1. TX Electronic Death Registration
Texas Department of State Health Services
Vital Statistics Unit
Albert Rivera
Manager,
Field Services

2. Agenda Background TER Technical Reminders Burial Transit Permits
Disinterment Permits
Fetal Death Registration

3. A Death Record is Important because:
It is a permanent legal record of the fact of death
Considered as prima facie evidence of a death
It is crucial for the decedent’s family
Used to apply for insurance benefits; settlement of pension claims; transfer of title of real and personal property; etc.
Used for a variety of medical and health-related research efforts

4. Use of Death Records - Global
Death Certificates are valuable in understanding the Public Health in Texas. The Center for Health Statistics uses the data collected from death certificates for the Texas Vital Statistics Annual Report. Some examples of data in the report include:
Deaths by Public Health Region, County, and City of Residence
Leading Causes of Death by race/ethnicity, sex, and age
Years of potential life lost before Age 65 – Leading causes of premature deaths by race/ethnicity and sex
Infant, Neonatal, fetal, perinatal, and maternal deaths by public health region
Infant Deaths by age, Race/ethnicity and sex

5. Uses of Cause of Death Information
Examples of how information on death certificates have helped with surveillance of natural disasters
Texas Panhandle Wildfires in March 2006
Total of 12 reported deaths
Smoke inhalation
Blunt force trauma and complications due to injuries from car accidents caused by reduced visibility due to smoke from the wildfire
Individuals driving to work who were trapped and overcome by the wildfire
Individuals involved in car accidents caused by reduced visibility from smoke
Recommendations
Disseminate wildfire prevention messages
Local, regional and state public health departments need to strengthen collaboration with emergency managers and local officials before, during and after all hazard events.
Hurricane Ike in September 2008
Total of 74 deaths
64% from injuries
Carbon monoxide poisoning (18%) (due to inappropriate use of gas generators or use of charcoal grills inside for cooking)
Drowning (11%)
Hit by falling tree (9%)
31% from illnesses
Cardiovascular failure leading cause if illness related
4% undetermined
Strengthen public education on preventing injuries associated with hurricane preparedness activities
Highlight the improper use of gas-powered generators associated with fatal carbon monoxide poisoning and prevention
Promoting safe cleanup and recovery activities
Tropical Storm Hermine in September 2010
Total of 9 deaths
ALL deaths caused by drowning
Vehicles washed off the road
Vehicles driving around barricades
Some locations didn’t have any barricades
Swimmers and kayakers in strong currents
Continue to disseminate public health messages of the dangers of driving vehicles into hazardous flood waters
Develop and disseminate news releases and messages about the dangers of swimming and kayaking in flooded waters
Continue to work with external partners to (Health Departments, National Weather Services, Texas Flash Flood Council, American Red Cross) to develop educational interventions to reduce deaths associated with flash floods

6. Why Use TER? Complies with the law
Instant Social Security verification process
Reduces fraud and duplicate registrations
Secure registration system
Edit and cross-checks reduce errors and amendments
A faster, more efficient, more accurate process
Instant Social Security verification process –
92% of all Social Security numbers are successfully validated using TER
TER is linked to the social security database, which helps stop social security fraud.
SSA gave us multi-million dollar grant to develop this process to keep checks from going out to deceased individuals.

7. TER Improves Timeliness
2007 = over 40 days
2012 = over 11 days
*** Do we have updated stats for 2012?
This slide shows how TER has reduced the time it takes to file a death certificate, which is important for the decedent’s family members
2012

8. The Number of all Electronic Records is Increasing
In 2012, 93.57% of records were totally electronic
In 2007, only 3.5% of records were totally electronic.
Total number of records filed
2009 – 167,034
2010 – 169,861
2011 – 172,152
Total all-electronic records filed
% all-electronic % % %
Total DTP records filed
% DTP % % %
Number of all-manual records registered
2011 – 13
These are calendar years, so 2011 is through August 31, 2011.
Total Number of Physicians enrolled in TER 17945
Total Number of Physicians enrolled and participating in TER 9347
2012
2012
As of June 2012ytd
93% of records were totally electronic

