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

2. Electronic Death Registration is Required By Law
Health and Safety Code § 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 § 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.

3. 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
We are gaining ground, and most focused on the Medical Certifiers.

4. 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
Of course, optimal with all parties participating when the record is fully electronic.

5. 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.

6. Computer Specifications
1.0 gigabyte processor speed or faster with 512MB 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 56K or better
1024 x 768 resolution color monitor
If you are using a computer purchased in the last five years, it should be fine.

7. How can do I register to use TER?
Go Texas Electronic Registration Page:
Complete the online Registration Form

8. Enroll By Going Here
Click on this icon – but also notice other resources on this page.

9. Complete this form online & submit.

10. Welcome to Texas Electronic Registrar Death Registration
Once Enrolled You Will Receive an from 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 or
Password Guidance document
Remote Access Security Policies document
You will receive an with all this information. It’s a good idea to go ahead and put these addresses in your address book so the start-up doesn’t go to your spam or junk folders and you miss it.

11. Example of the Start up email from help-ter@dshs.state.tx.us
Here’s what that will look like. Be sure to scroll down to get all the information. Print this and keep it handy – but locked away if others frequent your office.

12. User Setup *see back of TER brochure
VSU will set up one Local Administrator who will Add, Remove, and Modify Users in TEDR, Medical Certifiers and other staff.
You can have several people within one office or entity registered under that particular entity. One will need to be designated as the Local Administrator.
*see back of TER brochure

13. Let’s get started.
You may want to follow along on your brochures so it makes sense when you get back to the computer.

14. The notification prompt will be in the form of an email, or
can be sent to any other electronic device that uses an address (pager, PDA, etc).
The contains the name of the funeral home
The basic information about the deceased
You may want to put the Administrator’s name as an automatic “copy” any time a MC is to receive a notice of a death certificate waiting to be certified.
And the unique EDR #

15. Accessing The Record Access the Internet by clicking on the icon.
Copy to the address bar.
Select ‘Enter’ or icon.
This is another address you may want to put in your favorites or post nearby.

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

17. Logging into TER Enter User Name Password Click Login Select Location
Location name is filed as whatever you entered on your registration form.
Dr. Kilgore
Select Location
Click OK

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

19. This is the Medical Data Entry screen Let’s retrieve the record.
From the Medical Data Entry screen, click the ‘Search Record’ icon
This is the Medical Data Entry screen
Let’s retrieve the record.
Remember that the binoculars is the “search” key.

20. or, select ‘Search’ from the registration menu

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

22. Enter your search information or EDR #
Click ‘Find’

23. The system will retrieve all records matching the search criteria

24. Click on the desired record or records – the row(s) will become highlighted
Must highlight the correct name before clicking on “select records”.
Click ‘Select
Records’

25. The selected record will be displayed

26. or, click to choose Filter Option

27. Choose desired filter option
The work queue contains death records that have been started but still need some action to complete them. The work queue can be accessed by any of the filter options shown.
All Unresolved – all records that need any action
Medical Data Entry Incomplete – records that have some missing data fields that need to be filled in.
Not Medically Certified – records with Medical Data Entry completed but Medical Certification not done. Note that records not complete regarding medical data entry will not appear in this filter.

28. Click to access records in queue

29. Select record to complete
Notice the names appear in date order so you know which ones have been waiting longest to be certified. With the 80th Legislature’s passage of HB 755 that requires death certificates to be filed with the state in 10 days, this feature can help keep you on top of the D/C that need to be handled.

30. The selected record will be displayed
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
The record is retrieved and available for completion.

31. Start entering data on Medical 1 tab
Notice the visual cueing – when you enter information in the yellow fields, they turn white, indicating you have completed the required information. If the box appears white or gray, nothing needs to be done. If still yellow, you will need to complete that information. Note that you do not have to complete the Medrec field but you most tab on and off. Also, the blue field between the fields and the tabs will have further instructions.

32. 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.
This system was designed for heads down data entry or “type-tab”. This means that if you will complete information for a field and then hit tab”, it will automatically take you to the next field where information needs to be entered. Using your mouse to move from field to field takes extra time and you may not select the correct field – which causes you more delay as you go.

33. If there is no middle name, press ‘TAB’ to skip to the next field.
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.
This may seem cumbersome to re-enter a bit of the demographic information we already know is there – you will be happy to know that one of the enhancements that is currently being implemented is that much of this information will be pre-populated from what the funeral director has already entered.

34. A box will appear that will indicate that your information is different from what the Funeral Home has put in the System.
Once the medical certifier has change any information, The Funeral Home will have to go back in and edit their information before they will be able to demographically verify the record.

35. Medical Certifiers will have to indicate the date of death type.
If you ignore it, you will have to come back later and address the question.

36. 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 § (c) to complete the medical certification.
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 § (c) to complete the medical certification.

37. 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.

38. We are now on the Medical 2 Tab
You should be careful to save often, preferably after each Tab is completed.

39. Complete each item by selecting the appropriate response from the pull-down lists

40. 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.
If this is the situation, please contact the funeral home to let them know you are not eligible to certify this death and you have declined the record so the funeral home can re-designate the record to a JP or ME. The 10 day time frame to file the DC is still in effect.

