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3 Operational Considerations for Individual Counts of Mortality and Morbidity
Pages 79-120

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From page 79...
... The latter part of the chapter focuses on the current practices, tools, and systems for using individual mortality data and identifies potential best practices and opportunities for bringing these practices to scale. Because of the differences between disaster-related mortality and morbidity data for individual counts, the chapter handles these issues separately.
From page 80...
... and recording data on reported mortalities and morbidities involves a multitude of factors at the state or local level -- policies and case definitions for individual attribution; the availability of evidence and guidance to support decision making, the structure of the state or local medicolegal death investigation system, the process of death registration, and the training and professional judgment of medical examiners, coroners, and other medical certifiers to perform this work accurately and consistently. No standard practices, policies, or systems exist for recording these data.
From page 81...
... Although this report will not discuss the integration and use of social determinants of health data into mortality and morbidity data to enhance their actionability for use in disaster management, Appendix D provides two high-level case studies, which examine how social determinants of health relate to mortality and mortality during and following disasters. THE INVESTIGATION AND REGISTRATION OF DEATHS IN THE UNITED STATES In the United States, individual mortality data are collected through a process that spans multiple medical, legal, and administrative systems: the nationwide network of state, local, tribal, and territorial (SLTT)
From page 82...
... . Despite the essential skills and expertise that medical examiners bring to the medicolegal death investigation system, the number of professionals in the field is in decline and funding remains insufficient (IOM, 2003; NSTC, 2016)
From page 83...
... FIGURE 3-1  Variation in types of death investigation systems in the United States.
From page 84...
... . BOX 3-2 Medical Certifiers of Death in the United States Certain classes of deaths are typically investigated by medical examiners or coroners prior to being recorded by vital statistics offices.
From page 85...
... The state-level death registration system takes in data entered from multiple sources at the local and county levels, such as information from the case management systems used by ME/Cs and information from other medical certifiers and funeral homes, in order to create death records in state-based electronic death registration systems (EDRSs)
From page 86...
... The State and Territorial Exchange of Vital Events system, operated by the National Association for Public Health Statistics and Information Systems, provides a platform for secure inter-jurisdictional exchange of mortality data between state-level electronic death registration systems and the national system (NAPHSIS, 2020b)
From page 87...
... FIGURE 3-2  Simplified ideal process of certifying and registering a death in the United States. NOTE: CDC = Centers for Disease Control and Prevention; ME/C = medical examiner and coroner.
From page 88...
... Understanding the impact of the heterogeneity of medicolegal death investigation and death registration systems and the many different stakeholder roles is foundational to understanding the challenges related to operationalizing the collection, reporting, and recording of disaster-related mortality data. The structural consequences of this heterogeneity include poor interoperability and coordination among systems and stakeholders, variability in SLTT practices for attributing and collecting data on a death, and issues related to the completion of the death record in the state EDRSs.
From page 89...
... ME/C systems typically have clearly defined legal requirements for which cases are reported as being disasterrelated; however, inconsistencies among different states' requirements affect the accuracy of national-level reporting. A literature review of medicolegal death scene investigations after natural disaster- and weather-related events found no consistent approach for attributing deaths to a disaster and significant variation in how death scene data collection tools were being used (Rocha et al., 2017)
From page 90...
... 48 42 19 30 36 NOTE: FEMA = Federal Emergency Management Agency; NOAA–NWS = National Oceanic and Atmospheric Administration–National Weather Service; State response agencies = medical examiners and coroners and emergency operations centers; Vital Statistics = post-disaster review of death certificates in state-based vital statistics systems.
From page 91...
... Iowa • Coronavirus disease 2019 or COVID-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death. All deaths suspected or confirmed of COVID-19 must be reported to the medical examiner.
From page 92...
... and register the death within 72 hours. The city's centralized medical examiner office and rapid timeline for death registration are conducive to using death records for real-time mortality surveillance.
From page 93...
... , then NCHS cannot assign an ICD-10 code that attributes a death to a disaster.2 Prior research has noted that the quality of basic data recorded on death certificates is poor overall (Noe, 2018; NVSS, 2017) and that many death records in state EDRSs do not include clear, precisely defined terms for attributing a death directly or indirectly to a disaster.3 This can make it difficult for a medical certifier to record whether a disaster contributed to the death and to what degree.