9. Responsibilities of Funeral Director
Initiate death record in TER to transmit Report of Death within 24 hours [TAC §181.2]
Obtain personal information from person most qualified to furnish information [HSC § ]
Notify JP or ME office when appropriate
All Death Certificates MUST be filed within 10 days of the date of death [HSC § (a)]
It doesn’t matter if the COD is Pending…
Reminder: Reports of Death are required so the LR can keep up with the deaths occurring in the district

10. Who is suppose to get the information for the death certificate?
The person required to file a death certificate shall obtain the required personal information from a competent person with knowledge of the facts. [HSC ]

11. Who Should Provide the Personal Information (Demographic)?
the person designated in a written instrument signed by the decedent;
the decedent's surviving spouse;
any one of the decedent's surviving adult children;
either one of the decedent's surviving parents;
any one of the decedent's surviving adult siblings; or
any adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.
[HSC ]
This is regarding who has the right to control the disposition of the decedents remains
[HSC ] Unless a decedent has left directions in writing for the disposition of the decedent's remains the following persons, in the priority listed, have the right to control the disposition, including cremation, of the decedent's remains, shall inter the remains, and are liable for the reasonable cost of interment:
the person designated in a written instrument signed by the decedent;
the decedent's surviving spouse;
any one of the decedent's surviving adult children;
either one of the decedent's surviving parents;
any one of the decedent's surviving adult siblings; or
any adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.

12. Notifying JP or ME Office
A body is found and the cause and circumstances of death are unknown.
Death is believed to be attributed to unnatural or unknown causes.
Death occurred in a correctional institute.
Death occurred within 24 hours of admission to a hospital.
Death occurred without medical attendance.
Decedent is under six years of age.
Physician is unable or unwilling to sign the death certificate.
Note: Only have to notify the ME office if death occurred within 24 hours of admissions to a hospital TCC (sec 6)(a)(1)
The Laws regarding the JP office doesn’t specify w/in 24 hours of admission to a hospital

13. Physicians Physicians can only certify natural deaths
Any death occurring by any means other than natural causes must be certified by either a Medical Examiner or a Justice of the Peace – Do not accept a DC medically certified by anyone other than an ME or JP for any COD other than natural.
HSC

14. Statutory Requirements
Texas Health & Safety Code
PERSON REQUIRED TO FILE. The person in charge of interment or in charge of removal of a body from a registration district for disposition shall:
(1)  obtain and file the death certificate or fetal death certificate;
(2)  enter on the certificate the information relating to disposition of the body;
(3)  sign the certificate; and
(4)  file the certificate electronically as specified by the state registrar.

15. Statutory Requirements
Texas Health & Safety Code Sec  (h)  
PERSONAL INFORMATION
(h)  The person completing the medical certification shall submit the information and attest to its validity using an electronic process approved by the state registrar.
Reminder: The TMB is actively following up on complaints
To file a complaint:
** need specific dates and details of an incendent

16. Time Requirements

17. Legislative changes
The 82nd Texas Legislative Session

18. Completing Date Fields
HB 2940 changed how dates will be entered on death and fetal death certificates:
Forms will specify a “Month/Day/ Year” order of entering dates
The month must be spelled out
Vital Statistics Unit is charged to revise the VS-113 form and modify the TER software to incorporate the changes
Starting by January 1, 2012

19. Upcoming TER Updates
Changes that will be released during the next TER update

20. New Enhancements Automatic Password Reset Automatic PIN number Reset
Notification to Funeral Home if Medical Certifier Changes decedent name
JP/ME inquest cases.
Enhancements to Medical Amendment Process

21. New Automatic Password Reset Security Question

22. When the new enhancements are put in place you will see a new log in screen.

23. When you enter your user id and password into TER you, a window will appear asking you to select and enter two security questions

