Induced Termination of Pregnancy (ITOP): Auditing and Reporting Activities

1. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health Induced Termination of Pregnancy (ITOP):Auditing and Reporting Activities Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010

2. Richard H. McCoy Phone (802) 651-1862 Induced Termination of Pregnancy (ITOP) The Vermont Department of Health The 1992 Revision of the Model State Vital Statistics Act and Regulations includes the following definition of induced termination of pregnancy: ‘‘Induced termination of pregnancy’’ means the purposeful interruption of an intrauterine pregnancy with the intention other than to produce a live-born infant and which does not result in a live birth. This definition excludes management of prolonged retention of products of conception following fetal death.” Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 2

3. Richard H. McCoy Phone (802) 651-1862 ITOP Reporting in Vermont The Vermont Department of Health Title 18, Section 5222 requires that all ITOPs be reported to the Vermont Department of Health within seven days of the procedure. (a) The following fetal deaths shall be reported by the hospital, physician, or funeral director directly to the commissioner within seven days after delivery on forms prescribed by the board: (1) All fetal deaths of 20 or more weeks of gestation or, if gestational age is unknown, of 400 or more grams, 15 or more ounces, fetal weight shall be reported; (2) All therapeutic or induced abortions, as legally authorized to be performed, of any length gestation or weight shall be reported; (b) The physician who treats a woman as a result of a miscarriage or abortion shall report the fetal death if it is not known to be previously reported under subsection (a) of this section. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 3

4. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health • Exempt from Vermont’s ITOP reporting: (3) Spontaneous abortions and ectopic pregnancies of less than 20 weeks gestation are not required to be reported. • Records are maintained for a specified period of time: (d) Fetal death reports are for statistical purposes only and are not public records. They shall be destroyed after five years. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 4

5. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health MODEL LAWVERMONT STATUTE / POLICIES 5 days for reporting 7 days for reporting Standard form Modified form based on the standard Disposition TBD by regulation Maintain record for five years and then destroy the paper reports • Also, we modify the statistical file after five years to remove the identifiers: • Patient I.D. is set to 0. • Date of Birth is changed to 99/99/9999. • For VT residents, the city/town is changed to County. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 5

6. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health • The data is important for statistical purposes: • To calculate the pregnancy rate: Number of resident pregnancies to women ages 15 to 44 x 1000, divided by the total resident female population ages 15 to 44. Note: “pregnancy” includes all live births, plus fetal deaths and abortions. • The data is also important for public health planning: • Identifying characteristics of women who are at high risk for unintended pregnancy and use this information to develop interventions to prevent such pregnancies. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 6

7. Richard H. McCoy Phone (802) 651-1862 ITOP Reporting in Vermont: Process and Awareness The Vermont Department of Health Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 7

8. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health • Reporting source (hospital, physician, or clinic) completes a paper ITOP report and mails or faxes it to Vital Records. • ITOP “report” is received and stamped with a state file number. • The reports (paper forms) are data-entered on a monthly basis. • The paper form is stored in a locked file cabinet in the vault for five years. • An audit is conducted on a quarterly basis for the ITOP reports submitted by the clinics (e.g., Planned Parenthood). • An audit is conducted on an annual basis for the ITOP reports submitted by the hospitals. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 8

9. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health To communicate the reporting requirement, the following activities are conducted: • A letter describing the reporting requirement is sent to all newly licensed physicians in Vermont every month. (Part of a “new physician packet.”) • Occasional reminders (letters) are sent to physicians in Vermont that traditionally perform abortions. (Usually when a change in reporting pattern is noted.) • Occasionally ask the Vermont Medical Society to remind their members of the requirement. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 9

10. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health • We do not currently enforce the seven-day reporting requirement. Our expectation is 30 days since we are unlikely to data enter the forms any sooner. • We are confident that compliance with ITOP reporting exceeds 99% of all reportable events due to our audit procedures. • No method for estimating or accounting for abortions that occur without the involvement of a physician or facility (such as the use of medications without a prescription). • Members of the Vermont Legislature have requested an update in most years on the completeness of ITOP reporting and basic trends. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 10

