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, MPH
State 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
- Oklahoma • 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
– 2013 Q3: 98% within 1 month: 44% 1-6 days
70% 7-30 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
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, MPH
CSTE/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 Policy
Thomas Matte
Bureau of Environmental Disease Prevention
Catherine Stayton
Office of the Chief Medical Examiner
Leze Nicaj
CDC, National Center for Environmental Health
Rebecca 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
Death
Clinician
medically
certifies
24 hours
Electronic Death Registration System
Medical
examiner
investigates
Line List
Preliminary
death record
Death Registration Flow Chart
Death
Clinician
medically
certifies
Funeral
director
completes
24 hours
+ 48 hours
Health
Department
registers
Electronic Death Registration System
Medical
examiner
investigates
Preliminary
death record
Line List
Preliminary
data file
Registered
death
record
Death data file
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 Death
Drowning
Blunt 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
Percent Differences in All-Cause Deaths Counts in 2012 compared
with 2010-11 averages, from October 1 – December 31, New York
40.0%
Influenza Season
30.0%
Percent Difference
20.0%
10.0%
0.0%
OCTOBER
NOVEMBER
-10.0%
-20.0%
Hurricane Sandy
-30.0%
-40.0%
*Deaths were registered as of December 31st of each year
DECEMBER
Median Days to Medically Certify and
Register Deaths by Year (Oct 29-Nov 10)
3.5
3.1
3
Days
2.5
2.2
2.3
2010
2
2011
1.5
2012
1
0.5
38%
increase
0.38
0.30
0.36
0
Medically Certify
Register
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
Thanks!
Contact information:
Renata Howland
rroney@health.nyc.gov
646-632-6728
Catherine Molchan Donald
State Registrar and Director
Alabama Center for Health Statistics
Cathy.molchan@adph.state.al.us


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.p
df





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





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

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

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
Number of deaths
250
200
206
150
100
50
0
20
3
1
1
1
1
Day and month
1
1
1
1





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?


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




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
Health Studies Branch, National Center for Environmental Health
Centers for Disease Control and Prevention
NAPHSIS Seminar
February 19, 2014
National Center for Environmental Health
Division for Environmental Hazards and Health Effects
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
FEMA
Cross
NOAANWS
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?
Case 1
not identified initially
Case 2
was identified initially
Because no indication that COD or
consequences were disaster-related
Because circumstance indicated this
was disaster-related
But determined as disaster-related
via other data sources
Without this information, other data
sources would be required
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
Use FEMA
and
Red Cross
to cross
check
State EDRS
NOAA Storm
Data and
Other Key
Partners
Information
securely
transmitted
via STEVE
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 Sandyrelated, 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
Suffocation
Drowning
Submerge
Poisoning
Impact
Asphyxia
Traumatic
Injury
Fractures
Electrocution
Hypothermia
Carbon
Monoxide
Struck
Crushed
Blunt
Injuries
Object
Debris
Fall
Tree
Motor Vehicle
Crash
Collision
Automobile
Truck
Flood
Signal
Road
Light
Puncture
Fire
Burn
Sandy
Pedestrian
Fumes
Heat
Inhalation
Toxic
Smoke
Storm
Hurricane
Immediate Cause
Hours
Intermediate Cause
Days
Intermediate Cause
Months
Underlying Cause
Years
Other significant conditions