Failure to file death certificates electronically could be behind lag in demographic reporting on COVID-19 deaths

Roughly 12 percent of COVID-19 deaths in Virginia don’t include information on a patient’s race or ethnicity — a lag in data that some are attributing to the way death certificates are filed with the state’s Office of Vital Records.

Health Commissioner Dr. Norman Oliver said that some physicians still aren’t using the state’s electronic death registration system, a now-mandatory network for electronically registering and recording death certificates.

Using the electronic system dramatically cuts down the time it takes for a death certificate to be registered with the state, said Larry Spiaggi, the owner of Morrissett Funeral & Cremation Service in Richmond and past president of the Virginia Funeral Directors Association. 

A death certificate must be signed by an attending physician or medical examiner before it’s completed and reviewed by a funeral director and passed onto a local health department, Spiaggi added. The document then goes to the state’s Office of Vital Records, where the statistical data becomes available, according to State Registrar Janet Rainey.

When death certificates are completed electronically, they can be filed with the state in less than a day. “I’ve had it done in two hours when it’s done correctly,” Spiaggi said. But he added that it can take between three and four weeks to file the document with the state if it’s completed on paper.

Non-electronic death certificates have gradually become a rarity since the system was introduced in Virginia nearly a decade ago. Seth Austin, the state’s director of vital records, said that roughly 90 percent of certificates are now completed electronically.

But the portion that aren’t can significantly delay how quickly demographic information is reported to the state, Oliver said. 

“If you recall, a few weeks ago, the portion of COVID-19 deaths for which we didn’t know race and ethnicity was much higher,” he said after a news briefing on Monday. “It was around 30, 40 percent. Now it’s much lower. And that’s what happened — we finally got the death certificates and could match that against the daily counts.”

The continued lags come three weeks after Gov. Ralph Northam called for better tracking of demographic data connected to the COVID-19 pandemic. Virginia, like many other states, has seen increasing evidence that communities of color have been disproportionately affected by the virus.

On Monday, Oliver said that about one-third of the state’s COVID-19 cases and deaths have occurred among black and Latino residents. Virginia is one of 25 states to report COVID-19 data by race or ethnicity, according to the National Academy for State Health Policy, though the racial categories on its daily surveillance dashboard include only “white,” “black or African American” and “other.”

Reporting is further complicated by continued gaps in demographic data. Approximately one-third of the state’s 14,339 known coronavirus cases do not include race or ethnicity, in addition to roughly 12 percent of deaths. As of Tuesday, just over 10 percent of hospitalizations also lacked racial data, according to Virginia’s COVID-19 surveillance dashboard.

When Northam first addressed the issue in early April — a time when more than half of the state’s COVID-19 cases lacked race and ethnicity data — Oliver attributed the lack of information to reporting on test results. In his latest clinician letter, he again asked that providers “include race and ethnicity data when ordering COVID-19 testing from a reference laboratory and when reporting COVID-19 illness to VDH.”

But Spiaggi said he was frustrated by the way Oliver addressed COVID-19 fatalities in the same letter, in which he emphasized that physicians needed to complete death certificates “preferably through the Electronic Death Registration System.”

“That really got my goat,” Spiaggi said. “It should have said, ‘fill out the death certificate with EDRS as is mandated by law.’”

The system became mandatory for all providers in 2019, after nearly a decade in use. During that year’s General Assembly session, legislators passed a law requiring all practitioners who sign death certificates to register and begin using the system by December 1.

There were some initial problems when the system first became mandatory, including concerns from physicians who practiced at multiple facilities but could only include one on the EDRS enrollment platform, said Clark Barrineau, assistant vice president of government affairs for the Medical Society of Virginia.

MSV hasn’t received any COVID-19-specific complaints relating to the system, he added. But Spiaggi said he had to address a delay in early April, as coronavirus cases were continuing to rise, when he realized that the attending physician for one of his decedents wasn’t registered with EDRS.

“We finally did a paper certificate because we needed to cremate her,” he added. “It took us two weeks to get him onto the system. And if it was a COVID death, that’s going to delay that information getting to the state.”

In Virginia, it’s still unclear to what extent people of color are being disproportionately affected by the virus. But assessing that is especially important given long-standing and historic inequities in health care, said Derek Chapman, the interim director of the VCU Center on Society and Health. 

“We want to have that information because we want to focus our attention on the most vulnerable populations and those most at risk,” he continued. “And communities of color are among those more likely to be living in poverty or with underlying health conditions, which we know increases susceptibility to COVID-19.”

Chapman also said it could become more difficult to glean racial and ethnic data from COVID-19 deaths as the pandemic continues. Even if death certificates are completed electronically, most hospitalized patients are restricted from receiving visitors to reduce the risk of transmission. 

If a patient dies, their family might not be there to provide race and ethnicity data, Chapman pointed out. And if a physician doesn’t know for sure, many could be unwilling to guess.

“It’s just a speculation, but I suspect part of that gap might be an actual lack of information about what the race and ethnicity actually is,” he said.