Transcript From Birth to Death: An Update on Vital Records (or, “Just how will

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
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Induced Termination of Pregnancy (ITOP)
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
2
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP Reporting in Vermont
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
3
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
4
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
MODEL LAW
•
VERMONT 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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
5
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
6
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP Reporting in Vermont: Process and Awareness
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
7
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
1.
Reporting source (hospital, physician, or clinic) completes a paper ITOP
report and mails or faxes it to Vital Records.
2.
ITOP “report” is received and stamped with a state file number.
3.
The reports (paper forms) are data-entered on a monthly basis.
4.
The paper form is stored in a locked file cabinet in the vault for five years.
5.
An audit is conducted on a quarterly basis for the ITOP reports submitted
by the clinics (e.g., Planned Parenthood).
6.
An audit is conducted on an annual basis for the ITOP reports submitted by
the hospitals.
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
8
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
9
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
10
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP Reporting in Vermont: Audit Activities
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
11
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
12
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process: Clinics (PPNNE)
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
13
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
14
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
15
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process: Hospitals
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
16
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process: Hospitals
Hospital facilities
Hospital
Discharge
2000 – 2003*
2004
2005
2006
2007
2008
2009
Vital
Records
Unreported
(count / hospitals)
% of Hospital Events
(unreported)
120
50
70
(5 facilities)
58%
34
24
34
27
34
37
29
17
26
19
20
26
5
7
7
8
14
11
(4 facilities)
(3 facilities)
(4 facilities)
(3 facilities)
(5 facilities)
(3 facilities)
15%
29%
21%
30%
41%
30%
*2000 – 2003 was an audit combining four years after agreement on the definition utilizing the hospital
discharge dataset.
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
17
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Audit Process: Unaffiliated Physicians
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
18
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP Reporting in Vermont: Trends
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
19
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP reports by reporting source since year 2000:
2000
2001
2002
2003
2004
2005
2006
2007
2008
Planned Parenthood
facilities
82%
84%
86%
87%
89%
90%
87%
88%
90%
Unaffiliated Physicians
17%
15%
13%
11%
9%
8%
11%
10%
8%
1%
1%
1%
2%
2%
2%
2%
2%
2%
VT Hospitals
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
20
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
1600
1500
1454
1400
1457
1422
1373
1200
1000
VT Residents
800
Out-of-State
600
400
307
234
200
224
154
120
Richard McCoy
(802) 651-1862
[email protected]
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
20
00
0
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
21
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
25
20
20.1
19.1
17.2
15
13.7
13.5
% of Total to Out
of State Patients
10
9.6
8.0
5
0
20
20
20
20
20
20
20
20
20
19
19
19
19
08
07
06
05
04
03
02
01
00
99
98
97
96
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
22
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
200
180
160
173
165
140
120
100
95
80
Out of State - NH
87
Out of State - NY
60
59
53
40
39
20
23
0
08
20 7
0
20 6
0
20 5
0
20 4
0
20 3
0
20 2
0
20 1
0
20 0
0
20 9
9
19 8
9
19 7
9
19 6
9
19
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
23
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
ITOP Reporting: Future Challenges
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
24
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
25
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
26
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
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
27
Richard H. McCoy
Phone (802) 651-1862
The Vermont Department of Health
Cindy Hooley
[email protected]
Phone: (802) 651-1636
Vital Statistics Information Manager
Richard McCoy
[email protected]
Phone: (802) 651-1862
Public Health Statistics Chief
Richard McCoy
(802) 651-1862
[email protected]
Genealogical
Society
of Vermont
Gateway to the
Future:
October
2006
Improving the National Vital Statistics System
St. Louis, MO
June 6th – 10th, 2010
28