Death Investigation and Forensic Pathology Data: Uses and Issues in Public Health

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Death Investigation and Forensic Pathology Data
Uses and Issues in Public Health
Randy Hanzlick, MD
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Learning Objectives

• Review public health uses of ME/C data
• Discuss interactions with public health
  departments
• Discuss data system use by ME/Cs
• Discuss factors which hamper data use

• Discuss reporting of notifiable diseases
• Describe interactions with various reporting
  systems
• Describe NAME reporting systems
• Discuss rise and fall of CDC MECISP

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Disclosure

• The presenter has no financial interest in any
  of the subject matter or products mentioned
  except for potential royalties received through
  sales of the data system named HOMER. HOMER is
  licensed through the Technology Transfer
  Department of Emory University.

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Forensic Pathology

• Forensis (public)
• (of the courts, open to debate/argument)
• Pathology (pathos suffering) (study of)
• (suffering is due to disease and injury)
• Forensic Pathology
• (the study of disease and injury that is
• of interest to the public and courts)

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What do Forensic Pathologists do?
Medical Examiner
Medicolegal Death Investigation
Coroner
Coroners Pathologist
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Overall Role of ME/Cs
Criminal Justice
Public Health
Fatality Review
Medical Examiners And Coroners
Public Safety
Medicine
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Overall Role of ME/Cs
Public Health
Criminal Justice
Fatality Review
Medical Examiners And Coroners
Public Safety
Medicine
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-Historical Information-

• Development of Medical Examiner/Coroner Interest
  in Data and Public Health

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A Pioneer in Death Investigation Interest in
Informatics and Public Health
George E. Gantner, Jr., MD 1927 1988
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Dr. Gantners Interests

• Began with computer background in the Navy
• Medical Examiner for City of St. Louis
• Computers and their applications
• Coroner and Medical Examiner Systems
• Death certificate quality
• Nomenclature of disease and injury
• Professional Guidelines/Quality Assurance
• Autopsy Policy and Practice
• Public Health Issues

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Computers
Dr. Gantner and.
Presentations, Papers, Seminars

• Computers for MDs (1965)
• Data processing systems for MEs (1969)
• Computerized autopsy reports (1972)
• Automation of investigative reports
• Potential for computer in forensic
  decision-making (1986)

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Death Certification
Dr. Gantner and.

• Consultant to NCHS (1970s)
• NCHS Subcommittee on Death Certification
• Grant to assess accuracy of death certificates in
  ME/C systems (1972)
• NCHS Subcommittee on Revision of US Standard
  Death Certificate (1980s)
• Assisted in preparing NCHS Handbook

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Nomenclature/Classification
Dr. Gantner and.

• Assisted in SNOMED development
• CAP Committee on Nomenclature and Classification
  of Diseases
• NCHS International Classification of Diseases
  Committee (ICD-9)

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Public Health
Dr. Gantner and.

• Initiated a grant to partner with CDC for sharing
  and dissemination of information between medical
  examiner/coroner and the public health agencies
  (1987)

Presentations by Dr. Gantner about the issues in
the previous slides raised awareness and interest
of the Medical Examiner/Coroner community.
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1983
Gantner and Hanzlick met at the NAME Meeting in
Williamsburg, 1983
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Others with Public Health Interests
James Luke, MD Washington, DC 1970s Early
1980s Heroin, Narcotics Deaths
Charles Wetli, MD Miami 1980s and 1990s Cocaine
Deaths
Kurt Nolte, MD Albuquerque, NM Late 1980s to
present Emerging Infections
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Medical Examiner/CoronerInformation Sharing
Program

• (MECISP)

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MECISP 1986 - 2004
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The MECISP/Hanzlick Connection

• CDC MECISP were in Atlanta
• Hanzlick worked at FCME in Atlanta
• Hanzlick worked with CDC on publications

Graitcer P, Williams W, Finton R, Goodman R,
Hanzlick R, Thacker S. An evaluation of the use
of medical examiner data for epidemiologic
studies of natural death. AJPH.
198777(9)1212-14.
CDC. Deaths among homeless persons-Atlanta,
Georgia. MMWR (reported by R Hanzlick).
198726(19). (Also reported in JAMA,
19873191-3192.)
Hanzlick R. Death certificates, natural death,
and alcohol the problem of under-reporting. Am
J Forensic Med Path. 19889(2)149-50.
These types of articles seemed of direct interest
to MECISP, so in 1991, Hanzlick began to work
part-time with MECISP through an IPA.
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MECISP Program Goals

