Can Texas Do Death Better?
By Sean Price Texas Medicine January 2018

Filling out death certificates can be confusing and difficult for Texas physicians, and that can lead to errors that skew death statistics 

Cover Story — January 2018

Tex Med. 2018;114(1):26–31. 

By Sean Price
Reporter

In 2006, the Texas Department of State Health Services (DSHS) made a major change in how it processed death certificates: switching from traditional paper forms to a computerized system called the Texas Electronic Registrar (TER).

The transition, however, did not go over well with physicians. 

"I emailed them way back then and said, 'Hey, not to be mean, but this is probably the worst software I've ever seen,'" said Rodney Young, MD, professor of family medicine at Texas Tech University Health Sciences Center in Amarillo. "I actually said, 'If you want to redesign this, I'll be glad to help out.'"

Physicians using TER must fill out an electronic death certificate within five days of receiving it or face penalties from the Texas Medical Board (TMB). But the electronic forms created so many problems that the penalties had to be suspended for two years ― not to redesign TER, but to give physicians time to learn it.

Dr. Young says the difficult software is no problem for him now because he does hospice work and uses TER frequently.  

"The system's not that bad once you know it well," he said. "But I also know new users whom I've added as local site administrators for TER, and none of them can just sit down at the computer and fill out a death certificate without someone with experience showing them, 'OK, do this, now do that.'"

DSHS is planning a replacement system for TER, called TxEVER, which is scheduled to come online in 2019. (See "TxEVER at TMA's Winter Conference.") 

But concerns about death certificates go far beyond TER. For instance, new doctors receive almost no training on how to fill out death certificates, and many say the information often represents nothing more than a "best guess" by a physician who might know little about a patient's medical history. 

These and other issues have serious repercussions for public health because death certificates are the foundation of many vital statistics, such as the leading causes of death. If physicians and policymakers don't have an accurate picture of what is killing people, they cannot accurately shape health care policies. 

"Concerns about data quality are not just found in Texas," said Tara Das, PhD, state registrar for DSHS' Vital Statistics Section. "These are national- and international-level concerns."

Registering Death in Texas

Texas' system of registering deaths is similar to most other states. 

If any person dies by violence or suspected foul play, an autopsy to determine cause of death is done by a medical examiner, who fills out a death certificate. 

In rural areas, a justice of the peace fills out death certificates for people who die at home or away from medical care. Justices of the peace are not required to have medical training.

But attending physicians tend to handle most death certificates because people most often die in a hospital or under a doctor's care. 

However, Texas law is vague about which physician is responsible for the medical information on a death certificate (see example). Generally speaking, the job falls to the deceased's attending physician, who might know little about the patient's overall medical history, says John Holcomb, MD, who specializes in pulmonary and critical care in San Antonio. 

Texas law says that "the person required to file a death certificate shall obtain the required personal information from a competent person with knowledge of the facts." 

But tracking down accurate information on the deceased patient can be difficult for already busy physicians, says David Lakey, MD, chair of the Texas Medical Association's Council on Science and Public Health.

"They're doing a lot of other things in clinic and taking care of people who are alive," said Dr. Lakey, who also is a past commissioner of DSHS. "Filling out the death certificate a lot of times is on the lower end of the priority [list]. It's hard for physicians to put the time in to make sure everything is right."

Dealing With TER

Filling out death certificates is made more difficult by TER and Texas' current system of assembling death certificate information. 

The DSHS handbook on TER says a death certificate must be filed within 10 days.

"What happens is that the funeral home picks up the body, takes it to the funeral home," Dr. Holcomb said. "They then execute the first part of the death certificate, which includes the demographics, the date and time of death, and those sorts of things. After they've done that, they load [the certificate] into the system and then send the doctor an email that it's ready."

At that point, physicians have five days to make their report.

The problems often start with how physicians are notified that they are responsible for a death certificate. Physicians receive one email as notification, with no follow-up emails or other notices. Physicians can easily miss these solitary emails because they're mistaken for spam or because they automatically get routed to spam filters. 

More importantly, many physicians don't rely on email anymore for day-to-day communication, says Charles Duncan, MD, another primary pulmonary and critical care physician in San Antonio. 

"Doctors communicate through texts now," he said. "Email is really starting to die out." 

Physicians who miss the five-day deadline usually get reported by the funeral home, Dr. Duncan says. When that happens, TMB frequently administers a nonjudicial punishment of a $500 fee and four hours of continuing medical education (CME), though the CME is not tied to helping people learn the TER system, Dr. Duncan says.

"[The punishment] doesn't train people to do anything, [and] it doesn't solve anything," he said. "It just makes physicians feel bad that they got slapped for something they [often] didn't have any control over."

Physicians who do fill out a death certificate face a steep learning curve, partly because the TER form can be a verbal minefield. 

"If somebody has a stroke, that's [an OK term to use]," Dr. Young in Amarillo said. "But if you call it a 'cerebrovascular accident,' the medical name for [a stroke], the system will kick you out and say, 'I see the word 'accident,' that's a non-natural cause of death. That has to go to the medical examiner.' … There are a number of little scenarios like that."

