Electronic death registration still alive

You’re born. You die. And someone else is buried in paperwork. Not the circle of life exactly, but that’s the reality as seen through the eyes of workers who issue some 2.5 million paper death certificates every year. The process for creating that truckload of forms is antiquated, cumbersome and prone to errors.

To improve the situation, the Social Security Administration is working with states and other jurisdictions to create a national Web-based system called E-Vital that can better handle the process. The initiative seeks to streamline the creation and management of death-registration records, significantly reduce reporting errors, better secure data and cut the time required to complete the reporting process.

But overhauling a decentralized and entrenched system has proven to be difficult. Bedeviling the transition are challenges presented by a multiplicity of jurisdictions, software vendors, end users, local registrars, peripheral players and unforeseen impediments.

Progress on E-Vital has been slow and frustrating, said Thomas Hughes, SSA’s chief information officer, in a speech last year. He declined to comment on the program’s status for this article, but experts are beginning to recognize that the agency’s vision of an integrated national system of electronic death reporting will take years to accomplish.

“I don’t think they fully understood the practicality and the reality of how states implement the system,” said Garland Land, executive director of the National Association for Public Health Statistics and Information Systems (NAPHSIS), which serves as the liaison between SSA and the states adopting the electronic system. “It indeed is a complex system to bring up.”

13 states have gone electronic
Inefficiency is costly. As recently as a few years ago, the delay in reporting deaths to SSA averaged 179 days, during which the agency frequently sent checks to dead people, who somehow managed to cash them.

According to projections published by the Office of Management and Budget, “Initial estimates indicate that E-Vital will produce cost savings in [the] hundreds of millions for federal and state government agencies.”

Plans to modernize the process gained traction about a decade ago with the publication of a report by SSA, the National Center for Health Statistics (NCHS) and organizations representing funeral directors, physicians, medical examiners, coroners and other professionals involved in the process of issuing death certificates.

The study concluded that advances in computer technology made an electronic system feasible, and efforts were undertaken to create standards and a plan for implementation.

Eager to put electronic death registration on the fast track, SSA began awarding contracts to states in 2001 to defray the costs of the new technology. The agency has awarded 22 such contracts, and as of February, electronic death registration systems were operating in 13 states — with varying degrees of success — and in development in a dozen others. Three of those jurisdictions have moved forward without a grant from SSA.

As upgrade projects go, E-Vital is more fraught with political concerns than most. It is part of the President’s Management Agenda and one of OMB’s 23 e-government projects, but officials seem reluctant to discuss it. Several SSA and OMB officials declined to talk about the project, as did Rep. E. Clay Shaw Jr. (R-Fla.), chairman of the House Ways and Means Committee’s Social Security Subcommittee.

In addition, OMB has not mentioned E-Vital’s progress in its annual reports to Congress on the implementation of the E-Government Act of 2002. The president’s proposed budget for fiscal 2007 provides scant data, though it notes that the average monthly number of deaths recorded through the electronic system was 4,812 in 2004.

Creating a Web-based system that can accommodate multiple users and ensure the accuracy and security of records requires specialized software, and a number of new and established technology companies have developed such products. All such systems are expected to meet reporting standards developed by SSA, NCHS and NAPHSIS.

Systems must record demographic information about the person who died, including name, address, race, sex, parental data, date of birth, place of death and method used to dispose of the body. Funeral directors most often provide such information.

They must also record information about the cause, time, date, place and manner of death. Doctors typically fill out this portion of the death certificate, but another official — such as a coroner or medical examiner — can complete it.

Policies can kill effective systems
Creating and implementing an electronic death record system requires overcoming unforeseen challenges.

A policy prohibiting doctors in South Dakota’s largest health care system from downloading software onto work computers, for example, effectively blocked them from using the state’s new system. South Dakota officials say they recently negotiated with the health care system to allow the use of the software.

“We’ve broken through,” said Kathlene Mueller, administrator of South Dakota’s Office of Data, Statistics and Vital Records.

Occasionally, problems have arisen when states insisted that vendors create automated systems that mimicked the workflow of outdated manual systems. Such efforts can amplify faults in the original process and don’t take advantage of the strengths that automation offers.

South Dakota, for example, eliminated a state regulation that required funeral directors to ensure that physicians completed the cause-of-death portion of death certificates. The law required the funeral director to “stand at the physician’s feet and wait for him to sign,” Mueller said. “That was broken. We fixed it.” The state also retooled the workflow process so that death certificates would no longer pass through the local registrar’s office before being submitted to the state office en route to the federal government. One of the biggest challenges in automating death registration is persuading people who complete death certificates to embrace a new system. Users can be wary of unfamiliar technology or lack Internet access.

“Many doctors are accustomed to a paper-based culture in which they sign what is put in front of them,” Mueller said. “When there’s no paper being pushed at them, it’s hard to respond.” An OMB official who asked not to be identified said getting users to accept the changes has been a challenge.

Nonetheless, OMB reported that electronic death record systems that have been in use for at least six months are generating 98 percent of new death certificates.

That claim that seems implausible. In South Dakota, for example, funeral directors use the new Web-based system to complete their portion of death certificates 99 percent of the time. But physicians who complete cause-of-death sections are providing information online for only about one in three new death certificates.

“We always knew that physicians would be the hardest piece,” Mueller said.

Pulley is a freelance writer based in Arlington, Va.