Applying the CDC NEDSS Model to Vital Records

1. Applying the CDC NEDSS Model to Vital Records Cindy Hooley Richard McCoy Vermont Department of Health Center for Health Statistics

2. Applying the CDC NEDSS Model to Vital Records: Background • Vermont initiated re-engineering of Vital Records operations with planning in 2002 / 2003. • Legal birth certificate and birth reporting system identified as first vital event to undergo revision. • Old system: EBC system (Genesis software) with hospitals transmitting weekly to Vital Records. Certificate sent to town clerk and then to Vital Records. • Birth registration typically required 10 - 11 days (from hospital event to receipt at Vital Records).

3. Applying the CDC NEDSS Model to Vital Records: Background • Decision was made to move vital events data to the Department’s new database built on the NEDSS model. • CDC’s National Electronic Disease Surveillance System (NEDSS). • All vital events for an individual stored in one database based on “entity” (person) rather than an event. • Example: an individual’s birth, immunizations, death, etc. stored as one entity (person) record rather than three separate data files.

4. Applying the CDC NEDSS Model to Vital Records: Background • Department’s database called: SPHINX (Shared Public Health Information Exchange. • Vermont an early adopter of NEDSS model for infectious disease tracking / reporting, but would be first state to successfully apply the model to Vital Records. • Vermont had early experience in applying the model to the Immunization Registry. However, did not fully prepare us for the challenges of applying the model to vital events.

5. Applying the CDC NEDSS Model to Vital Records: SPHINX

6. Applying the CDC NEDSS Model to Vital Records: VTEBRS / OBNet • Vermont’s Electronic Birth Reporting System (VTEBRS) built in-house with existing ITS staff / resources with no additional funds or resources. Utilized the NAPHSIS use cases and the NCHS guidelines and materials. • Implemented the revised U.S. standard birth certificate. • In-house development: no funds to purchase third-party solution; too difficult to modify and integrate third-party solution with SPHINX database (SQL environment); some tools already built as part of Immunization Registry.

7. Applying the CDC NEDSS Model to Vital Records: VTEBRS / OBNet • OBNet: partnership of Dartmouth Hitchcock Medical Center and Fletcher Allen Health Care. Application is a Web-based obstetrical delivery registry. • Primary function of OBNet is to provide data for quality assurance and quality improvement projects. Registry to collect data -- maternal and fetal risk factors, interventions, and outcomes. • OBNet licensed to several VT hospitals in 2005. Accounts for 55% of Vermont births (not counting Dartmouth Hitchcock…those Vermont resident births reported to Vermont by NH’s Vital Records office).

8. Applying the CDC NEDSS Model to Vital Records: VTEBRS / OBNet • OBNet hospitals approached Vital Records to inquire about building a birth certificate / reporting module into OBNet. Avoid double data-entry for the hospitals into both OBNet and VTEBRS. • Agreement reached to allow OBNet birth reporting into SPHINX if OBNet incorporated NCHS edits / standards. • This began a two-year development cycle starting in 2003: VTEBRS interface / edits; OBNet design / edits; and, SPHINX database design and testing (de-duplication; reports; data warehouse).

9. Applying the CDC NEDSS Model to Vital Records: Challenges • Timetable: Missed launch date of Jan. 1, 2005 Launched July 1, 2005 (which created new problems) Amount of time / work involved with OBNet partnership Time with use case review and modifications Complete rethinking of business processes • Technology: De-duplication Data warehouse Reports, extracts, etc. Messaging system with OBNet

10. Applying the CDC NEDSS Model to Vital Records: Challenges • Birth record must be preserved! - SPHINX is entity based, with relational tables. - Concept is that Health Department Programs “share” common information. - Had to convince IT that changes to birth information could affect changes in other tables, but not other way around! ex. Mom updates address when she brings infant to physician’s office for immunization…but does not change the original address on b.c. - Result: separate tables containing demographics, medical information, race/ethnicity, and amendments created and maintained for birth records.

11. Applying the CDC NEDSS Model to Vital Records: Challenges • Standards: - Some NCHS codes did not match NEDSS standards. - No standard for Race provided by NEDSS. - IT decided to go with NCHS codes as the “standard” especially given how extensive it is. - Bigger issue in terms of data warehouse….

12. Applying the CDC NEDSS Model to Vital Records: Challenges • De-duplication - Whenever a program starts to enter a new record, search function looks for possible duplicates. - Function works well, but always under review for improvement. - Analysts checking EBRS and IMR data warehouses regularly for matches or near matches.

