Electronic Death Registration Never Sign a Death Certificate

Electronic Death Registration “Never Sign a Death Certificate Again” Presented by Texas Department of State Health Services Texas Vital Statistics www. texasvsu. org

Electronic Death Registration is Required By Law Health and Safety Code § 193. 002 requires the person in charge of interment or in charge of removal of a body from a registration district for disposition to file death certificates electronically as specified by the State Registrar. Likewise, Health and Safety Code § 193. 005 requires that medical certifiers on a death certificate submit the medical certification and attest to its validity using an electronic process (currently Texas Electronic Registrar) approved by the State Registrar.

Fast Facts As of October 10, 2009: § There are 1, 364 funeral homes registered to use TER § There are 8, 114 physicians registered to use TER § There are 319 local registrars registered to use TER § All 13 County Medical Examiner’s offices registered to use TER § 44. 67% of all death certificates are fully electronic. § 92% of all Social Security numbers are successfully validated using TER

Texas Electronic Registrar Is: • Internet Application • Accommodates all levels of participation • Initiates social security verification process • Edits, cross-checks, SSN verification – all reduce potential errors • Result – a faster, more efficient, more accurate process

What about my Signature? • When Funeral Directors and Medical Certifiers (Physicians, JP’s, ME’s) are entered as users in TER, they are assigned a temporary PIN (Personal Identification Number). • The first time each Funeral Director or Medical Certifier verifies/certifies a record, they will be required to change the PIN to a number only they will know. • This PIN must be kept confidential; therefore, each Funeral Director and each Medical Certifier MUST verify/certify their own records (in other words, the signature process cannot be delegated to office staff). • The PIN holds the same legal standing on the electronic death certificate as a signature has traditionally held on the paper certificate.

Computer Specifications § 1. 0 gigabyte processor speed or faster with 512 MB of RAM or more § Adobe Acrobat Reader § Pentium 4 or equivalent § Windows XP Operating System § Web browser with Flash Player (7. 0 or greater) § Internet access at 56 K or better § 1024 x 768 resolution color monitor

How can do I register to use TER? § Go Texas Electronic Registration Page: www. request. TER. texasvsu. org § Complete the online Registration Form

Enroll By Going Here

Once Enrolled You Will Receive an Email from help-ter@dshs. state. tx. us that will include: § Welcome to Texas Electronic Registrar Death Registration § Computer specifications § Resources and website information § Service Level Agreement § Confidential and Non-disclosure Agreement § User ID, Password and PIN number § help-ter@dshs. state. tx. us or help-ter@texasvsu. org § Password Guidance document § Remote Access Security Policies document

Example of the Start up email from help-ter@dshs. state. tx. us

User Setup VSU will set up one Local Administrator who will Add, Remove, and Modify Users in TEDR, Medical Certifiers and other staff. *see back of TER brochure

Let’s get started.

The notification prompt will be in the form of an email, or can be sent to any other electronic device that uses an email address (pager, PDA, etc). The email contains the name of the funeral home And the unique EDR # The basic information about the deceased

Accessing The Record • Access the Internet by clicking on the icon. • Copy https: //ter 2. dshs. state. tx. us/edeath to the address bar. https: //ter 2. dshs. state. tx. us/edeath • Select ‘Enter’ or icon.

This is Called The Portal Page. Click on ‘Thin Client Application’

Logging into TER Enter User Name Password Click Login Dr. Kilgore Select Location Click OK

Under ‘Functions’, click Medical Data Entry or click on icon This screen is called the Main Menu

From the Medical Data Entry screen, click the ‘Search Record’ icon This is the Let’s retrieve Medical Data the record. Entry screen

or, select ‘Search’ from the registration menu

This is the Search Record screen You can search with any combination of items

Enter your search information or EDR # Click ‘Find’

The system will retrieve all records matching the search criteria

Click on the desired record or records – the row(s) will become highlighted Click ‘Select Records’

The selected record will be displayed

or, click to choose Filter Option

Choose desired filter option

Click to access records in queue

Select record to complete

The Demographic Information that has been entered by the Funeral Home will pre-populate in the corresponding fields in Medical Tab 1 The selected record will be displayed

Start entering data on Medical 1 tab

If you do not wish to enter a Medical Record number, tab, with your ‘Tab’ button. When the Soft-Check Alert’ Appears, select ‘No’ if you do not wish to complete this item at a later time or ‘Yes’ if you do. The ‘Medrec’ field and the ‘MECase Number’ Field are optional. However you still have to tab through the fields to resolve them.