From page 94...
... 94 MORTALITY AND MORBIDITY AFTER LARGE-SCALE DISASTERS FIGURE 3-3  Example of content from the EDRS data entry screen for cause and manner of death from the District of Columbia Vital Records Division. SOURCE: Personal communication, R
From page 95...
... , and medical certifiers outside the medicolegal system frequently do not have access to descriptive health and personal data about the decedent that could be used to inform their completion of the death record. In many cases of "natural" death, the physician in the hospital is often asked to complete the death certificate without any knowledge or training in reporting disaster-related fatalities.
From page 96...
... Conclusion 3-1: The heterogeneity of the nation's systems of death investigation and registration prevents the accurate recording and re porting of disaster-related mortality data and impedes the meaning ful analysis and use of these data to improve disaster management. Adoption of uniform practices for collecting, recording, and reporting mortality data is needed, as is improved vertical coordination across stakeholders and improved interoperability of electronic systems among medical certifiers, state vital records offices, and the national vital sta tistics system.
From page 97...
... MECISP also conducted site visits to assist in office computerization, supported educa tional meetings and the development of training materials for death investigators, facilitated ongoing projects being carried out by relevant professional organiza tions, contributed publications to the death investigation literature, conducted surveillance of selected types of deaths, and responded to specific inquiries from medical examiners and coroners about administrative and practical death investigation issues. SOURCE: Hanzlick, 1997.
From page 98...
... CDC has also provided support for transitioning to and strengthening electronic death registration data systems for mortality data and piloting system improvements.9 In Oklahoma, CDC supported the implementation of an electronic flagging process within the state EDRS to capture data on tornado-attributed deaths (Issa et al., 2019) , which is noted in this chapter as a best practice for individual-level disaster reporting.
From page 99...
... Beyond the barriers associated with the collection of reported individual cases and deaths and mirrored by similar operational challenges associated with capturing morbidity data in other natural disasters, the early months of the COVID-19 pandemic have demonstrated ongoing reporting challenges. In order to be included in a public health database, the patient first must seek health care, then the health care provider must decide to order a diagnostic test, then the test must be available, and, in many cases, the patient must then go somewhere else to obtain the test.
From page 100...
... However, as with other reporting for other disasters, some COVID-19 deaths will be missed in both public health case counts and on death records, and other deaths might be inaccurately attributed to COVID-19 on death records. For instance, in April 2020 vital statistics reports indicated a large increase in individuals dying at home rather than in the hospital (Gillum et al., 2020)
From page 101...
... Many entities across this enterprise are working diligently toward the aim of using individual mortality counts to protect the health and well-being of communities, but these efforts would benefit from greater collaboration and coordination across all systems and stakeholders to enable the network of state and federal death investigation and registration systems to function more effectively. At the outset, accurate and descriptive information to indicate, if present, the relationship of a death to a disasters -- direct, indirect, or partially attributable to a disaster -- needs to be entered into the death
From page 102...
... Furthermore, the purposeful inclusion of leaders and other stakeholders from these SLTT systems in the disaster management enterprise would be a step toward elevating the quality of disasterrelated mortality data. Conclusion 3-4: The implementation of an enterprise approach for im proving the assessment of mortality and morbidity following large-scale disasters is essential to the implementation of systemic improvements involving multiple, siloed stakeholders.
From page 103...
... NOTE: EDRS = electronic death registration system; NCHS = National Center for Health Statistics; OCME = Office of the Chief Medical Examiner.
From page 104...
... The use of existing disaster-related mortality tools developed by CDC and other agencies should also be promoted among medical certifiers, vital statistics staff, and emergency management staff alike. Importantly, most direct disaster-related deaths will be certified by a medical examiner or coroner because they are unnatural deaths.
From page 105...
... Several states have already made efforts to enhance partnerships across these siloed entities. In Florida, for example, partnerships among the state vital records system, county medical examiners, funeral directors, and professional associations are supported by state-level coordination by the State Commission.
From page 106...
... For instance, ME/C case management systems often include rich data that are not entered into death records created in the EDRS due to the administrative burden on ME/Cs to enter these data twice. Furthermore, individuals affected by disasters do not always remain in the declared disaster area and often cross jurisdictional and state lines, further underscoring the necessity of interoperability systems and easy data sharing across stakeholders.
