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Electronic Death Registration System (EDRS)

The Journey of a Death Certificate

Since at least 2017, the PA Department of Health has had a
system in place for electronic rather than paper death certification.
As it turned out, neither the Chester County Coroner's Office nor
most medical facilities and physicians were using EDRS at the
time COVID-19 began to spread in our community. On March
6, the DOH mandated via State Registrar Notice 2020-01 that all
COVID-19 deaths were to be reported only via EDRS, that the
certifier should complete the medical certification before releasing
the body to a funeral home, and that the death certificate needed
to be completed within 24 hours1. Physicians overwhelmed with
caring for COVID-19 patients did not have time to learn a new
electronic system and paper certificates were rejected by funeral
homes.

Once the medical certifier and funeral home enter data, a death
certificate goes to a local registrar. There it is reviewed and officially
"registered," next proceeding on to the PA Vital Statistics office in
Harrisburg. Death certificates with COVID-19 are undergoing
further scrutiny, including cross-referencing to COVID-19 test
results (also reported to the State). There is extensive coding into
ICD-10 codes, with reassignment of the entered terminology, just
as with medical billing4. Eventually the funeral home has access to
the registered death certificate, which is then provided to the next
of kin for a fee of $20.00 for each copy.

In order to meet the electronic reporting requirement and to
ensure decedent disposition could proceed promptly and with
appropriate safety precautions, the Coroner's Office has assisted
many health care providers with EDRS medical certification for
COVID-19 deaths. Completed death certificates are required for
authorization of cremation. If death certificates are not completed
quickly during a mass fatality event like a pandemic, cremations
cannot proceed. This would result in undesirable outcomes,
including lack of morgue capacity and delay in disposition of
potentially contagious bodies.

Summary

The pandemic has focused attention on death certification
and posed new challenges to medical certifiers. The demand for
information on the number of deaths caused by the SARS-CoV-2
virus motivated a state requirement that COVID-19 deaths only
be certified electronically. A new disease and new terminology
came into use. The complexity of assigning an underlying cause
of death in elderly chronically ill patients means medical certifiers
must be specific, logical, and accurate when completing a
COVID-19 death certificate. Furthermore, certification must be
done very quickly so disposition of the decedent can be promptly
and safely carried out.

Presumed COVID-19: To Test or Not To Test
That has been the question over the past weeks and months,
as inept planning at the highest levels and restricted testing led to
a shortage of tests and test results for COVID-19. While hospitals
in Chester County always tested for COVID-19 in suspected
cases, long term care facilities did not. They were advised by both
State and County Health Departments that if a certain number
of residents (usually 4) had already tested positive, other residents
with exposure to those residents or with symptoms could be
"presumed-positive" and did not need to be tested. Unfortunately,
this population surveillance concept quickly became confused with
the death certification of individual deaths. As certain long term
care facilities became overwhelmed with the number of deaths, the
default cause of death was often simply "Presumed COVID-19."
Using terms like "probable" or "presumed" is common and
acceptable in medicine, but when a simple test can confirm or rule
out a disease, there is no reason to defer to this kind of hedging.
It is easy to write off the death of an elderly person with many
comorbidities, but not a good practice. In my opinion, each
individual and their family deserve, at the very least, an accurate
death certificate.

References
PA Department of Health Registrar Notice https://www.health.pa.gov/
topics/Documents/Reporting-Registries/SRN 2020-01 COVID-19 for
Medical Professionals.pdf

1

Guidance for Certifying Deaths due to Coronavirus Disease
2019 (COVID-19). CDC COCA-Webinar April 6, 2020.
https://emergency.cdc.gov/coca/calls/2020/callinfo_041620.
asp?cid=EPRhomepage

2

National Center for Health Statistics. Guidance for certifying deaths
due to COVID-19. Hyattsville, MD. 2020. Accessed 5/2/2020 at
https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf

3

Alexander, Lily. July 23, 2018. Determining causes of death: How we
reclassify miscoded deaths. Institute for Health Metrics and Evaluation.
Accessed May 1, 2020 at http://www.healthdata.org/acting-data/
determining-causes-death-how-we-reclassify-miscoded-deaths.

4

SPRING 2020 | CHESTER COUNT Y Medicine 23
http://www.chestercms.org https://www.health.pa.gov/ https://emergency.cdc.gov/coca/calls/2020/callinfo_041620 https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf http://www.healthdata.org/acting-data/
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