Death certificates from North Carolina residents who died since March 1 show many who died from symptoms similar to those who died from illnesses related to COVID-19, but without any record of them having been tested for the virus. Frank Taylor / Wmforo
Death certificates from North Carolina residents who died in March and April 2020 show many who died from symptoms similar to those who died from illnesses related to COVID-19, but without any record of them having been tested for the virus. Frank Taylor / Wmforo

At Haywood Funeral Home, every service triggers a bureaucratic process that’s been largely unchanged across North Carolina since 1914, when the company pulled its hearses along Raleigh’s streets with horses.

More than 100 years later, staff members at Haywood — just like every other funeral home in the state — produce a physical copy of every death certificate. They hand-deliver the form, printed on 100% cotton paper, to the right doctor and wait. When they pick the form up again, they drive it to the local health department and wait again.

“We’re talking substantial time,” said Orrin Ray Haywood Jr., president and funeral director of Haywood Funeral Home. “We’re talking hours of time in a week. You multiply that times 52 — good gracious.”

It can take days or weeks for the death certificates to complete their journey back to the family, and even longer for the forms to migrate by mail to the state’s vital records office, which must hand-enter each field into a database.

The death certificate process is identical for the 100 to 150 services Haywood Funeral Home conducts every year, as well as for the roughly 95,000 deaths annually across the state.

But that will soon change. Over the next few weeks, North Carolina is set to pilot a new electronic system to register deaths. Only two other states — West Virginia and Rhode Island — still lack such systems, making North Carolina one of the last in the country to modernize its death reporting process.

“The biggest change is that instead of it taking somewhere between two and three months to tell you who died in North Carolina last week, I should be able to do that within five to six days,” said Delton Atkinson, interim director for the State Center for Health Statistics and project manager for the upgrade.

For families, waiting for an official death certificate can mean financial and legal delays. It puts cremations on hold.

And in the aggregate, the current paper-based system means data on how people in North Carolina die can languish for months in bureaucratic limbo. That matters to public health experts working to analyze everything from cancer and birth defects to the novel coronavirus in real time.

“For some things like tracking long-term trends, it may not make that much of a difference,” said Melissa McPheeters, co-director of the Center for Improving the Public’s Health through Informatics at Vanderbilt University Medical Center. “But when we have situations like COVID or when there are quickly moving crises, like overdoses, you want to get that information as fast as you can.”

Upgrading from ‘brute force’

The pilot, starting Monday, will include eight of the state’s most populous counties, including Wake, Durham, Guilford and Mecklenburg. Atkinson said other counties will join in groups of about 20 before the system is fully implemented by summer 2021.

The N.C. General Assembly authorized about $2 million for the project — a priority of then-Gov. Pat McCrory — back in 2015, and additional funding comes from the Centers for Disease Control and Prevention and the state’s Division of Public Health.

The bulk of that funding will go to VitalChek, a firm that specializes in vital records management software either already operating or coming online in eight other states.

Instead of printing the physical forms, funeral directors, doctors and medical examiners will access the new N.C. Database Application for Vital Events through a web-based portal.

That will mean training for funeral directors like Haywood, who said he expects the system to save his operation a lot of time.

But Atkinson said the new system will mean broader benefits for public health, too.

Once deaths are complete in the state’s system, they’ll be transmitted daily to the CDC’s National Center for Health Statistics, which codes each cause of death based on an international standard. The data can then flow to more specific registries tracking issues like cancer or birth defects.

“We’re using the power of technology, the power of systems to be able to automate the processes,” Atkinson said. “The thing that we’re trying to do is minimize the human interventions that are necessary that we have lived with forever.”

Atkinson said the current system relies on “the brute force of people doing things.” And as the COVID-19 pandemic has made clear, the data lags woefully behind as a result.

As of Friday, the number of deaths from those testing positive for COVID-19 approached 4,000, according to data from the N.C. Department of Health and Human Services. DHHS gathers that information directly from labs and clinicians via a separate electronic system. But the state’s most recent public release of its death database from Oct. 2 tallies only 2,100 deaths linked to COVID-19, a shortfall caused by data entry that’s fallen months behind.

The backlog has created something of an information vacuum for North Carolina on questions of excess mortality, a measurement of a larger-than-expected number of deaths used in recent months to quantify the true toll of the novel coronavirus and its related effects. An Oct. 12 study in the Journal of the American Medical Association, for example, found that U.S. deaths increased by 20% overall from March to June compared to previous years.

North Carolina was one of two states excluded from the study because of missing data.

No ‘panacea’

Other states that have upgraded to electronic death reporting systems have seen turnaround times for data drop significantly soon after the switch.

That’s true of Tennessee, where Vanderbilt’s McPheeters saw the transition away from paper firsthand as the state health department’s assistant commissioner for informatics and analytics. Before the change, she said it took about 15 days to register deaths and 30 days to produce even basic data.

Now, deaths are registered on average within 10 days. Health officials currently get basic data within 12 days, and a complete dataset with standardized cause-of-death codes in two to three weeks — a “tremendous improvement,” McPheeters said.

Although she called electronic death registration systems a huge step forward, she added that they’re just one piece of a nationwide public health system that has long been inadequate.

“It’s not a complete panacea for everything,” McPheeters said.

Across the country, she said, health experts have been dogged by a failure of interoperability — how well their systems can efficiently merge data from disparate sources like labs, funeral homes, hospitals and doctor’s offices.

“It’s a whole complex system of systems, really, that need to be able to speak to each other better,” McPheeters said.

And those problems, she said, have meant an “absolute breakdown” in the U.S. response to the COVID-19 pandemic.

“You can’t act without good data,” McPheeters said. “And you can’t have good data without good systems.”

At his funeral home in Raleigh, Haywood said he’s looking forward to the upcoming training and rollout of the system starting next week. Less time driving around the county means his staff can focus on more personalized services in times of grief, and get families what they need faster.

“We’ve been hearing and hoping and praying about this coming to fruition,” he said. “Only because we can see — gosh — the amount of time that it would save.”

This story was jointly reported and edited by Kate Martin and Frank Taylor of Wmforo, Ames Alexander of The Charlotte Observer, Tyler Dukes and Dave Hendrickson of The News & Observer, Nick Ochsner of WBTV, Emily Featherston of WECT, Travis Fain of WRAL, and Jason deBruyn of WUNC.

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