1. NAPHSIS Annual Meeting 2010 State Pilot Project Using the Electronic Death Registration System for H1N1 Surveillance Linette T Scott, MD, MPH Deputy Director Health Information and Strategic Planning California Department of Public Health June 9, 2010

2. NAPHSIS Annual Meeting 2010 Path Travelled Background Data Flow in California Query Development Other Issues and Next Steps

3. NAPHSIS Annual Meeting 2010 California Electronic Death Registration System (EDRS) Electronic creation and registration of Death Certificates, Amendments, and Disposition Permits Went “live” January 2005 By February 2010, 99.4% of Certificates created in EDRS ~ 240,000 – 250,000 deaths in California annually

4. NAPHSIS Annual Meeting 2010 Cause of Death fields

5. NAPHSIS Annual Meeting 2010 Value of EDRS Surveillance Identifies most serious cases for further epidemiological investigation Complements other data sources (e.g. Confidential Morbidity Reports, ED visits, hospitalizations) Encompasses entire population, not just a sample Minimum added resource cost— uses data from existing system

6. NAPHSIS Annual Meeting 2010 Data Flow in California GG note: Would say FH transcribes information

7. NAPHSIS Annual Meeting 2010 Why wait until local registration? Quality Check: Local offices will contact physicians if needed (e.g. Cause of Death is non- specific) Prior to local registration, medical information can be freely changed without documentation After local registration, certificate becomes a legal document and further changes must be done by filing an amendment

8. NAPHSIS Annual Meeting 2010 Free Text Surveillance Free text search: Cause of Death (COD) entries from physician Done before ICD-10 coding for COD assigned to Death Certificates Influenza disambiguation example: – Haemophilus influenzae – Parainfluenza – Misspellings

9. NAPHSIS Annual Meeting 2010 Cautions of Preliminary Data Late Entries Pending Certificates Amendments Duplicate Entries

10. NAPHSIS Annual Meeting 2010 Average Processing Times (YTD 2010) Date of Death to Local Registration – EDRS (fully electronic): 6.1 days – Non-EDRS: 4.5 days Date of Death to State Registration – EDRS (fully electronic): 15.7 days – Non-EDRS: 71.0 days

11. NAPHSIS Annual Meeting 2010 Processing Delays Biggest delays: – Physician COD entry – Physician signing of certificate Delays can also occur on the personal information half of certificate (e.g. clarifying family information) Can pull data prior to local registration but at cost of decreased data quality

12. NAPHSIS Annual Meeting 2010 How to Improve? Physician education: on importance of accurate COD entry on importance of timely COD entry and signature

13. NAPHSIS Annual Meeting 2010 Steps to Develop Query 1.Obtain listing of confirmed cases 2.Look up cases in EDRS for COD 3.Select most common/promising COD text strings and do test run 4.Of new results, how many are potential new cases versus “noise”? 5.Refine query

14. NAPHSIS Annual Meeting 2010 Steps 1 & 2 Confirmed case listing from May to August 13, 2009 55 out of 107 cases had “H1N1” or “Swine” or “Pandemic” in COD Others were non-specific (“Influenza”, “Pneumonia”, “ARDS”) Spelling variants found: “H1 N1” “H1-N1” “N1H1” etc

15. NAPHSIS Annual Meeting 2010 Steps 3-5 Test queries run in same time frame in EDRS “H1” “Swine” “Pandemic” brought up 21 additional deaths listed as H1N1 “Pneumonia” “ARDS” brought up too many non-specific results (e.g. aspiration pneumonia, sequelae of cancer)

16. NAPHSIS Annual Meeting 2010 Final Query Parameters “H1” or “Swine” or “Pandemic” anywhere in COD fields (107A, 107B, 107C, 107D) or Other Significant Conditions field (112)

17. NAPHSIS Annual Meeting 2010 EDRS PullConfirmed Cases Unreported confirmed case COD not confirmed (“clinical diagnosis”) Search term not in COD Delayed registration or amendment Out of state death Case both in EDRS pull and epidemiology- confirmed N=21N = 52 N = 55

18. NAPHSIS Annual Meeting 2010 Other Issues & Next Steps

19. NAPHSIS Annual Meeting 2010

20. Media & Public EDRS deaths are not confirmed EDRS and epidemiology-confirmed numbers will be different Media confusion regarding availability and interpretation of source data Not part of Public Records Act

21. NAPHSIS Annual Meeting 2010 Other Uses Seasonal influenza surveillance Other infectious disease surveillance Investigative resource (retrospective look) Chronic diseases?

22. NAPHSIS Annual Meeting 2010 Lessons Learned EDRS surveillance is feasible and of potential benefit Importance of partnering with programs (i.e. Vital Records and Communicable Disease Control) What is the program business need that EDRS surveillance can fulfill?

23. NAPHSIS Annual Meeting 2010 Thank you! Special thanks to: Dr. Scott Fujimoto (HISP) Dr. Glenna Gobar (U.C. Davis School of Medicine) Entire EDRS Staff Meileen Acosta and Division of Communicable Disease Control staff