28. Then continue with the log in.

29. Enter your user ID and select “Reset Password”

34. Reset PIN Number

37. TER Technical reminders
Names
Designating Medical Certifiers
Designating Local Registrars
Add on the Fly
Demographic Verification
Decertifying
Death Certificate Ordering Information (DCOA)

38. Entering Names 26 letters of alphabet without diacritical marks
Spaces, hyphens, apostrophes OK
Name automatically converts to all caps
REMINDER:
Have informants sign the Death Facts Verification form so that the informant knows exactly what is going to be on the death certificate
According the Health and Safety Code § (a) the Texas Department of State Health Services is responsible for prescribing the form and content of the death certificate.  The form and content that the Texas Department of State Health services uses is set by National Center for Health Statistics (NCHS) and the National Association for Public Health Statistics and Information Systems (NAPHSIS). 
Like a Social Security Card or a Texas Drivers License, all the information on a death certificate will be in all capital letters. The system automatically puts the data in all caps to ensure that the data received through the Texas Electronic Death Registration system is uniform and consistent.  It also alleviates any issues the end users may have with proper formatting.  This makes the data easily compatible with the databases used by other state and federal government stakeholders (e.g. Social Security Administration, Department of Motor Vehicles, Office of Attorney General, National Center for Health Statistics, etc) and makes it easier on the end user.
In addition to the all capital lettering, Federal Public Law , AKA the “Computer Security Act of 1987” requires that all federal databases follow the standards determined by the National Institute of Standards and Technology (NIST) and to use the 26 letters of the alphabet without diacritical marks. (note: Spaces, hyphens, and apostrophes are acceptable). 

39. **** ASK VICTOR*****
Is this correct? - Using AKA If they open an AKA form box but don’t need to add an alias, choose “Cancel”, not OK. Don’t hit OK if nothing is added. Otherwise an AKA will be added as a blank line and it will show up on the d/c.

40. TER Technical reminders
Designating Medical Certifiers

41. Select ‘Designate Medical Certifier’ or click the icon.
Step 1: To Designate a Medical certifier, select the “Designate Medical Certifier” from drop down or click on the icon…..

42. The ‘Medical Participating’ toggle will indicate if a medical certifier is found to be participating.
Next steps
the Medical Certifier Designation Search Box will appear. Select the appropriate Medical Certifier Type.
Enter the Medical Certifier name
If it is a common last name (like smith), enter the first initial or name
You can also use the license number. For example, if you know they are in TER but they don’t come up, call the office and get the license number.
Once you locate the Medical Certifier
Verify they are participating in TER. Sometimes they might be listed because they signed a DTP record and were added by the State
Highlight their name and select “Designate” elect the
If no one comes up after the search, the medical certifier is not participating, if this is the case you might have to follow up with the Doctor, TMB, etc or drop to paper .
NOTE: If the medical certifier is participating the toggle “Medical Part” will be checked.
NOTE: If the Local Registrar is participating the toggle will be checked. If a Local Registrar isn’t on TER, contact us after the presentation or call the State because we have legislative power of LR’s

43. This is sent to the medical certifier after they have been designated by the funeral director. The medical certifier can access the record using the EDR number.

44. TER Technical reminders
Designating Local Registrars

45. Verify or Designate a ‘Local Registrar’.
LR pick will be based on where the decedent died.
If the death occurs in a facility (hospital, nursing home, hospice, etc. licensed by DSHS) then the system will automatically designate the correct local registrar office based on the association between the facility and a local registrar. Otherwise, the funeral director must designate a Local Registrar before the record can be demographically verified. To designate a local registrar, the ‘Local Registrar’ field must be blank.
Keep in mind that TER does not know where homes, businesses, etc. are located. You may need to call the local registrar’s office to ask which is the appropriate LR.

46. Again, this happens when the death occurred at home, is ‘unknown,’ or marked ‘other.’
Steps to Designate a LR
Select the Designate a Local Registrar Button
When the local designation box appears, click the arrow on the “please select local registrar” field, and choose a local registrar from the pull down list
Select a LR by clicking on the name and then press OK
Verify that the LR was selected by going to the Dem 5 tab and viewing the LR field
Designate a local registrar office when the ‘Local Registrar’ field is not complete. Under ‘Registration’, click ‘Designate Local Registrar’ or click on icon.