• Improve quality of death investigations
• Promote more standardized practices
• Facilitate communication between death
  investigators and public health
• Improve quality, completeness, management, and
  dissemination of information on investigated
  deaths
• Promote sharing and use of ME/C data

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MECISP Activities

• Publish Directory of ME/C laws and contacts
• Collaborate with ME/C on epidemiologic studies of
  death investigations
• Conduct studies to identify problems with current
  death investigation and mortality data
• Consult with ME/C offices to help establish
  computerized data systems
• Develop model forms and data file structures
• Develop model formats for annual and statistical
  reports

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Key People in MECISP Development

• James Mason, CDC Director
• Vernon N. Houk (Director, CDC NCEH)
• Stephen Thacker
• Gib Parrish
• Roy Ing
• Debbie Combs
• Myra Tucker
• Crystal Gresham

EPO
Wrote the proposal
NCEH-EHHE
Started MECISP
NCEH-EHHE
During its 18 years, MECISP operated under five
CDC DirectorsJames Mason, William Roper, David
Satcher, Jeffery Koplan, and Julie Gerberding.
Richard Jackson followed Houk as NCEH Director
and Henry Falk was Division Director in DEHHE. In
2002, MECISP moved to EPO. MECISP activities
ended in 2004. R Hanzlick worked with MECISP from
1991-2002. Kurt Nolte Also worked with MECISP in
the late 1990s- 2002.
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Example MECISP Products Forms
These were the basis of the 1996 CDC MMWR Infant
Death Investigation Forms (SUIDIRF)
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Example MECISP Products Coding Schemes
Back then, field lengths and file sizes had
limits!
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Example MECISP ProductsDatabase Reviews
Commercial Systems 1993 Status MESS 1983 35 CME
2 1986 8 InQuest 1989 4 ForenCIS 1990
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These were DOS-based. Some other offices had
MUMPS-based or other types of systems.
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Example MECISP ProductsDatabase Structure
MecDIDS
This was used by many offices and vendors to
develop database programs
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Other Example MECISP Products and Services

• Databases ME/Cs (eg, SIDSdb)
• Epi Info case management system
• Site visits to assist in database development
• Collection and analyses of data from multiple
  ME/C offices
• Annual Reports for ME/C offices

MECISP had a strong presence at professional MEC
meetings and CDC also provided some conference
grants.
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Todays ME/C Database Status
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Todays Status (April 2007)
11 were Access or Excel, the others varied.
55 have either no system or a probably unique
system.
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Systems Currently in Use

• BEAST
• CME/VertiQ
• CoronerSoft
• Forensic Filer
• HOMER
• Justice Trax
• LIMS
• MECMS
• Medical Examiner 2100
• Quincy

These account for 68 of installations reported
in the survey. A given vendor product may also
vary in data elements from place to place.
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Factors Hampering Collection of Public Health
ME/C Data
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Diversity in Systems
Status of the Nation
2177 counties (69) are served by a coroner
system or equivalent. There is potential for at
least 239 different case management data systems
just for ME offices. This potential for data
system variation is much greater when coroner
offices are considered.
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Lack of Health Department Ties
The shaded states are State ME Systems organized
within Health Departments
Some county systems are within health departments
as well. Most, however, are NOT. Thus, emphasis
is not public health.
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Problems Within Offices

• Cant afford expensive vendor systems
• IT Department Policies may dictate system
• Lack of in-house programming capability
• High caseload, short staffing, lack of time
• Lack of interest/incentive/perks/pay
• The Black Hole philosophy/fear
• Higher and other priorities
• Lack of standard forms and databases
• Concerns about privacy violations
• State laws concerning data, open records etc
• Requests (redundant) from multiple agencies

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Public Health Rolesof the ME/C

• Traditional
• Emerging

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Traditional Activities
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Traditional Activities

• Notifiable Condition Reporting
• DAWN (SAMHSA)
• MedWatch (FDA)
• MECAP (CPSC)
• FARS (NHTSA)
• NTOF (NIOSH)CFOI (BLS)
• Autopsies and Death Certificates
• Epi Investigations

Health Dept
Drug abuse deaths
Adverse Drug and Device events
Consumer product deaths
Road traffic fatalities
Job-related fatal injury
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Pseudomonas Sepsis
3 days
Thermal burns (90 body surface)
7 days
Self immolation
7 days
Diabetes mellitus, insulin dependent
Yes
Yes
Doused self with gasoline and lit match
01/22/06
2348
No
X
Garage at own home
123 Fake St, Charleston, WV 25309
X
March 3, 2006
Deputy Medical Examiner
Randy Hanzlick, MD OCME, 619 Virginia St. W,
Charleston, WV 25302
Dont forget Most autopsies in the U.S. are done
by ME/Cs 20 of deaths
certified by ME/Cs
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A Problem..