41. Why Can’t A Doctor Put the Manner of Death as Accident?
Code of Criminal Procedure Art 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 (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;

42. Why Can’t A Doctor Put the Manner of Death as Accident?
Art 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.

43. Why Can’t A Doctor Put the Manner of Death as Accident?
Art 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.

44. Why Can’t A Doctor Put the Manner of Death as Accident?
Art 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.

45. NO
Responding ‘NO’ to the Injury question will “disable” the rest of the injury questions and not allow entry
Nice time-saving bonus for you.

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

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

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

49. We are now on the Medical 3 Tab
Remember to save your work.

50. You must also type “PENDING” on Line A
If the cause of death has not yet been determined, check the “Cause of Death Pending” box
Two places to enter “pending” information.
You must also type “PENDING” on Line A

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

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

53. We recommend several resources to assist you with cause of death…
If there are no contributing conditions, TAB past this field and select ‘No’ in the Soft-Check Alert.

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

55. 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)

56. Tips and Pointers “Probable” and “presumed” are allowed
Be as specific as possible about conditions reported
Provide as much information as possible
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

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

58. Why It’s Important
Two key vital statistics uses:
DATA
RESEARCH

59. 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.

60. DATA… Mortality statistics by county and statewide
Health issues specific to geographic area, socio-demographic, age, gender, ethnic characteristics
Leading causes of death
Infant and maternal mortality rates
Trends in the effect of current health issues on mortality

61. Why We Need You RESEARCH Assess the general health of the population
Comparison of medical issues at the county and state level
Indicate areas in which medical research may have the greatest impact on reducing mortality
Allocate medical services, funding, and other resources

62. Approximate interval between onset and death
Example
Part I. Diseases, injuries, or complications that caused the death.
Part II. Other significant conditions contributing to death but not resulting in the underlying cause d.
Immediate cause a.
Due to (or as a consequence of) b. c.
Sequentially list antecedent causes,
if any, leading to the immediate cause with underlying cause last
Approximate interval between onset and death
Condition which directly preceded death
Antecedent condition
Underlying cause
Underlying Cause of Death
The disease that initiated the train of morbid events leading directly to death
or…
The circumstances of the accident or violence that produced the fatal injury
General Instructions
Events and conditions should be logically linked in terms of time, etiology and pathology
Underlying cause should be on the last used line in Part I
One cause on each line in Part I
Interval between onset and death
For each condition reported, report the interval between the presumed onset of the condition (not the date of diagnosis) and the date of death
General terms such as minutes, hours, days or years are OK
Terms “unknown” or “approximately” are OK
General Guidelines
The certification should represent your best medical opinion.
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.

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

64. Cause-of-Death Statements
CDC’s website provides several links to aid in writing cause-of-death statements
Multiple links on CDC’s National Vital Statistics System page
Recommended tutorial: NYC Department of Health and Mental Hygiene online training on improving causes of death reporting

65. Who Can Certify Deaths? Physicians Certify natural deaths
Primary care physician would have best knowledge of patient
medical
Medical Examiners and Justices of the Peace
Certify un-natural deaths
May request autopsy
See handbook for list of cases requiring a medical examiner / JPs

66. 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!

67. 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?

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

69. Your information is now stored in the system

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

71. Click ‘Yes’ to continue

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

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

74. Close Unresolved List screen by clicking the red X
Any unresolved fields will be indicated
The area or areas that need completing – or answering will be displayed.

75. Incomplete or Unresolved fields will be displayed in bright yellow

76. And click the ‘SAVE’ icon to store the information
Enter the appropriate response
Enter the missing info & SAVE.

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

78. Click ‘Yes’ to continue

79. Click ‘Yes’ to continue

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

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

83. This is an opportunity for you to print this for your records if you need it. If not, you can always go back to this and print it later.

84. Or, click ‘Certify’ to electronically sign the death certificate
If not printing, …… just certify,
Or, click ‘Certify’ to electronically sign the death certificate

85. 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.

88. Click ‘Certify’ again to electronically sign the death certificate

89. Click ‘OK’
Enter your PIN
sign – with your PIN and…

90. Success! You are now finished with this record
…you will get a Success message. Wohoo!

91. The information “locks down” and cannot be changed

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

93. 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.”
The information can not be changed – unless it is de-certified.

94. Click the ‘De-Certify’ icon

96. The record is now De-certified
Click ‘OK’
The record is now De-certified

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

98. After all changes are made, the record must be electronically certified again
The first few times may feel pretty cumbersome but most users tell us they love the system after they learn it and appreciate what it means for social security and public health.

99. Please email your questions and comments to:
Questions? Comments?
Please your questions and
comments to:
My suggestion is to keep the texasvsu.org website and the address posted close to your computer.
The good news about the TER help desk (at help-ter) is that it is staffed by very knowledgeable and helpful individuals– the bad news it is two people. If you can remember to put a specific topic in the subject line of your and include the EDR number, they can research your situation faster and respond with more knowledge.
Examples:
-Record/Order Status
-Password/Pin
-Add/Change Location
-DTP Counter
-Relinquish
We thank you for your time and attention and appreciate your efforts in learning the TER system. What questions do you have?