47. TER Technical reminders
Add-On-The-Fly

48. What if my option isn’t listed? Add-On-The-Fly!
Go down to the bottom of the list of cities for the and Select (Add New)

49. Adding a Precinct
Enter the city and/or precinct and select Save New AOF Location

50. Adding a Precinct
New City will be entered into location

51. TER Technical reminders
Demographic Verification

52. Select ‘Demographic Verification’ or icon.

53. Select ‘Preview’ or ‘Verify’ to generate and review the information.
This is your opportunity to preview what’s been entered.
Pressing the ‘PREVIEW’ button will cause a printing message to appear: ‘Are you sure you want to print this record?’ (Y/N). Answering ‘Y’ will present a print preview of the death abstract so it can be reviewed before verifying it. The abstract can also be printed from this preview if desired. Exercising the ‘Preview’ option will exit the verification process and the user will need to access the process again to verify the record.
Pressing the ‘VERIFY’ button will initiate the Demographic Verification process.
Pressing the ‘CANCEL’ button results in exiting from the Demographic Verification screen.
1st opportunity to print something.
Select ‘Preview’ or ‘Verify’ to generate and review the information.

55. Select the Print Button then close this window.

56. Then Select Verify

57. New users will need to create a perm pin number…..

58. Your “Old Pin” is a your temporary pin given to you by your local TER Administrator.

60. Then Select Verify again

61. Enter your PIN number.
Enter your PIN number into the next box and press ‘OK’. You will receive a message that demographic verification for the record has been successful. Other staff may enter the demographic information, but only the funeral director should enter their PIN.
*******STRESS IMPORTANCE OF ALL STAFF HAVING THEIR OWN USERNAME ID’S AND PASSWORDS, per the TER agreement

64. TER Technical reminders
Decertifying

65. Decertifying
If the record has already been filed by the LR the funeral home can not decertify the record and will have to create make an amendment

66. TER Technical reminders
Death Certificate Ordering Information (DCOA)

67. Note that both the local registrar and medical certifier are participating in TER.
Click the DCOA icon.
Notice how boxes are checked. Since this record is electronic, the funeral director must place their order for at least 1 certified copy of the death certificate through VSU.
Reminder: Don’t order a DC until after the Medical Certifier certifies the record
The record is now required to be processed electronically and certified copies can be ordered.

68. Complete the DCOA order information.
Place the order from this screen. To place the order:
Complete all fields
Must have valid credit card
First DC cost $20 and additional copies are $3 each
Don’t forget to SAVE at the end. This is one of the most common problems – once you’ve entered your information – you are not finished. You must hit SAVE to actually send the order

69. Note the ‘DCOA Response’ and exit.
This lets the user know their order has been placed.

70. Burial Transit Permits
When Burial Transit Permits are Required

71. Texas Administrative Code §181.2(b)
Assuming Custody of Body (b) If a dead body or fetus is to be removed from this state, transported by common carrier within this state, or cremated, the funeral director, or person acting as such, shall obtain a burial-transit permit from the local registrar where the death certificate is or will be filed, or from the state registrar electronically through a Bureau of Vital Statistics electronic death registration system. The registrar shall not issue a burial-transit permit until a certificate of death, completed in so far as possible, has been presented
From the VSU Handbook for Death Registration:
"Completed in so far as possible" means all of the information relating to the deceased, such as the name, date of death, place of death, and funeral director's information is complete. In a few instances, the physician may not have certified the cause of death before removal from the district.
It is the responsibility of the funeral director filing the Certificate of Death completed as far as possible, and obtaining the Burial-Transit Permit, to assure that the fully completed Certificate of Death is filed with the local registrar as soon as possible. If an incomplete certificate is used to obtain the Burial-Transit Permit, the registrar may wish to confirm that the body is no longer needed by the certifier before issuing the permit. This helps assure that a completed death certificate will be received.
A Burial-Transit Permit is not necessary if transporting the body within the state by means other than common carrier. A copy of the Report of Death form is sufficient.
Texas Administrative Code §181.2(a) Assuming Custody of Body
(a) The funeral director, or person acting as such, who assumes custody of a dead body or fetus shall obtain an electronically filed report of death through a Bureau of Vital Statistics system or complete a report of death before transporting the body. The report of death shall within 24 hours be mailed or otherwise transmitted to the local registrar of the district in which the death occurred or in which the body was found. A copy of the completed or electronically filed report of death as prescribed by the Bureau of Vital Statistics shall serve as authority to transport or bury the body or fetus within this state.

