Tell DSHS What Killed a Patient

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Law Feature – November 2012

By Crystal Conde 
Associate Editor

Tex Med. 2012;108(11):45-47/

Just listing "cardiac arrest" as a cause of death in the Texas Electronic Registrar (TER) death registration system doesn't cut it anymore. That's because the Texas Department of State Health Services (DSHS) wants physicians to be more specific when listing the cause of a patient's death in the system.

"From a public health perspective, the cause of death section is a very important portion of the death certificate. Inaccurate data affect the usefulness of the state and national health database and all of the programs planned and implemented as a result," said Geraldine Harris, the state registrar.

She says merely listing "cardiac arrest" on a death certificate doesn't provide a helpful, in-depth picture of what led to the patient's death.

"The person could have died from anything, such as natural disease, homicide, suicide, or drug overdose," Ms. Harris said.

When a physician lists only cardiac arrest on a death certificate, she says, medical examiners routinely have to request medical records to verify whether the death was due to natural causes.

"Sepsis" is another general term that is difficult to interpret from a death certificate.

"It could be that the decedent was in a car accident two weeks prior and while in the hospital developed sepsis and died. This would make the death an accidental death due to a car crash, which must be reported to the medical examiner's office," Ms. Harris said.

DSHS says cause-of-death information is the basis of the state's mortality statistics. It relies on accurate data to illustrate how Texans fare on several health indicators, including heart disease, cancer, stroke, diabetes, and injuries. Inaccurate and nonspecific cause of death data can hinder the state's ability to receive grant funding for targeted health interventions.

According to Christine Mann, DSHS assistant press officer, once physicians list the immediate cause of death, TER then asks them to enter the chain of events – diseases, injuries, or complications – that directly caused the death, along with the corresponding interval between onset and death. TER provides four distinct rows for capturing the information. Physicians can help DSHS gather useful, accurate cause of death data by following the electronic registration system's prompts and including the chain of events leading up to the death.

But Houston cardiologist A. Tomas Garcia, MD, chair of the Texas Medical Association Board of Trustees, says the electronic death registry system "makes it difficult to be more specific when listing cause of death."

"The electronic death registry system needs to be set up differently so that once physicians have entered the immediate cause of death they can then easily enter the conditions that may have caused the death. The system provides only four entry lines for cause of death, and it's not enough for physicians to accurately express the risk factors and conditions that led to the patient's death. Once physicians are given more space to enter the information, then DSHS can connect the dots and study the data," Dr. Garcia said

He also encourages David Lakey, MD, DSHS commissioner, to meet with TMA leaders to discuss the department's need for more specific cause-of-death data.

"Texas physicians can help in this process, but we need to know who is going to control the data, how it's going to be used, and how it's going to be safeguarded," Dr. Garcia said.

Ms. Mann says a state data center protected by firewalls and data encryption houses death certificate information, which only authorized people can access.

Ms. Harris says having more specific cause-of-death data will help the state:  

  • Monitor public rates of morbidity and mortality,
  • Assist in scientific study and research,
  • Plan and monitor health policies and strategies,
  • Provide a basis for seeking legislative changes,
  • Prioritize health funding, and
  • Fund scientific research. 

 Properly listing causes of death in TER takes education, practice, and experience, Harris says, acknowledging that some physicians may not have been properly trained on how to complete death certificates accurately. (See "TER Training Available.")

The Physician's Handbook on Medical Certification of Death, published by the Centers for Disease Control and Prevention, has instructions for physicians on cause-of-death certification and describes how physicians can enter death information on certificates accurately. Pages 17 through 30 feature case studies, some of which illustrate the proper way to enter conditions leading up to the immediate cause of death.

 It's the Law

Since Sept, 1, 2008, state law has required all physicians who sign death certificates to register in TER, maintained by the DSHS Vital Statistics Unit, and to complete death certificates electronically. Physicians have five days after receiving the death certificate to electronically complete their portion of the form.

