Making Modernization Work… For Everyone

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In Maryland, we’ve changed the way we capture information about deaths. We’ve made our death reporting systems more electronic, connected, and responsive. We’ve rewritten our policies and regulations. Because we’ve made big changes, we’re now better at handling evolving threats like the drug overdose epidemic and COVID-19.

But big change doesn’t happen overnight. And it doesn’t come just from getting a new system or making a new law, although both of those things can be useful. If you want change to be meaningful and lasting, you also have to give people on the ground what they need to make it work.

Technology is just the first step

Getting an Electronic Death Registration System (EDRS) was a critical step toward modernizing our death reporting. Until about five years ago, all of our systems were paper-based. Physicians, medical examiners, funeral directors, and the state vital records office would pass death certificates physically from one place to the next.

Our partners at the California Department of Public Health came to the rescue. They offered to share their EDRS with us, and we customized it to work in our state.

However, when we rolled out the new system in January 2015, we discovered it wasn’t an instant fix for everyone. For people used to the old system, new technology felt more like an obstacle than an improvement.

Helping technology work for people

For example, our physicians – who were used to filling out a form and handing it off – suddenly had to navigate sets of pull-down menus, tabs, options. They had to keep track of accounts with passwords that changed periodically. If they worked in different medical facilities (and many do), they would have to remember their sign-on for each one. It was a lot more complicated.

On top of that, people were adopting the new EDRS at different rates. Funeral homes were required to use the electronic system, but they were still getting paper records from medical facilities. Funeral directors had to spend valuable time typing all the information in.

Listening to people’s concerns led us to modify the system to make it easier for them to use. For physicians, we created a single sign-on process so they could use their own login to enter the system from any facility. The system is also web-based so they can access it from their phones.

To help lighten the workload for our funeral directors, we added training coordinators to help more medical facilities start using the system. Ultimately, we changed our regulations in 2019 to require all medical facilities by law to start the death certificate electronically.

Not just speed, but quality

Today, almost everything we do is electronic. We’ve recently added long-term care facilities, hospices, and large physician medical groups to the EDRS. When the COVID-19 pandemic reached Maryland, we adapted the system to handle surge facilities.

Beyond making our death certificate registration faster, working electronically is also allowing us to improve the quality of the data. For example, we’ve been preventing more errors by using the VIEWS II system, which automatically checks every cause-of-death entry for spelling mistakes and inaccuracies. We’ve been able to do more geocoding to help with tracking deaths at the community level. We’ve also created a new database that allows us to do better statistical analyses using the cause-of-death information we get back from the National Center for Health Statistics (NCHS).

A vision for a connected future

Even with all these accomplishments, our work is far from done. We won’t have reached our goal until we’re not only electronic, but also fully interoperable with the many other systems we touch. For example, we want to be able to integrate our system with those that handle electronic health records.

Interoperability means finding a “common language” for our technologies so that we can pass information more seamlessly from one place to another. We’re looking toward standards like HL7’s Fast Healthcare Interoperability Resources (FHIR) to make that happen. NCHS is connecting a broad community of states and IT experts to innovate around these new challenges.

As we reimagine our systems, we’re going to continue putting people first. Our close relationships with NCHS and our partners in California have strengthened our outside community of support. Inside our state, connecting with the people who use the technology every day will remain the key to making this next phase of change a reality.

Special thanks to the Maryland Department of Health and Lee Hurt, DrPH, MS, Director, Vital Statistics Administration, for contributing to this story.