72. TX Health and Safety Code § 193.008
BURIAL-TRANSIT PERMIT. (a) A burial-transit permit issued under the law and rules of a place outside of this state in which a death or fetal death occurred authorizes the transportation of the body in this state. A cemetery or crematory shall accept the permit as authorization for burial, cremation, or other disposal of the body in this state.
A Burial Transit Permit is required to ship or transport a body out of the state or to transport a body by common carrier within the state.

73. Texas Administrative Code §181.3(c)
Transportation of Dead Bodies (c) Duties of transportation companies. No transportation company shall accept any body for shipment until it has been ascertained that a properly completed burial-transit permit accompanies the body.

74. FUNERAL DIRECTORS can print out Burial Transit Permits if:
The Cause of Death is natural
The record is fully electronic
Funeral Directors will have to obtain a burial Transit Permit from the Local Registrar when:
The record is fully manual or has been dropped to paper
The Death is anything other than natural.

76. Disinterment Permits
When Disinterment Permits are Required

77. Is a Disinterment Permit needed?
Texas Administrative Code §181.6 Disinterment (a) remains may not be removed from a cemetery except on written order [a Disinterment Permit] of the state registrar or the state registrar's designee. (d) A disinterment permit shall not be required if a body is to be disinterred and reinterred in the same cemetery. (e) A disinterment permit shall not be required to remove cremains. (f) Cremation is considered to be a final disposition of remains.
Funeral directors have to send application to the state with consent form.
Applications on the website
From VSU Handbook for Death Registration
The Disinterment Permit issued by VSU serves as the authority to disinter, transport, and reinter a body within this state. If the body is to be removed from the state, transported by common carrier within the state, or cremated, a Burial-Transit Permit must also be obtained. [HSC , HSC , 25 TAC 181.6]
A Disinterment Permit shall not be required if a body is to be disinterred and reinterred in the same cemetery.
The Application for a Disinterment Permit (VS-271) (39K .doc), must be signed by the funeral director or embalmer licensed by the Texas Funeral Commission making application for the permit. The sole responsibility for obtaining the consent of the cemetery, the owner of the plot, and the deceased's next-of-kin rests with the funeral director or embalmer making application for a Disinterment Permit. The application, consent forms, and $25.00 required fee must be sent to VSU.
The State Registrar issues the Disinterment Permit in four parts. The funeral director to whom the permit is issued shall retain a copy, a copy is to be filed by the sexton of the cemetery in which the reinterment is to be made, a copy shall be filed by the local registrar with the local registrar's copy of the Certificate of Death, and a copy will be filed by the State Registrar with the original Certificate of Death.
A Disinterment Permit is good for one (1) year from the date of issuance.
Full Statute for 181.6
(a) Except as is authorized for a justice of the peace acting as coroner or medical examiner under the Code of Criminal Procedure, Chapter 49, remains may not be removed from a cemetery except on written order of the state registrar or the state registrar's designee.
(b) The licensed funeral director to whom the disinterment permit is issued shall be responsible for the proper conduct of the disinterment and removal.
(c) The state registrar shall issue a disinterment permit so as to provide a copy for the state registrar, a copy retained by the funeral director to whom issued, a copy filed with the sexton or person in charge of the cemetery in which the disinterment is to be made, and a copy for the local registrar of the district in which the death occurred. The state registrar and the local registrar shall amend the certificate of death filed in their respective offices.
(d) A disinterment permit shall not be required if a body is to be disinterred and reinterred in the same cemetery.
(e) A disinterment permit shall not be required to remove cremains.
(f) Cremation is considered to be a final disposition of remains.
(g) A disinterred body must be transported in a container which insures against the seepage of fluid or the escape of offensive odors. When shipped by common carrier, a disinterred body must be enclosed in an airtight metal casket encased in a strong outside shipping case, or in a sound casket encased in an airtight metal or metal-lined shipping case. This requirement shall not apply if the disinterred remains involve no soft parts.
(h) The disinterment permit issued by the state registrar shall serve as the authority to disinter, transport by means other than a common carrier, and re-inter a body within this state. (See §181.2 of this title (relating to Assuming Custody of Body).
(i) A body kept in a receiving vault shall not be regarded as a disinterred body until after the expiration of 30 days.
(j) All disinterred remains kept in receiving vaults shall be thoroughly embalmed in a manner approved by the Texas Funeral Service Commission and shall be enclosed in a permanently sealed casket.
(k) The licensed funeral director or embalmer requesting a disinterment permit shall be responsible for obtaining a written consent of the cemetery, the owner of the plot, and the decedent's next-of-kin.
(l) The licensed funeral director or embalmer requesting a disinterment permit shall be responsible for obtaining a written consent order from the county judge to disinter a body from a grave when the cemetery, plot owner, and the decedent's next-of-kin are unknown.

