available online at http://www.cdc.gov/nchs/data/databriefs/db16.htm and http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_25.pdf
The National Center for Health Statistics, Centers for Disease Control and Prevention, Department of Health and Human Services purchases data from the vital records jurisdictions through the Vital Statistics Cooperative Program to produce national vital statistics and for research purposes as part of the National Death Index.
The EAB program allows parents to complete applications for SSNs for their newborns as part of the hospital birth registration process. About 96 percent of SSNs for infants are assigned through the EAB process.
Among the 44 vital records jurisdictions with EDRS, five states have not integrated the capability to verify SSN into their EDRS: Maine, Maryland, New York, Pennsylvania, and Wyoming. However, Maine and Wyoming are expected to have this capacity in 2015.
The 9/11 Commission Report, Final Report of the National Commission on Terrorist Attacks upon the United States, July 2004, p. 390.
Department of Health and Human Services, Office of Inspector General, Birth Certificate Fraud, Sept. 2009 (OEI-07-99-00570).
Government Accountability Office, Department of State: Undercover Tests Reveal Significant Vulnerabilities in State's Passport Issuance Process, Mar. 2009 (GAO-09-447) and State Department: Undercover Tests Show Passport Issuance Process Remains Vulnerable to Fraud, July 2010 (GAO-10-922T)
OPM conducted a pilot in parallel with their manual voucher process of requesting certification information from the vital records jurisdictions. The match rate for those same queries was 84 percent in both manual and EVVE mode. In addition, the response time was just 10 seconds using EVVE compared to 42 days using the manual process.
Potential EVVE users interested in obtaining additional information about applying to become an approved EVVE user for either verification or certification of vital events should contact Rose Trasatti Heim via email at email@example.com.
i Implementation status as of March 1, 2015.
ii This column indicates in which jurisdictions the vital records office has adopted an EDRS. It does not indicate total penetrance of EDRS among death data providers in that jurisdiction. The implementation of EDRS is in progress in four states: Colorado, Massachusetts, Mississippi, and Tennessee. North Carolina has completed planning but has not yet begun the development phase. Planning or development has not yet begun in three states: Connecticut, Rhode Island, and West Virginia.
iii This column indicates in which jurisdictions the vital records office has implemented EVVE and is ready to accept birth record queries.
iv This column indicates in which jurisdictions the vital records office has implemented EVVE and is ready to accept death record queries. NAPHSIS continues to work with all jurisdictions that currently online with EVVE to ready their systems to accept death record queries.