From page 107...
... NCHS has worked with states to strengthen and improve the interoperability of their electronic death registration systems, and improving the quality of data captured on death records is a major priority for NCHS and NVSS. Vital statistics model law could be updated to incorporate data sharing and collection during disasters (e.g., standardized operation of electronic death records)
From page 108...
... Challenges and opportunities with respect to data sharing for population-level mortality and morbidity data will be explored in more detail in Chapter 4. Continuity of Data Collection and Recording During Disasters The difficulty of maintaining electronic data systems' continuity during disasters is another barrier to the collection and reporting of individuallevel mortality data.
From page 109...
... As with mortality, the variability in the capacities of SLTT health departments -- and the fact that many are under-resourced -- makes the creation of a standard system for collecting individual-level morbidity data especially difficult. There are many possible data sources for tracking morbidities, particularly within the health care systems, which already generates individual-level morbidity data.
From page 110...
... As described by officials in Paradise, the lack of rapid access to actionable data from the county level required Paradise responders to rely on local hospital data to guide their initial response and recovery efforts. Other county health departments have invested heavily in data systems that allow for greater collection and use of real-time mortality and morbidity data and have benefited from embracing greater collaboration between the public health and emergency management departments at a county level (see Box 3-7)
From page 111...
... Standardizing data collection processes specific to morbidity after disasters can be built into the nation's operational disaster response function, in a way that is similar to (but with different collection procedures) that proposed for mortality data collection.
From page 112...
... . Use of Electronic Health and Claims Data to Assess Morbidity: COVID-19 Case Study The recent COVID-19 pandemic presents a potential model system for the recording and reporting of health data related to the virus, which could be replicated for morbidity data in future disasters.
From page 113...
... Barriers to and Best Practices for Use of Individual Level Mortality and Morbidity Data Data sharing and system interoperability within and across jurisdictions are major barriers to the operationalization of individual-level mortality data. Establishing data sharing agreements during interim periods between disasters as a best practice could address these barriers.
From page 114...
... Cost-effectiveness research would also be useful in gaining buy-in from policy makers and other stakeholders for investment system improvements, practices for collecting and reporting individual-level mortality data, and training for medical certifiers. RECOMMENDATIONS Recommendation 3-1: Strengthen Existing Systems to Improve Individual-Level Mortality Data Quality The Centers for Disease Control and Prevention (CDC)
From page 115...
... , working with the states, should update the Model State Vital Statistics Act to drive uniformity of data collection and recording with respect to disaster related mortality. To promote uniformity in definitions and practices for collecting and recording disaster-related mortality data and enhance the quality and comparability of these data, NCHS should revise the Model State Vital Statistics Act to provide clear guidance and data stan dards to state vital records offices and medical certifiers.
From page 116...
... • The National Association of Medical Examiners, the Inter national Association of Coroners & Medical Examiners, the American Board of Medicolegal Death Investigators, and state based medical examiner and coroner professional organiza tions should support the proposed framework for collecting and recording uniform mortality and morbidity data, encour age the use of existing CDC tools and guidance by all profes sionals, and provide continuing education courses for their members that reflect this guidance. • CDC, through the National Center for Health Statistics, along with appropriate licensing bodies should provide standardized training and materials designed for medical certifiers (physi cians, nurse practitioners, physician assistants, and others as applicable by state)
From page 117...
... This new function could complement ESF8 and ensure focused attention on assessing mortality during and after disasters, while those charged with ESF8 responsibilities are focused on providing services to survivors. This new function could include the involvement of medical examiners, coroners, and other relevant professionals in planning drills for mortality management; effective, efficient, and unbiased data collection during disasters; training for family assistance centers; and standards for after-action reports and other mortality data reporting activities.
From page 118...
... 2006. Medical examiners, coroners, and public health: A review and update.
From page 119...
... 2019. Evaluation of Oklahoma's electronic death registration system and event fatality markers for disaster related mortality surveillance -- Oklahoma USA, May 2013.
From page 120...
... 2017. Medicolegal death scene investigations after natural disaster- and weather-related events: A review of the literature.


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