13. Applying the CDC NEDSS Model to Vital Records: Challenges • Address Issues: Data Entry and Analysis - NCHS wanted FIPS. Too many choices representing the “same place” in VT. Clerks would not know which one to choose at data entry! We edited the list based on class codes. - IT wanted ZIPs for mailing addresses. Zips to FIPS is a many to many relationship, so difficult to map / translate/recode from one to the other.

14. Applying the CDC NEDSS Model to Vital Records: Challenges - VDH Analysts wanted CTC codes! These are 4-digit county/town codes that were assigned to 255 major places in VT and have been used for analysis for many years. - Management wanted HSA codes! “Hospital service areas” based on mom’s town of residence. - We’ll have ALL of them in next release!

15. Applying the CDC NEDSS Model to Vital Records: VTEBRS/OBNet Collaboration • Review of OBNet information • Implementing NCHS Edits - “Unknown” responses for medical conditions not acceptable – “information will always be known with hospital births.” - Baby born in a restroom in the lobby of the hospital – APGAR scores: “Unknown” - Method of delivery: Unsuccessful forceps/vacuum: “not applicable for vaginal births.”

16. Applying the CDC NEDSS Model to Vital Records: VTEBRS/OBNet Collaboration • Printing the legal birth certificate - BCs printed from OBNet must look like those printed from EBRS! - Fonts: Different versions of Crystal Reports! - Special characters. - Foreign addresses. - Labels for Parent’s fields: married vs. civil union. - Business rules for printing father’s information.

17. Applying the CDC NEDSS Model to Vital Records: VTEBRS/OBNet Collaboration • Security - State ensuring that OBNet has levels of security. - Records go through layers of review at hospital. - Clerk prints the legal birth certificate and local administrator does final review of record before extracting to State. - Clerks cannot “unlock” and change info on birth certificate without management approval.

18. Applying the CDC NEDSS Model to Vital Records: VTEBRS/OBNet Collaboration • Data Issues - Some items missed in testing. - License number of attendant not being sent. - Confusion around what to send for birth order and number born alive for single births. - No entry for APGAR scores at 10 minutes when APGAR 5 was > 6. NCHS specs specify ’88’.

19. Applying the CDC NEDSS Model to Vital Records: Results • Benefits - Opportunity to change legal birth certificate – fields and appearance. - Review business processes in detail; improved and streamlined some: amending records, birth notifications. - Getting out of the paper business and moving forward: electronic signatures; scanning VAPs. - Better relationship with our reporting sources. - Better understanding of hospital processing through work with OBNet.

20. Applying the CDC NEDSS Model to Vital Records: Results - Improved timeliness. - Event history – Log captures date, user, and information that was changed. - Creation of a central database for all vital events – puts us a step ahead for Intel Reform regs. - Lays the groundwork for EDRS module…much of the work is already done. - Foundation for the Child Health Profile: one database for birth, hearing screening, metabolic screening, lead screening, immunizations and birth defects (and soon, deaths).

21. Applying the CDC NEDSS Model to Vital Records: Lessons Learned • Timetable - Always allow more time. Double your time estimate – allow for vacations, maternity leave, temporary reassignments. - Do not implement mid year (unless you have no other choice!). • Staff resources - Need more than .5 FTE designated from Vital Records to work with IT. (We really needed 1.5 FTE as other projects went on hold for a year.) - Need staff devoted to testing, testing, and retesting!

22. Applying the CDC NEDSS Model to Vital Records: Lessons Learned • Integrating external reporting sources - Review internal business processes before starting collaboration! - Allow EXTRA time to modify use cases. - Need staff assigned/focused on the collaboration – specifications, edits, business processes, communications. - Don’t redesign and implement at the same time you are working on messaging and data extract with another organization. Finish your EBRS first – then collaborate! - Can never do enough testing!

23. Applying the CDC NEDSS Model to Vital Records: Contact Info. • Questions / Comments? • Cindy Hooley Vital Statistics Information Manager Phone (802) 651-1636 Email: chooley@vdh.state.vt.us • Richard McCoy Director, Center for Health Statistics Phone (802) 651-1862 Email: rmccoy@vdh.state.vt.us Special thanks to VDH’s Information Technology staff, especially the Development team and the Database team: Ed, Amy, Becky, Craig, Pat, Esmy, Eileen