using electronic death registration systems (edrs) to conduct "real-time" disaster...
TRANSCRIPT
Using Electronic Death Registration Systems (EDRS)
to Conduct "Real-Time" Disaster Mortality Surveillance
NAPHSIS Training Webinar February 19, 2014
Overview
• Jurisdiction experiences using EDRS during disaster response– Oklahoma: Kelly Baker– New York City: Renata Howland– Alabama: Cathy Molchan
• CDC will present a conceptual framework to leverage EDRS for disaster mortality surveillance system
• Q and A session with participants
What is surveillance?
• Public health surveillance is the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. Such surveillance can:– serve as an early warning system for impending public health
emergencies;– document the impact of an intervention, or track progress
towards specified goals; and– monitor and clarify the epidemiology of health problems, to
allow priorities to be set and to inform public health policy and strategies.
(WHO website: http://www.who.int/topics/public_health_surveillance/en/)
What is surveillance?
• …continuous, systematic collection, analysis and interpretation…– Continuous: 100% Deaths collected through vital
statistics for now and in future– Systematic: Can be through EDRS and
coordination across jurisdictions– Analysis and interpretation: By vital stats or other
programs?
What is surveillance?
• …warning system for impending public health emergencies…– What is “impending” given deaths already
occurred• Post-disaster risk due to environmental conditions• Mental health• Repeat catastrophies
Electronic Death Registration - Oklahoma -
Kelly M. Baker, MPHState Registrar and Center for Health Statistics Director
Oklahoma State Department of Health
EDRS Webinar Series - 2014
What is an EDRS?
• Electronic Death Registration System
• Allows record participants to file death certificates – On-line, Anytime, from Anywhere (with internet access)
• Hospital, home, office, vacation
• Jurisdiction Goals– More timely, more complete, more secure, more
accurate, minimize business costs, improved service to families
• Funded in part by SSA since 1999– 24 hr death report sig reduce incorrect payments to
beneficiaries* – Terminate benefits to deceased immediately*– Improve accuracy of data shared with other Federal
agencies*
*SSA contract/award background statement
Why Register Deaths Electronically?
• Paperless filing of a death record– Funeral Dir is no longer physically chasing a physician for
signature– Collaborative registration process between funeral home,
physician, nursing homes, ME, and Registrar
• Improves timeliness and data quality– Promote family support– Automatic edits– Proactive follow-up by VR– More timely data (public health, benefit resolution, etc.)
• Fraud Prevention– Automate birth/death linkages to prevent identity theft– Secure signatures by physician and funeral director
• Verify SSN against SSA system before record registered
Savings Realized• Funeral home
– Reduced visits to Drs for signature, e.g. time, gas, etc.– System auto-verifies and auto-notifies SSA, Auto-pops
applications• Family
– Records placed on file quicker for earlier benefit resolution
• State– Modify electronic form vs dispersal/storage of paper forms– On-line communication/training– Reduced number of staff needed to process amendments
• SSA– Prevent erroneous payments
• Jan 2014: average payment per retired worker $1,183/mo* • Jan 2014: 39,762,000 people receiving SS only (no SSI) age
65+**SSA website
How EDR Has Made a Difference
• Time from event to filing– Before EDRS: 13 days After EDRS: 7 days – Note: Only 54% filed completely electronically so far!
