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

2. New Legislation Requiring Electronic Death Registration House Bill 1739, which mandates electronic death registration for funeral homes and medical certifiers, was signed by the Governor on June 15, 2007, and became effective on September 1, 2008. Section 193.002 of the Texas Health & Safety Code will now require 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, Section 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.

3. Fast Facts As of 3/15/09:  There are 1,228 funeral homes registered to use TER (1,354)  There are 5,168 physicians registered to use TER (15,000)  There are 305 local registrars registered to use TER (400)  There are 13 medical examiner offices registered to use TER (13)  27% of all death certificates are fully electronic.  92% of all Social Security numbers are successfully validated using TER

4. Texas Electronic Registrar 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

5. Funeral Director Participating Medical Certifier NOT Participating, AND/OR Local Registrar Participating Funeral Director Initiates D/C in TER (demo tabs 1-5) Validates social security info with SSA Designates medical certifier (if participating in TER) OR Prints the death certificate from TER - drop-to-paper (DTP) (if medical certifier not participating in TER) Delivers DTP death certificate to medical certifier for cause of death completion Files DTP death certificate with Local Registrar Scenarios of Participation

6. Funeral Director NOT Participating Medical Certifier Participating Local Registrar Participating (or NOT) If coordinated between Medical Certifier and Funeral Director – Medical Certifier may initiate record in TER Medical Certifier prints the death certificate from TER (drop-to- paper) Funeral Director completes appropriate death certificate information manually Funeral Director delivers death certificate to Local Registrar Process continues as it does currently… Scenarios of Participation

7. Funeral Director Participating Medical Certifier Participating Local Registrar Participating Scenarios of Participation 100% TER Death Registration!

8. 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.

9. Record Types Local Registrar ElectronicManual Drop-to-Paper (DTP) Medical certifiers using TER will usually only be involved in Electronic registration. In some cases, a medical certifier may initiate a record in TER and drop-to-paper for a non-participating funeral home. Not using TER (8.5” x 14” only) Using TER (8.5” x 11” only)

10. 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

11. How can I Participate?  Fax Request for TER – Death  Receive Updates  Visit VSU E-Death Website www.tedr.texasvsu.org

12. Click here

14. Start-up email from help-ter@dshs.state.tx.us  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

15. Start up email from help-ter@dshs.state.tx.us

16. User Setup *see back of TER brochure

17. Let’s get started.

18. Help-TER John Smith 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). And the unique EDR # The basic information about the deceased The email contains the name of the funeral home

19. Accessing The Record Access the Internet by clicking on the icon. Copy https://ter2.dshs.state.tx.us/edeath to the address bar. Select ‘Enter’ or icon. https://ter2.dshs.state.tx.us/edeath

20. This is called the Portal Page. Click on ‘Thin ClientApplication’

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

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

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

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

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

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

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

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

29. The selected record will be displayed

30. or, click to choose Filter Option

31. Choose desired filter option

32. Click to access records in queue

33. Select record to complete

34. The selected record will be displayed

35. Start entering data on Medical 1 tab

36. Enter First Name and press ‘TAB’ to advance to the next item

37. If there is no middle name, press ‘TAB’ to skip to the next field.

38. If an item is skipped, you will be asked if you mean ‘NONE’ or if you need to complete the item later – if you say NO, the item will resolve

39. Enter the rest of the information, TABBING from field to field

40. Select Date of Death Type

41. Select Type of Place of Death

42. Type the first letter of the name of the Place of Death

43. Select Place of Death

45. The certifier section will already be completed based upon the funeral director’s designation

46. Complete the rest of the items. Clicking ‘TAB’ from the AM/PM field will move you to the next page of information

47. We are now on the Medical 2 Tab

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

49. 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.

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

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

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

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

54. We are now on the Medical 3 Tab

55. 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

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

57. If there are no contributing conditions, TAB past this field

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

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

60. 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.

61. 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

62. 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 Why We Need You

63. Example Approximate interval between onset and death 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. Due to (or as a consequence of) c. Due to (or as a consequence of) Sequentially list antecedent causes, if any, leading to the immediate cause with underlying cause last Condition which directly preceded death Antecedent condition Underlying cause

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

65. 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

66. 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

67. 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)

68. 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

69. “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 Tips and Pointers

70. WHY NOT? – TIME! Your time is important and valuable – VSU is working to remedy time issues! ISSUES New process – requires complex training New process – requires practice SOLUTIONS VSU will provide field and web based training Initial set-up is a long process but experience will decrease data entry time

71. TIME! Your time is important and valuable – VSU is working to remedy time issues! Repetitive information Data entry is time consuming Have to remember ID & password VSU is changing TER so that entered information will pre- populate Physician may use designated staff to enter data (Physician will need to use his PIN) Develop a manual with essential processes and information for using TER system

72. 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!

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

74. Your information is now stored in the system

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

76. Click ‘Yes’ to continue

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

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

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

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

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

82. Once again, click the ‘MEDICAL CERTIFICATION’ icon to electronically “sign” the record

83. Click ‘Yes’ to continue

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

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

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

88. Enter your PIN Click ‘OK’

89. Success! You are now finished with this record

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

91. 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.”

92. Click the ‘De-Certify’ icon

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

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

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

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