Back in 2010, more than 150 physicians were in hot water with the Texas Medical Board (TMB) over complaints they didn't complete death certificates within the time the law requires, a violation that carries a $500 fee per offense.

Leigh Hopper, TMB public information officer, says as of August, about 140 physicians had agreed to remedial plans for not using TER and/or not signing a death certificate in a timely manner.

TMB Executive Director Mari Robinson says physicians have two options when notified of a violation. They can agree to the remedial plan, pay the $500 fine, and complete any required continuing medical education; or they can request an informal settlement conference.

The law says a person required to file a death certificate (typically the funeral director) "shall obtain the required medical certification from an attending physician if the death occurred under medical attendance for the care and treatment of the condition or disease process that contributed to the death."

It also says an associate physician, the chief medical officer of the institution where the person died, or the physician who performed an autopsy may complete the medical certification if:  

  • The attending physician is unavailable,
  • The attending physician approves,
  • The person completing the medical certification has access to the deceased's medical history, and
  • The death is due to natural causes.  

By law, when a physician does not have enough information to determine the cause of death, he or she may contact a justice of the peace or medical examiner and request an inquest. To view chapter 193 of the Health and Safety Code relating to death records, click here.

No More Excuses

At this point, Dr. Garcia says, Texas physicians should know they must use TER when filing a death certificate.

"Physicians have had more than enough time to educate themselves on TER. If they haven't registered, they need to do so immediately. They can't make excuses anymore," he said.

DSHS says as of June, 1,558 funeral homes, 4,897 funeral directors, 21,820 physicians, 794 justices of the peace, 314 local registrars, and all 13 medical examiner's offices had enrolled in TER. DSHS reports as of June, 91 percent of this year's death certificates had been filed electronically. Of those, physicians certified about 81 percent.

Last year, certifiers filed 80 percent of death certificates electronically, compared with 63 percent in 2010, 44 percent in 2009, 19 percent in 2008, and 3.5 percent in 2007.

Ms. Mann says several factors have contributed to increased electronic filing of death certificates: 

  • DSHS online and conference training;
  • Collaboration with regulatory organizations and associations such as TMA and county medical societies, TMB, the Texas Funeral Service Commission, the Texas Funeral Directors Association, the Texas Hospital Association, and the U.S. Department of Veterans Affairs;
  • Assistance from local registrars, funeral homes, physicians, justices of the peace, and medical examiners; and
  • Technical assistance from the TER Help Desk and representatives of professional groups. 

The limitations in listing causes of death aside, Dr. Garcia says the system is easier to use now compared with two years ago.

"I can get into the system more easily now, and it doesn't take as long to fill out the forms," he said.

Ms. Mann says the department continues to improve the TER system based on feedback from users. DSHS has pre-populated the medical certifier forms with data from funeral homes to streamline the entry process.

Data quality was enhanced, too. Ms. Mann explains TER prompts physicians and other medical certifiers when additional information would provide more complete and meaningful data. For example, if a physician enters "cancer" as a cause of death, the system asks him or her whether the condition had metastasized and requests more information regarding the site and cell type.

Registration processing time has improved. Ms. Mann says DSHS currently processes TER registration applications within five business days. In 2010, it took the department 15 to 20 business days to issue a user name and PIN to a newly registered physician. Moving forward, she says, DSHS plans to enable the system to allow users to reset their own forgotten passwords by answering security questions.  

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at crystal.conde[at]texmed[dot]org.


TER Training Available

To register with and use the Texas Electronic Registrar (TER) death registration system, visit the Texas Department of State Health Services website. For assistance with registering, email the TER Help Desk.

Free TER training is available online. The training explains how to use, log in to, and navigate the system and includes a video of an electronic record being completed.

If you and your staff members need training on how to use TER, plan to attend the annual Texas Vital Statistics Conference Dec. 5-7 in Austin. Register before Nov. 16 for a discounted registration fee of $180. On-site registration is $200.

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