• Lag time between date of registration and date sent to NCHS– Before EDRS: 29 days (2008) After EDRS: 1 day (2013)– Promotes faster national datasets for Public Health
• Lag time between DOD and date sent to SSA– 2012 Q1: 93% within 1 month: 23% 1-6 days 70% 7-30 days– 2013 Q3: 98% within 1 month: 44% 1-6 days 54% 7-30 days
• Amendments– Processing time: Before EDRS: 75 min each (2,546 Man hours in
2008) After EDRS: 1-2 min each ( 166 Man hours in 2012*)
– Improved data quality: Auto edits on SSN, DOB, DOD and Age allow us to refocus efforts on Public Health/statistical items*
• Specific Cause of Death, Smoking, Pregnancy, Condition onset *76% more records amended in 2012 compared to 2008
- Oklahoma -
System Costs• Variability
– State size– In-house development vs vendor– Equipment/licensing needs e.g. upgrades– Integrate other modules e.g. birth, fetal death, point of
sale– Data conversion may be required– Timing
• Oklahoma– Users: ~ 2,000 funeral directors, physicians, and
assistants– Death module ~$700,000– Total vendor cost (B/D/FD/POS/5 yr maintenance): $3.2
mil– Received $494,000 from SSA (2005)
May 20, 2013 - Moore, OK
• F5 tornado 1.3 mi wide at peak
• Touched down Monday 2:56pm
• On the ground 39 min; 17 mile path
• 25 killed (1 indirect)– Initial reports as high as 91
• 377 injured
• ~1,150 homes destroyed
• F5 tornados took similar paths May 3, 1999 and May 8, 2003
• Preliminary damage estimates > $2 billion
Impact During A Crisis Response
• DCs filed by Medical Examiner within 4 hrs of F5 tornado– Immediately ready for transmission to Funeral Homes
• System automatically linked deaths to Oklahoma births– Deaths to those born/reside outside OK immediately
sent to appropriate state
• Records were flagged as catastrophic event for future analyses and tracking
• Contribute to accurate public reporting of casualty counts
• Deployment for on-site issuance of BCs to victims– Assist with re-establishing identities
With Additional Funding• Physicians
– Better integration with the OCME system – Improve/expand the training & support of physicians– Support mandated physician use– Develop more user friendly interfaces to improve
compliance
• Data Enhancements– Audit medical records to improve COD quality– Automatic geocoding of records– Implement in states without EDR – fill in national gaps– Enhance Continuity of Operations capacity
• Reporting– Make real-time reporting of aggregate data available
online– Enhanced data analysis e.g. economic impacts to
families, communities, nation from all CODs
Source: NAPHSIS
Tracking Deaths in “Real-Time” during Sandy, New York City
Renata Howland, MPHCSTE/CDC Applied Epidemiology Fellow
Acknowledgements
Bureau of Vital Statistics Elizabeth Begier, Wenhui Li, Ann Madsen, Howard Wong,
Tara Das, Flor Betancourt
Bureau of Environmental Surveillance and PolicyThomas Matte
Bureau of Environmental Disease PreventionCatherine Stayton
Office of the Chief Medical Examiner Leze Nicaj
CDC, National Center for Environmental HealthRebecca Noe
Presentation Objectives
1. Describe death registration and surveillance during and after Hurricane Sandy
2. Summarize findings and uses
3. Identify lessons learned and next steps
Hurricane Sandy
• On October 29, 2012 Sandy made landfall approximately 100 miles south of NYC
• Record storm surge and high winds– Flooding across coastal areas– Widespread power outages– Transit shutdown
• On-going environmental hazards
Mortality Surveillance
1. How many Sandy-related deaths occurred during the storm?
2. Was there an increase in all-cause mortality following the storm and if so, why?
Electronic death registration system (EDRS)
• Web-based platform implemented in 2005– By 2010, >90% electronically reported
• Data providers: – Clinicians– Funeral directors– Medical examiners
Death Registration Flow Chart
Clinician medically certifies
Electronic Death Registration System
Death
24 hours
Line List
Medical examiner
investigates
Preliminary death record
Death Registration Flow Chart
Clinician medically certifies
Funeral director
completes
+ 48 hours
Electronic Death Registration System
Registered death record
DeathHealth
Department registers
24 hours
Preliminary death record
Preliminary data file Death data fileLine List
Medical examiner
investigates
Sandy Surveillance
• Received line list from medical examiner office within 24 hours of death
• Searched cause of death text fields• Monitored news/media inquiries• Activated popup notice
If Hurricane Sandy was the direct cause of this death or contributed to this death either directly or indirectly, please report the death to the NYC Office of Chief Medical Examiner (OCME) at xxx-xxx-xxx before certifying the case. Please include cases involving cold stress or carbon monoxide exposure occurring in residences without heat. Do not continue with the case if OCME is taking ownership.