• Most of these data systems do NOT automatically
  extract data from medical examiner records or
  databases
• They require specific input of data into separate
  data systems which usually involves re-entering
  of already existing data, which is not efficient
  for the ME/C office

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Sample Epi Investigations

• Hantavirus (Southwest US)
• Possible epiglottitis in infants (California)
• Methadone Deaths (Houston)
• Infant Pulmonary Hemorrhage (Cleveland)
• Heat Wave (Chicago)
• Infants and chemical spill (Louisiana)
• Product tampering (Chicago)
• Food poisoning at a salad bar
• Weather incidents (hurricanes, floods etc)
• Infant sleep position

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Emerging Activities
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Emerging Activities

• National Violent Death Reporting System (NVDRS)
  
• Electronic Death Registration
• (EDR)
• Emerging Infectious Disease Surveillance (MED-X)
• Bioterrorism Surveillance
• Various Registries

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WISQARS
All States participating by 2001?

• Problems
• Information is manually abstracted from hardcopy
  records or re-entered from data obtained from
  already existent electronic data files.
• The NVDRS software is cumbersome and not user
  friendly
• The goals of the project are slow in being
  realized
• Data are no more current than death certificates,
  at present

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• Problems
• Relatively few states have
• systems.
• Each state has a unique
• system and/or vendor.
• Data already stored usually
• need to be re-keyed.

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Emerging Infections and Bioterrorism Agents

• MED-X

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FCME Approach
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Geroncio Fajardo, MD Medical Epidemiologist Foren
sic Epidemiologist
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Registries
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CDC Sudden Unexplained Infant Death Initiative
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Use requires authorization
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Bioterrorism agent Bomb-related death Chemical
terrorism agent In custody- in jail In custody-
not in jail Law Enforcement Action Lightning
strike Product tampering Stampede
(human)-related Structural collapse Stun Gun
(Electrical) was used Unexplained death in adult
younger than 30 years Unsuspected neoplasm caused
death
For NAME Members Only
.Just added IV Fentanyl
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For NAME Members Only
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Use requires authorization
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Other Issues
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Cause of Death Coding Systems

• Methods vary and include
• No coding at all
• Home-made classification systems
• ICD
• SNOMED
• Forensic Microglossary (incomplete)
• There is no standard approach.

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The FCME Approach
147 options in the drop-down list
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Injury Coding

• Methods vary and include
• No injury coding at all (most common)
• Abbreviated Injury Scale (AIS)
• Injury Severity Score (ISS)
• Text storage only
• Few offices do this.

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Current Problems

• Many ME/C offices lag behind in public health
  awareness and prioritization
• ME/Cs are usually not within health departments
• Public health emphasis seems to be on terrorism,
  disaster preparedness, and emerging conditions
  rather than public health issues we encounter
  daily

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Everyday deaths in US (Yearly)

• Homicides 17,732
• MVAs 44,767
• Accidents 64,510
• Suicides 31,647
• 158,656

Disastrous proportions? This number at least
doubles if undetermined causes and initially
unexplained natural deaths are included.
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Public Health Problems

• Too many Acting Directors
• Turnover
• Loss of institutional memory
• Regulations are self-defeating
• Fear of treading on wrong turf
• Clearance process is too slow
• Too slow in finishing projects
• Redundancy fragmentation

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References
Hanzlick R. Medical Examiners, Coroners, and
Public Health A Review and Update. Arch Pathol
Lab Medicine 2006 13012744-1282
Hanzlick R, Parrish RG. Epidemiologic aspects of
forensic pathology. Clinics in Laboratory
Medicine 19981823-37.
Hanzlick R, Parrish RG. The use of medical
examiner/coroner data in public health
surveillance and epidemiologic research. Annual
Review of Public Health 199617383-409.
National Association of Medical Examiners ad hoc
Data Committee. Survey 10. Medical Examiner
Software Survey. April 2007. National
Association of Medical Examiners. Atlanta,
Georgia.