11. Richard H. McCoy Phone (802) 651-1862 ITOP Reporting in Vermont: Audit Activities The Vermont Department of Health Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 11

12. Richard H. McCoy Phone (802) 651-1862 Audit Process The Vermont Department of Health We have two audit procedures: clinics (Planned Parenthood) and hospitals. 1.Planned Parenthood of Northern New England (PPNNE) clinics: • Quarterly reconciliation with PPNNE to identify any missing ITOP reports. • Vital Records creates a list of all ITOP reports received and highlights possible duplicates. • The list is sent to PPNNE to be reconciled against their billing system. PPNNE notifies us of duplicates and provides corrections and any missing records. A list is received from PPNNE for comparison against our records. • Vital Records staff make the appropriate corrections and additions. Additional follow-up is sometimes required. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 12

13. Richard H. McCoy Phone (802) 651-1862 Audit Process: Clinics (PPNNE) The Vermont Department of Health Process has worked well when there is a consistent point of contact at PPNNE that coordinates the data reporting for all of the locations. There are delays and inconsistencies when business processes are modified and staff turnover at PPNNE. (Vital Records is rarely informed of changes.) 2003 – 2007 reconciliations went smoothly. 2008 and 2009 have experienced some challenges: • Dozens of unreported events; • Several duplicate reports; • Numerous reports with errors: date of the event; patient’s date of birth; etc. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 13

14. Richard H. McCoy Phone (802) 651-1862 Audit Process The Vermont Department of Health 2. Hospital facilities: (Hospital policy is only to perform the procedure when medically necessary for the patient’s life.) • We have experienced ongoing challenges with timely and complete reporting. • An analyst reviews the hospital discharge dataset for each calendar year (six months after the end of a calendar year) and identifies all ITOP events that meet the definition for reporting. • To identify the cases, we use Diagnoses beginning with DX code 635 and that has a Procedure code in the Group: 96.49, 69.51, 69.01, 75.0, 69.93, 74.91 by Bill Type (111=Inp., 131=Outp, includes Observ. Bed and Series patients). • This definition for auditing was agreed upon in 2002 by the Health Department, hospital association, and data quality staff at the hospitals. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 14

15. Richard H. McCoy Phone (802) 651-1862 Audit Process The Vermont Department of Health Code Definitions: ICD-9-CM Diagnosis 635.0 to 635.9 Legally induced abortion ICD-9-CM Procedure 96.49 Other genitourinary instillation (insertion of prostaglandin suppository) 69.51 Aspiration curettage of uterus for termination of pregnancy 69.01 Dilation and curettage for termination of pregnancy 75.00 Intra-amniotic injection for abortion (saline) 69.93 Insertion of laminaria 74.91 Hysterotomy to terminate pregnancy Therapeutic abortions - Abortion induced to save the life or health of a pregnant woman. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 15

16. Richard H. McCoy Phone (802) 651-1862 Audit Process: Hospitals The Vermont Department of Health As a result of the hospital audits, complete and timely reporting improved in the first few years after implementation. However, the % of unreported events found by the audit process is rising again. • Not considered as an important reporting activity by the hospital physicians; • Procedures are rare and the reporting requirement is sometimes forgotten; • Concerns about privacy / protection of the data. Hospital administrators and Quality Improvement Managers understand the importance for reporting. Several hospitals have implemented new internal procedures to ensure that the completed ITOP form is maintained in the patent’s medical record. These discussions have led to a renewed partnership with our state’s largest hospital on other data quality topics. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 16

17. Richard H. McCoy Phone (802) 651-1862 Audit Process: Hospitals The Vermont Department of Health Hospital facilities Hospital Vital Unreported % of Hospital Events Discharge Records (count / hospitals) (unreported) 2000 – 2003* 120 50 70 (5 facilities) 58% 2004 34 29 5 (4 facilities) 15% 2005 24 17 7 (3 facilities) 29% 2006 34 26 7 (4 facilities) 21% 2007 27 19 8 (3 facilities) 30% 2008 34 20 14 (5 facilities) 41% 2009 37 26 11 (3 facilities) 30% *2000 – 2003 was an audit combining four years after agreement on the definition utilizing the hospital discharge dataset. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 17