Sandy Surveillance
• Ran daily death reports compared to 2010-11– Extracted preliminary records to improve
timeliness (~2 days)– Summarized by age, cause of death, and proximity
to flooding
• Daily reports run for two months and distributed to emergency response personnel
FINDINGS
Direct injury fatalities
• 44 deaths were Sandy-related– 41 identified by November 2 – 2 additional deaths identified by Nov 11– 1 death discovered in June 2013
• Deaths were primarily the result of drowning– Did not represent an on-going hazard (e.g., carbon
monoxide poisoning, falling trees)
Cause of DeathDrowningBlunt Impact
Other
All-cause mortality
• Increase in all-cause mortality compared to 2010-2011– Preliminary records signaled increase,
underestimated compared with registered death records
– Not concentrated by age, cause, or proximity to flooding
-40.0%
-30.0%
-20.0%
-10.0%
0.0%
10.0%
20.0%
30.0%
40.0%
Perc
ent D
iffer
ence
Percent Differences in All-Cause Deaths Counts in 2012 com-pared with 2010-11 averages, from October 1 – December 31, New York City
Hurricane Sandy
*Deaths were registered as of December 31st of each year
Influenza Season
DECEMBERNOVEMBER
OCTOBER
Median Days to Medically Certify and Register Deaths by Year (Oct 29-Nov 10)
Medically Certify Register0
0.5
1
1.5
2
2.5
3
3.5
0.38
2.2
0.30
2.3
0.36
3.1
2010
2011
2012
Day
s
38% in-crease
LESSONS LEARNED
Challenges
• Operational: – Disruptions to infrastructure– Health Department building closed for
approximately 1 week– Internet down at hospitals
Challenges
• Analytical:– Manual processes were time consuming– No pre-established summary reports– Preliminary records not complete– No internal definition of Sandy-related
Strengths
• Electronic system stable, remotely accessible• Coordination with data providers• Timely identification of deaths• Minimal additional resources
– Local capacity to code, extract, & analyze data• Demographic, cause, and area-specific
information on decedents for exploring trends
Next Steps
• Publish evaluation of EDRS surveillance• CDC grant to study mortality in depth• Additional grant to develop more advanced
reports and consider system enhancements• Collaboration with other programs
– Red Cross/EDRS linkage to examine data quality and circumstances related to death
THE ROLE OF ELECTRONIC DEATH REGISTRATION
SYSTEMS IN STATE MASS FATALITY MANAGEMENT
PLANNING
Catherine Molchan DonaldState Registrar and Director
Alabama Center for Health [email protected]
Mass Fatality ManagementCapability 5, Public Health Preparedness Capabilities Document, CDC
The ability to coordinate with other organizations (e.g. law enforcement, healthcare, emergency management, and medical examiner/coroner) to ensure the proper recovery, handling, identification, transportation, tracking, storage and disposal of human remains and personal effects; certify cause of death; and facilitate access to mental/behavioral health services to the family members, responders, and survivors of an incident.
http://www.cdc.gov/phpr/capabilities/capability5.pdf
Mass Fatality ManagementCapability 5 Functions
Determine role for public health in fatality management
Activate public health fatality management operations
Assist in the collection and dissemination of antemortem data
Participate in survivor mental /behavioral health services
Participate in fatality processing and storage operations
What is EDRS?
EDRS, or an Electronic Death Registration System, is a software system that allows death certificates to be registered electronically
Built in edits help reduce errors Drop down boxes for education, county of death
and other common items help reduce errors The need for carrying/mailing paper death
certificates is eliminated – time to register a death certificate is reduced
Certified copies of the record can be issued to families more quickly
What are the Challenges – EDRS or Paper – with Mass Fatality?
Ensuring that the particular mass fatality event is recorded on the death certificate Ensures the cause of death will be properly
coded to the specific type of Mass Fatality Reaching out to Medical Certifiers to
ensure this happens Documenting accurately place of death or
where the body was found Delays in finding and identifying some
bodies Indirect causes of death
Challenges, continued
Depending on the type of event; deaths can be spread over time and distance Two tornado outbreaks in Alabama in April 2011
April 15/16 resulting in 7 deaths April 27 resulting in 237 deaths
First warning 4:16 am Last warning 9:48 pm
Crash of an airliner in concentrated area Pandemic
In 2011, Alabama was piloting EDRS Varying number of deaths based on source
62 confirmed tornados
Deaths by Day
April
27
April
28
April
29
April
30
May
1
May
2
May
9
June
1
June
5
June
8
Sep
tem
ber 1
60
50
100
150
200
250206
203 1 1 1 1 1 1 1 1
Day and month
Nu
mb
er
of
death
s
What do You Need to Know?
Who is planning for responding to a Mass Fatality Event in your State?
Are State and Local Vital Records Offices involved in the planning?
Does your State have an Electronic Death Registration System (EDRS)?
Can information on Mass Fatalities be readily obtained from the EDRS?
What percentage of death records are filed electronically?
What Should We be Doing?
Getting all the players to the table; Vital Records, Emergency Preparedness, Epidemiology, Coroners and Medical Examiners
Thinking about and document the information that will be needed and when it will be needed Be as specific as possible so an EDRS can be
modified to meet the needs How quickly do you need information? Preliminary vs. Final
What Should We be Doing?
Discuss different Mass Fatality events and how the information needed might differ
Discuss funding for enhancements to an EDRS to meet surveillance and emergency preparedness needs
Consider your sister states in the process Work together to fill in the empty space
on Capability 5
More information will be forthcoming regarding the role of the NAPHSIS Mass Fatality
Committee in this effort
Thank you for your time and attention
Electronic Disaster Mortality Surveillance – Is It Possible?