79. Whose signature do you need?
 Health and Safety Code
cemetery organization operating the cemetery
current plot owner or owners
one of the following persons, in the priority listed:
(1)  the decedent's surviving spouse;
(2)  the decedent's surviving adult children;
(3)  the decedent's surviving parents;
(4)  the decedent's adult siblings; or
(5)  the adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.
Along with the Application for Disinterment Permit, written consent is needed from the following: Cemetery Org, Current plot owner, and “next of kin”. 
Health and Safety Code REMOVAL OF REMAINS.
(a) Remains interred in a cemetery may be removed from a plot in the cemetery with the written consent of the cemetery organization operating the cemetery and the written consent of the current plot owner or owners and the following persons, in the priority listed:
(1)  the decedent's surviving spouse;
(2)  the decedent's surviving adult children;
(3)  the decedent's surviving parents;
(4)  the decedent's adult siblings; or
(5)  the adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.

81. Fetal death registration
Fetal Death Registration and Certificate of Birth Resulting in Stillbirth

82. Fetal Death vs. Life Birth
TAC (11) Fetal death (stillbirth)--Death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation, the fetus does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. TAC (18) Live birth--The complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy, which, after such separation, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered live born.
A Fetal Death occurs when a fetus dies before or during labor or delivery, regardless of the length of pregnancy. A Fetal Death is determined when the fetus does not breathe or show any evidence of life after being separated from the mother. A Fetal Death is sometimes referred to as a stillbirth and it is a death that was unintended.

83. Filing a Fetal Death Certificate
A certificate of fetal death shall be filed for any fetus weighing 350 grams or more, or if the weight is unknown, a fetus aged 20 weeks or more as calculated from the start date of the last normal menstrual period to the date of delivery.
Fetal Death certificates need to be filed within 5 days. [TAC 181.7]
Texas Administrative Code 181.7
(a) A certificate of fetal death shall be filed for any fetus weighing 350 grams or more, or if the weight is unknown, a fetus aged 20 weeks or more as calculated from the start date of the last normal menstrual period to the date of delivery.
(b) A certificate of fetal death shall be considered properly filed:
  (1) when all of the items thereon have been satisfactorily and definitely answered; and
  (2) when the certificate has been presented for filing to the local registrar of the registration district in which the fetal death (stillbirth) occurred or the fetus was found. A certificate of fetal death (stillbirth) shall be filed with the local registrar within five days after the date of fetal death (stillbirth).

85. Resources TER Help Desk TER Online Training VSU
Ext 3490
TER Online Training
VSU