These and other time-wasting problems with the TER system discourage physicians from filling out death certificates comprehensively, Dr. Duncan says. 

"All [the physicians] really want to do is just get it done and go on with their day," he said. 

Skewed Statistics

Complaints about Texas' death certificate process feed into a much larger area of concern: the overall accuracy of death statistics.

It's widely accepted that autopsies are the most accurate way to determine how someone died. However, objections by family members and the cost of the procedure have caused a steep decline in autopsies. According to a 2012 report by NPR, ProPublica, and Frontline, about half of all patients in the United States who died in hospitals in the 1970s were autopsied. That number now is closer to 5 percent.

Because of this, misdiagnosed illnesses have been reported as the official cause of death. 

"Historically, the literature reports a major discrepancy between the attending [physician's] diagnosis and the autopsy findings in about 5 percent to 7 percent of their cases," said Frank Papa, DO, associate dean for curriculum design and faculty development at the Texas College of Osteopathic Medicine in Fort Worth, and an authority on diagnostic error. 

Even a few errors on death certificates can have a profound impact on death statistics, Dr. Lakey says. That in turn can shape health policies on issues such as maternal mortality.

"A few numbers could really skew the data for a relatively rare event," Dr. Lakey said. "Maternal mortality is obviously a very important issue. In total numbers though, it's still relatively low ― 130 women [or so per year]. So if there are 20 deaths miscoded, you have a huge fluctuation in those numbers."

The misdiagnoses are widely assumed to have an impact on statistics for opioid use, Dr. Duncan says. Health issues caused by opioid use frequently resemble respiratory problems. An accurate diagnosis can be missed by trained doctors and are almost certainly missed by untrained justices of the peace.

"In most cases, you're going to see the respiratory failure and pneumonia [on a death certificate]," he said. "But you're not going to see the opioid addiction that created it."

The obvious alternative is to go back to requiring more autopsies for at least a small percentage of deaths, Dr. Papa says. 

"The only way to know how [a] patient died is to do an autopsy," he said. "A physician's professional judgments regarding the cause of death will be correct to some level of accuracy. And the literature tells us that such judgments might be accurate up to 92 percent to 93 percent of the time. … But it could be that error is even greater than what we've believed."

However, any effort to require more autopsies would encounter several obstacles. For physicians, it would require telling grieving relatives that a person who has just died must be autopsied. Also, more autopsies would be a financial burden: Insurance companies do not pay for autopsies, which can cost up to $2,500, so the expense would have to be shared by individuals or by state and local governments. 

The only reasonable alternative for now is to have the treating physicians use their best judgment to decide on the most likely cause of death, Dr. Young says.

"I'm not sure who would be better situated to guess than the treating physician," he said. "The word 'guess' is probably not the best choice, but the circumstances leading to death are not always clear cut, so you sometimes have to use your best judgment. We deal in probabilities all the time. This is just another situation in which you deal in probabilities."

Virtually all physician training on death certificates currently is done on the job, Dr. Duncan says, suggesting that medical schools need to do more to educate future doctors about the importance of death certificate information. 

"If you go to a medical school and say, 'Where in your curriculum do you teach how to fill out death certificates?' everybody will probably look at you like you're nuts because they never thought it was an important thing," he said.

Dr. Lakey says the bigger changes ― such as doing more autopsies and replacing justices of the peace ― are not going to happen anytime soon. But he says DSHS' proposed TxEVER system holds the promise of making the process easier and more accurate.

"It still comes down to somebody filling out the form accurately to have reliable data," he said. "I think that's why physicians need to be part of that process."

Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email. 

SIDEBAR

TxEVER at TMA's Winter Conference

In 2019, the Texas Department of State Health Services' (DSHS') Vital Statistics Section will launch TxEVER, which is designed to replace the current electronic death certificate system, the Texas Electronic Registrar (TER).

Victor Farinelli, deputy state registrar for DSHS's Vital Statistics Section, says the agency sees this as a way to replace an aging system with something more user-friendly for everyone who has to fill out death certificates: physicians, justices of the peace, medical examiners, and funeral home directors (as well as ― in limited cases ― physician assistants and nurse practitioners). 

"We want to make a more up-to-date, technology-forward system," he said.

DSHS will have a booth dedicated to TxEVER at TMA's 2018 Winter Conference on Jan. 26–28 in Austin. Physicians will be able to see what the new system looks like and discuss any matters tied to death certificates.

Tara Das, PhD, state registrar for DSHS's Vital Statistics Section, says physicians already have made contributions to the new system's design. For instance, she says thanks to their input, DSHS will be able to control and modify the types of editing and error messages that pop up when physicians fill out forms.

"[That's different from] our current system, where it's much more fixed and it's not under [DSHS'] control to make quick adjustments to respond to those types of user concerns," she said.

Dr. Das says in the months to come, physicians will also be able to comment on ― and help pilot ― TxEVER before it goes online next year. She says physicians can email DSHS. DSHS also will hold conference calls throughout this year.