Delayed rollout, wasted time
The Electronic Death Registration System — or EDRS — is not new, and it’s not unique to Pennsylvania.
The switch was part of a national effort, dating to the early 2000s, to create a new gold standard for death reporting. About 20 states were using their first iterations of the tool by 2006, according to the CDC. Neighboring states like New Jersey and New York said they finished the switch to electronic systems in 2013 and 2019, respectively.
Electronic death reporting is critical, as it helps officials to more quickly identify and assess a deadly crisis. Fast, accurate data can help inform decisions about where to send supplies and how to allocate resources. Having a modernized system that produces timely death information can “improve outbreak and disaster response efforts,” a CDC website says.
“It’s a whole lot easier to detect people who are dead than people who are sick,” said Robert Anderson, chief of the Mortality Statistics Branch at the CDC’s National Center for Health Statistics. “The earlier we can get information on mortality, the quicker we can develop interventions.”
Pennsylvania’s plan was to implement EDRS gradually, much like other states had done. The system was officially launched in October 2016, said Wardle, the spokesperson for the health department, and the rollout was set to occur in phases due to the “complexity of implementing an EDRS.”
Pennsylvania’s goal was to have “all end users trained to register deaths electronically … by the spring of 2017,” according to an early document.
At the time, there were few states in as dire need of an overhaul as Pennsylvania.
New data from the CDC shows that in 2017, the vast majority of U.S. states were able to send information about nearly all deaths to federal health officials within 13 weeks of the date deaths occurred. Pennsylvania, however, lagged far behind, able to manage only 65% of the work in that same time period. Connecticut was the next slowest state, at 68%, followed by Arizona (85%) and West Virginia (87%).
But by the end of 2017, and despite a quarter of a million dollars spent just on the first phase of the rollout, the state still had not trained everyone on the technology — let alone all 67 county coroner or medical examiner offices.
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‘Deer in the headlights’
The second phase of EDRS training, dedicated to onboarding the tens of thousands of medical professionals legally tasked with completing cause-of-death paperwork, didn’t begin until April 2019.
Ongoing delays were apparent at the beginning of 2020.
Kiessling said he met with a group of Pennsylvania physicians in late February 2020, at the request of a UPMC hospital in Williamsport. At that time, the coronavirus was already international news. Wuhan, China, had been ravaged by the pandemic, and the U.S. had documented its first confirmed case the month prior.
Kiessling said he traveled with Audrey Marrocco, director of the state’s Bureau of Health Statistics and Registries office, to discuss issues with death certificates. According to Kiessling, the physicians looked like “deer in the headlights” when it came to the electronic system.
They didn’t know what EDRS was, he said. But they would soon find out.
On March 6, just 12 days before Pennsylvania’s first recorded COVID-19 death, the state health department issued a mandate: All deaths attributed to COVID-19 would have to be reported through EDRS.
Two weeks later, the department went further. Beginning March 20, all funeral homes in the state would need to use the system to report all deaths, COVID-19 or not.
Funeral homes without computers or internet service could apply for EDRS waivers, allowing them to continue with paper, the department said. But for everyone else, protocol had shifted. The state was demanding tens of thousands of funeral directors, coroners, and physicians at hospitals and nursing homes to adjust their workflows effectively overnight.
Many weren’t prepared. Some even started flagging concerns with the health department.
Through a public-records request, Spotlight PA and WHYY News obtained copies of nearly 60 EDRS waiver applications submitted to the department.
“How can we do mandatory EDRS reporting when proper training has not been provided,” one funeral director wrote in a waiver application dated March 19.
“Physicians are not yet set up for this,” warned another on March 20.
“We are EDRS capable,” wrote a third funeral director on March 23. “But most of the hospitals, doctors, and nursing facilities are NOT able to respond in kind.”
According to data obtained through a public-records request, more than 7,550 medical professionals, support staff, and administrators rushed to sign up for EDRS between March and April, compared to only about 350 new users who signed up in January and February.
“The problem was, they implemented this in the middle of a pandemic,” said Kiessling.
Though Kiessling credited the state for pushing out a flood of digital training materials and webinars, he questioned the health department’s assumption that front-line physicians would even have time to participate.
“Doctors don’t have time to sit in the ICU and watch these videos,” he said. “People are dying.”
During the deadliest months of the pandemic, Health Secretary Rachel Levine often cited difficulties “reconciling” death data from different sources.
Death toll fluctuates
For the first two months of the crisis — the deadliest two months in Pennsylvania’s COVID-19 history — the state didn’t draw from EDRS to produce its public death count.
Instead, death data was being reported out of a different system, PA-NEDSS, and pulled from EDRS with the help of algorithms, Wardle, the spokesperson, said in April.
But without a fully functional electronic death system in place, the state found itself playing catch-up — adding weeks-old deaths to its count and causing the death toll to spike several times in April and May.
Health Secretary Rachel Levine often cited difficulties “reconciling” data from different sources, as she reported hundreds of deaths that had occurred in weeks prior.
In the spring, the state’s numbers for Philadelphia also consistently lagged behind the city’s own count, by hundreds of fatalities. Questioned by reporters in April, officials blamed the discrepancy on a vague computer update, but deaths jumped the next week as the state reconciled its numbers with the city.
That month, as neighboring states were showing enormous total death increases compared to the same period in 2019, health department officials said they were unable to provide an exact count of how many people had died — from any cause — in Pennsylvania in March.
The reason: 2,000 uncounted paper death certificates that continued to stream into the office.
Since mandating the use of EDRS, the state has seen improvement on that front. In January and February, about 30% of the state’s deaths were reported fully on paper. By April and May, that number had dropped to 2%.
And officially, the Wolf administration regards the rollout of its Electronic Death Registration System as a success story.
“The department has been focused on continuous quality improvement,” said Wardle, the spokesperson. The agency has made “significant improvements,” he said, adding that by early summer, the state was able to issue death certificates within two to three weeks. Wardle blamed additional reporting lags on delays in COVID-19 test results, citing the need for a medical certifier to amend a death record when a pending test comes back positive.
Yet data obtained by the news organizations show the state is still a long way from full adoption.