A Conceptual Framework
CDR Rebecca S. Noe MN, MPH, FNP-BC
National Center for Environmental HealthDivision for Environmental Hazards and Health Effects
Health Studies Branch, National Center for Environmental Health
Centers for Disease Control and Prevention
NAPHSIS Seminar February 19, 2014
Objectives
• Present how disaster-related deaths are being tracked in the U.S.
• Share a framework to leverage Electronic Death Registration System (EDRS) to track all disaster-related deaths in a timely fashion
• Describe challenges in using EDRS and potential solutions
Importance of Disaster Mortality Data
• Guide response effort• Qualify families for FEMA funeral
benefits • Maintain record of disaster-related
deaths in the National Vital Statistics System (NVSS) for epidemiologic research
• Link disaster-related fatalities to an event in NOAA’s Storm Data system
NOAA’s Storm Data
• Purpose to record extreme weather and climate events; economic and health impacts
• Fatality data not uniformly collected • Multiple data sources but no death
certificates
Storm Data Fatality Information
• Age• Gender• Date of Fatality• Location of Fatality• Direct or Indirect
Implications
• Unverified deaths attributed to specific weather events
• Impacts disaster research and national preparedness policies– Weather and climate scientists depend on Storm
Data information– Congressional and other gov’t agencies request
NOAA disaster reports– Underreporting especially indirect disaster-related
deaths
Disaster Mortality Surveillance
• Electronic Death Registration Systems (EDRS)– In 38 of the 57 vital records jurisdictions– Messaging application (STEVE*) permits the
electronic exchange of vital event data between jurisdictions and to federal agencies
• Death certificates could be the “gold standard” to record disaster attributable mortality
*State and Territorial Exchange of Vital Events
Response Agencies Identifying Disaster-related Deaths
Previous Disaster Deaths Identified
Data Source Number of Disaster-related Deaths Identified
Red Cross
FEMA
NOAA-NWS
Storm Data
Other State
Agency (EOC, ME)
EDRS (Search without names)
Hurricane Ike – TX (2009)
38 ? 20 74 4
April 27 Tornado – GA (2011)
15 ? 15 15 6
Hurricane Sandy – NJ (2012)
34 ~700 12 75 8
Really, Disaster-Related Deaths Not in the EDRS?
But determined as disaster-related via other data sources
Without this information, other data sources would be required
Case 1not identified initially
Case 2was identified initially
Because no indication that COD or consequences were disaster-related
Because circumstance indicated this was disaster-related
Challenges of using EDRS for Disaster–related Mortality Surveillance
• Disaster-relatedness often missing• Injury circumstances only captured • Indirect deaths underestimated
Challenges (2)
• Text string search capabilities vary• Variety of persons completing death
certificate• Pending cause(s) due to legal
implications
Possible Solutions
• State registrars in an ideal position to assess if disaster-relatedness on certificate
• EDRS built in capacity to “flag” or do text searches are necessary for emergencies
• Mass fatality plans could encourage that relatedness be recorded on death certificate
Possible Solutions (2)
• Verify disaster-related deaths after an event
• Provide training and guidance on certification to medical examiners, coroners, and other certifiers– Disaster-related deaths (e.g., hurricanes
http://www.cdc.gov/nchs/data/dvs/hurricane_certification.pdf)
• Provide disaster mortality surveillance guidance
Conceptual Framework
During a disaster identify and indicate disaster relatedness on death certificate
Information securely
transmitted via STEVE
NOAA Storm Data andOther Key Partners
State EDRS
Use FEMA and
Red Cross to cross check
Conclusion
• EDRS can be leveraged for timely disaster death identification and surveillance
• Electronic disaster mortality surveillance is possible and useful– Improve timeliness and accuracy – Guide response efforts– Enables states to answer inquiries rapidly– Measure and record the true burden of
disasters – Provide accurate information for disaster
research
Thank you
DISCLAIMER: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Q and A Session
ADDITIONAL SLIDES
OCME definition
• Injuries directly related to the storm or indirectly related, where the individual did not have a chance to avoid the hazard
• E.g., falling down the steps as a result of no electricity the night of the storm would be Sandy-related, but three days later it would not as the decedent had time to seek shelter elsewhere or use other sources of lighting while the power was out
Text String Search Terms
SuffocationDrowning SubmergePoisoningImpactAsphyxiaTraumaticInjuryFracturesElectrocutionHypothermia
Carbon MonoxideStruckCrushedBlunt InjuriesObjectDebrisFallTreeMotor Vehicle
CrashCollisionAutomobileTruckFlood SignalRoadLightPunctureFireBurn
SandyPedestrianFumesHeatInhalationToxicSmokeStormHurricane
Intermediate Cause
Immediate Cause
Underlying Cause
Hours
Months
Years
Intermediate Cause
Days
Other significant conditions