MEs and JPs: If your information is different from the Demographic your can add, edit, or delete the information that is different. If there is no middle name, press ‘TAB’ to skip to the next field.

A box will appear that will indicate that your information is different from what the Funeral Home has put in the System.

Medical Certifiers will have to indicate the date of death type.

If there is more than one Medical Certifier with your particular facility, you can select another physician if the physician that was assigned is unable to sign the death certificate. i. e. Attending Physician is out and an Associate Physician Has Approval by the Attending Physician in Accordance to HSC § 193. 005(c) to complete the medical certification.

Review the time of death and make that it is accurate in accordance to your records. You may edit this if you need to. 24 hour clock (military time) is acceptable.

We are now on the Medical 2 Tab

Complete each item by selecting the appropriate response from the pulldown lists

Quick tip – TER Death will not allow a physician to certify a manner of death other than ‘Natural’. A message will be displayed notifying the physician, who should then ‘DECLINE’ the record. The funeral home can re-designate the record to the appropriate JP or ME for certification.

Why Can’t A Doctor Put the Manner of Death as Accident? Code of Criminal Procedure Art. 49. 04. DEATHS REQUIRING AN INQUEST. • (a) A justice of the peace shall conduct an inquest into the death of a person who dies in the county served by the justice if: – (1) the person dies in prison under circumstances other than those described by Section 501. 055(b), Government Code, or in jail; – (2) the person dies an unnatural death from a cause other than a legal execution; – (3) the body or a body part of a person is found, the cause or circumstances of death are unknown, and: • (A) the person is identified; or • (B) the person is unidentified;

Why Can’t A Doctor Put the Manner of Death as Accident? • Art. 49. 04. DEATHS REQUIRING AN INQUEST (cont. ). – (4) the circumstances of the death indicate that the death may have been caused by unlawful means; – (5) the person commits suicide or the circumstances of the death indicate that the death may have been caused by suicide; – (6) the person dies without having been attended by a physician; – (7) the person dies while attended by a physician who is unable to certify the cause of death and who requests the justice of the peace to conduct an inquest; or – (8) the person is a child younger than six years of age and an inquest is required by Chapter 264, Family Code.

Why Can’t A Doctor Put the Manner of Death as Accident? • Art. 49. 04. DEATHS REQUIRING AN INQUEST (cont. ). • (b) Except as provided by Subsection (c) of this section, a physician who attends the death of a person and who is unable to certify the cause of death shall report the death to the justice of the peace of the precinct where the death occurred and request that the justice conduct an inquest. • (c) If a person dies in a hospital or other institution and an attending physician is unable to certify the cause of death, the superintendent or general manager of the hospital or institution shall report the death to the justice of the peace of the precinct where the hospital or institution is located.

Why Can’t A Doctor Put the Manner of Death as Accident? • Art. 49. 16. ORDERS AND DEATH CERTIFICATES. – The justice of the peace or other person who conducts an inquest under this subchapter shall sign the death certificate and all orders made as a necessary part of the inquest.

NO Responding ‘NO’ to the Injury question will “disable” the rest of the injury questions and not allow entry

The Manner of Death implies that an injury did occur This is an example of a cross-check

Changing the response to Yes will resolve the conflict Click ‘OK’ to continue

Complete each item by entering information requested or selecting responses from pull-downs

We are now on the Medical 3 Tab

If the cause of death has not yet been determined, check the “Cause of Death Pending” box You must also type “PENDING” on Line A

If the cause of death is known, enter the information on lines A – D, as appropriate, TABBING from field to field until complete

With certain wording TEDR will give medical certifiers alerts to give additional assistance in writing good Cause of Death statements

If there are no contributing conditions, TAB past this field and select ‘No’ in the Soft. Check Alert.

Cause-of-Death Statements WHAT’S SO IMPORTANT ABOUT THAT?

Information Guidelines • Certification should represent your “ Best Medical Opinion” -This means that your expertise, experience, and knowledge are valuable and necessary to provide useful information. -If for any reason your “Best Medical Opinion” changes, the death certificate can be amended to reflect that change ( there would be no legal repercussions from the change)

Tips and Pointers • “Probable” and “presumed” are allowed • Be as specific as possible about conditions reported Ø Provide as much information as possible Ø Avoid such terms as “old age”, “senescence”, or “infirmity” • If multiple morbid conditions are present and the underlying cause is uncertain, construct a logical sequence for Part I and then list other conditions in Part II

Tips and Pointers • Avoid abbreviations • Do not report only mechanisms or modes of dying ØCardiac or respiratory arrest ØCardio-pulmonary or cardio-respiratory arrest ØAsystole (cardiac arrest) • Indicate explicit information with regard to specificity, etiology, or if the cause of death is unknown

Why It’s Important • Two key vital statistics uses: ØDATA ØRESEARCH

Why We Need You • DATA - Data needs to be accurate, complete, detailed and uniform across the state. - Data needs to be useful to other physicians – pertinent to current health issues.

