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Volume 1:
No. 4, October 2004
ESSAY
Reengineering Vital
Registration and Statistics Systems for the United States
Charles J. Rothwell
Suggested citation for this article: Rothwell CJ. Reengineering vital
registration and statistics systems for the United States. Preventing Chronic
Disease [serial online] 2004 Oct [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2004/
oct/04_0074.htm.
Abstract
For more than a hundred years, the United States has operated a
decentralized vital statistics system as an essential component of public
health. Statistics based on births and deaths registered in the United
States are a primary source of data used to track health status, to plan,
implement, and evaluate health and social services, and to set health policy.
The national vital statistics system provides nearly complete, continuous,
and comparable federal, state, and local data. The system, however, is based
on outmoded vital registration practices and structures, which raises
concerns about data quality, timeliness, and the lack of real-time linkage
capabilities. While many organizations are working together to address these
issues and have made notable achievements, questions remain to be answered.
Efforts to rejuvenate the nation’s vital statistics system will need to
expand dramatically to provide public health with a timely, high-quality,
and flexible system to monitor vital health outcomes at the local, state,
and national levels.
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Essay
For more than a hundred years, the United States has operated a
decentralized vital statistics system as an essential component of public
health. Statistics based on births and deaths registered in the United
States are a primary source of data used to track the health status of the
U.S. population, to plan, implement, and evaluate health and social services
for children, families, and adults, and to set health policy at the
national, state, and local levels. Data on access to prenatal care, maternal
risk factors, infant mortality, disparities in health status, changes in the
rankings of causes of death, life expectancy, years of potential life lost,
and other pregnancy and mortality indicators provide the staples for public
policy and programmatic debates about improving health and health services
delivery. Unlike any other public health data system, the national vital
statistics system provides nearly complete, continuous, and comparable
federal, state, and local data to public health officials and programs. This
strength enables population-based analysis and comparisons to be undertaken
at the national, state, and local levels by age, race, ethnicity, and
sex. For example, with more than two million deaths each year,
disparities in the leading causes of death by race and age can be monitored
and compared at the local, state, and national levels. Rare and emerging
causes of death can be identified, and using both the underlying and
contributing causes of death, the impact of such diseases as hypertension,
diabetes, and atherosclerosis on mortality can be measured.
Despite the importance of the nation’s vital statistics system, it is
based on outmoded vital registration practices and systems, a fact that raises
concerns about data quality, timeliness, and the lack of real-time linkage
capabilities for the more than six million annual vital events. To resolve
these issues, vital registration requires more complete automation at the
level of primary data collection and changes in the relationships among the
providers of source records, the state registration offices, and the
National Center for Health Statistics (NCHS). For example, for almost 20
years, states have been using electronic birth certificate systems. While
this is a significant step forward, states continue to operate dual paper
and electronic systems, with the paper record considered the official legal
document. To compound these problems, the current electronic systems for
vital registration at the state level have been difficult to modify, causing
many states to delay implementation of the 2003 revisions to the U.S.
standard certificates, which would provide a wealth of new information.
Collection of death information continues to be primarily a paper-based
process, unchanged at the local and state levels for the last half century.
Funeral directors are responsible for collecting demographic information on
the decedent from the next of kin, while attending physicians, medical
examiners, or coroners provide and certify medical information on cause of
death. Demographic and medical information are brought together manually by
passing the paper certificate back and forth; the certificate data does not
become computerized until reaching the state vital registration office,
sometimes after considerable delay. The lack of automation at the source
precludes timely follow-back to improve data quality and does not take
advantage of existing internal systems of funeral directors and physicians.
The Internet is not even used for electronic data transfer between data
providers and state registration offices.
To address these problems, the National Association of Public Health
Statistics and Information Systems, NCHS, and the Social Security
Administration have developed a partnership to improve the responsiveness of
state vital registration and statistics systems. Their objective is to
improve the timeliness, quality, and sustainability of these systems by
adopting national, consensus-based standards and guidelines. It will be
necessary to go beyond modifying existing registration systems. State
processes and systems must dovetail with local data providers’ processes and
systems. Stand-alone systems and paper-based processes can no longer be
considered adequate. An overarching consensus within this partnership is
that business practices within state vital records offices and data
providers must be documented and then updated to be more efficient and
effective in light of today’s technology and that these systems must
be driven by national consensus-based standards and guidelines. The
resulting reengineered state systems will use the 2003 version of the U.S.
standard certificates of live birth, death, and fetal death. Reengineered
systems will include efficient methods for capturing data, standard
data-collection instruments, coding specifications, query guidelines,
standardized definitions, and Health-Level-7–based standardized messaging.
As the Public Health Information Network expands and is knitted together
with a National Health Information Infrastructure, these reengineered vital
statistics systems will need to be integrated with other health information
systems, such as those for immunizations, newborn screening, and hearing
screening, and with electronic systems used by data providers, including
hospitals, physicians, and funeral homes.
The national partnership and its consensus process have already had some
notable accomplishments, including the development of functional
requirements for reengineered birth and death registration. The consensus
national requirements will serve as the foundation for the design,
development, and implementation of reengineered, Internet-based vital
records and statistics systems for states. The most daunting challenge still
to be overcome is the funding of the development and implementation of new
systems, especially the automated reporting of deaths by the thousands of
funeral directors and physicians who now manually provide mortality data.
Many questions are yet to be answered. What is the most effective way to
retrieve quality medical information from the attending physician, coroner,
or medical examiner? How can funeral directors and physicians be connected
electronically and share with the state confidential information about the
decedent in a secure environment? At what level of specificity do prompts
and data edits for the medical information obtained from the physician
become counterproductive? How can the state vital statistics systems take
advantage of the data systems already in use by funeral directors and
medical examiners? Efforts are currently underway to address these
questions. Efforts to rejuvenate the nation’s vital statistics system are
encouraging, but they will need to expand dramatically to provide public
health with a timely, high-quality, and flexible system to monitor vital
health outcomes at the local, state, and national levels.
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Author Information
Corresponding author: Charles J. Rothwell,
National Center for Health Statistics, Centers for Disease Control and
Prevention, 3311 Toledo Rd, Room 7311,
Hyattsville, MD 20782-2003. Telephone: 301-458-4468. E-mail: CRothwell@cdc.gov.
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