18. Richard H. McCoy Phone (802) 651-1862 Audit Process: Unaffiliated Physicians The Vermont Department of Health We do not have an audit process in place for physicians that are not affiliated with Planned Parenthood or do not practice at a hospital. • In the past, we have requested from Vermont’s largest insurers the total number of abortions reimbursed in a calendar year and then compared the total to our historical data. We did not observe any worrisome differences. • However, not all insurers will provide the aggregate data. In the last three years, we have been unable to obtain the aggregate data from the insurers. • In 2010, the state will have an “all-payer database” containing all insurers’ claims data. We hope to use the database to supplement our audit procedures and identify if we have non-reporting with any unaffiliated physicians or problems with our reconciliation process with Planned Parenthood. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 18

19. Richard H. McCoy Phone (802) 651-1862 ITOP Reporting in Vermont: Trends The Vermont Department of Health Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 19

20. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health ITOP reports by reporting source since year 2000: Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 20

21. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health Total ITOP Reports by Year (2000 - 2008): VT Residents and Out-of-State Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 21

22. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health Abortions: 1996 – 2008 % of All Abortions that were Performed for Out-of-State Patients Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 22

23. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health Abortions: 1996 – 2008 Number of Abortions that were Performed for Out-of-State Patients from NH and NY Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 23

24. Richard H. McCoy Phone (802) 651-1862 ITOP Reporting: Future Challenges The Vermont Department of Health Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 24

25. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health 1.Electronic Reporting We had planned to begin electronic reporting of abortions from Planned Parenthood to Vital Records in 2009. • Goal was to save 10 – 15 person hours per month (no data entry). • During negotiations with Planned Parenthood, we had to compromise on a couple items. For example, we would not receive multiple race (only single race). • Pilot test on a portion of the 2009 records found a variety of inconsistencies after comparing the electronic data to the paper ITOP forms. Also, the reconciliation process found events that were not sent to us. • Cindy continues to work with their ITS staff to address the errors and inconsistencies. For 2010, we are continuing to compare the electronic data to the paper forms. We have not ended the paper forms…yet. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 25

26. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health 2.Access to Records Questions from politicians and special interest groups continue to grow. Expected to increase as new bills are introduced into the Legislature in future years (e.g., parental consent; fetal death as a felony; Vital Records’ overhaul.) • In recent years, the media and politicians have requested access to the records (containing identifiers). We have successfully prevented access. • Some states have been forced by court order to provide copies of the records to specific agencies. • For example, facilities performing abortions in a particular state were required by court order in 2006 to turn over the records to the state’s Attorney General. The basis of the request was to search the records for indications of child rape and abuse. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 26

27. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health 3.Establishing Trust Important to communicate clearly that we are a custodian of these confidential documents and will protect the patient’s privacy. Destroy the identifiers after an established period of time. • Reduces the potential for a legal fight in the future with agencies or organizations that want access to the record. Emphasize that our role is public health and not law enforcement. • We identify and plan for public health needs – not serve as investigators of criminal activity. This is an important distinction in order to achieve full and complete reporting from data sources. • We are helping them avoid unnecessary involvement by political and advocacy organizations. Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 27

28. Richard H. McCoy Phone (802) 651-1862 The Vermont Department of Health Cindy Hooley Vital Statistics Information Manager cindy.hooley@ahs.state.vt.us Phone: (802) 651-1636 Richard McCoy Public Health Statistics Chief richard.mccoy@ahs.state.vt.us Phone: (802) 651-1862 Richard McCoy Genealogical Society of Vermont (802) 651-1862 October 2006 rmccoy@vdh.state.vt.us Gateway to the Future: Improving the National Vital Statistics System St. Louis, MO June 6th – 10th, 2010 28