DATA… ØMortality statistics by county and statewide ØHealth issues specific to geographic area, socio-demographic, age, gender, ethnic characteristics ØLeading causes of death ØInfant and maternal mortality rates ØTrends in the effect of current health issues on mortality

Why We Need You • RESEARCH ØAssess the general health of the population ØComparison of medical issues at the county and state level ØIndicate areas in which medical research may have the greatest impact on reducing mortality ØAllocate medical services, funding, and other resources

Example Part I. Diseases, injuries, or complications that caused the death. Immediate cause a. Approximate interval between onset and death Condition which directly preceded death Due to (or as a consequence of) Sequentially list antecedent causes, b. if any, leading to the immediate cause with underlying cause c. last Antecedent condition Due to (or as a consequence of) Underlying cause Due to (or as a consequence of) d. Part II. Other significant conditions contributing to death but not resulting in the underlying cause

Example Part I. Diseases, injuries, or complications that caused the death Immediate cause Sequentially list antecedent causes, if any, leading to the immediate cause with underlying cause last a. Pneumonia Approximate interval between onset and death 1 week Due to (or as a consequence of) b. Renal Failure 4 weeks Due to (or as a consequence of) c. Cerebral Thrombosis 7 weeks Due to (or as a consequence of) Part II. Other significant conditions contributing to death but not resulting in the underlying cause Hypertension

Cause-of-Death Statements • CDC’s website provides several links to aid in writing cause-of-death statements Ø Multiple links on CDC’s National Vital Statistics System page Ø Recommended tutorial: NYC Department of Health and Mental Hygiene online training on improving causes of death reporting www. nyc. gov/html/doh/media/video/icdr/index. html

Who Can Certify Deaths? Physicians Ø Certify natural deaths Ø Primary care physician would have best knowledge of patient medical Medical Examiners and Justices of the Peace Ø Certify un-natural deaths Ø May request autopsy Ø See handbook for list of cases requiring a medical examiner / JPs www. cdc. gov/nchs/about/major/dus/handbk. htm

YOU ARE THE KEY • The data provided by the TER system is only as good as the information provided on the death certificate • You are not just signing a death certificate – you are investing in the future of improved medicine!

I Have Completed the Death Record • How Do I Sign the Death Certificate? • How Do I Get Something for My Files? • How Do I let the Funeral Home Know I am Done?

Click the ‘SAVE’ icon before continuing The system will bring you back to Medical 1 tab

Your information is now stored in the system

Click the ‘MEDICAL CERTIFICATION’ icon to electronically “sign” the record

Click ‘Yes’ to continue

If a field was not completed, you will see this message

Quick tip – Using the Unresolved List feature can help quickly identify missing information.

Any unresolved fields will be indicated Close Unresolved List screen by clicking the red X

Incomplete or Unresolved fields will be displayed in bright yellow

And click the ‘SAVE’ icon to store the information Enter the appropriate response

Click the ‘MEDICAL CERTIFICATION’ icon to electronically “sign” the record

Click ‘Yes’ to continue

Click ‘Yes’ to continue

The basic information is displayed The type of certifier is checked and the appropriate certification statement is displayed

Click ‘Preview’ to view the entire medical certification portion of the death certificate

Or, click ‘Certify’ to electronically sign the death certificate

The first time you Medically Certify a record you will need to verify the PIN number given to you by VSU and assign a new one.

Click ‘Certify’ again to electronically sign the death certificate

Click ‘OK’ Enter your PIN

Success! You are now finished with this record

The information “locks down” and cannot be changed

Notifying the Funeral Home Once the record is electronically signed, TER automatically sends an email to the funeral director listed filing the death certificate that the medical certifier has completed their portion of the record.

Quick tip – The certifier can make changes to the record only until the record has been electronically accepted by the Local Registrar. If changes are needed on a record that has been electronically certified, the record must first be “de-certified. ”

Click the ‘De-Certify’ icon

The record is now De-certified Click ‘OK’

The record is now “open” and information can be corrected as needed

After all changes are made, the record must be electronically certified again

Questions? Comments? Please email your questions and comments to: help-TER@dshs. state. tx. us