2008 Model Practice Application (Public)

A Coroner-Based System for Near Real-Time Community Mortality Surveillance

Louisville Metro Health Department

To implement a community mortality surveillance system for the early detection of outbreaks and health situational awareness that operates in near real time using data from medicolegal death investigations performed by deputy coroners.

In "Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and case management," the Centers for Disease Control and Prevention (CDC) recommends the use of data from medicolegal death investigations—those carried out by coroners and/or medical examiners—for mortality surveillance, particularly for sudden or unexpected deaths. Because they investigate deaths among persons who have not accessed the healthcare system and who may have died without a confirmed diagnosis, the CDC has recommended that coroners and medical examiners “should be a key component of population based surveillance for biologic terrorism.” The CDC has further recommended that electronic information systems for sharing data between medicolegal death investigators and public heath authorities be designed for the rapid recognition of excess mortality. What process was used to determine that the practice is an inventive use of an existing tool or practice? Please provide any supporting evidence you may have, e.g. literature review. Literature review How does this practice differ from other approaches used to address the public health issue? If you used a tool to implement your program (e.g. PACE EH, MAPP, Assessment Protocol for Excellence in Public Health (APEX PH), Planned Approach to Community Heath (PATCH), etc), how was your approach to implementing the tool unique? This program leverages the relationship between the Health Department and the Coroner’s Office, provides for rapid field data collection and establishes an informatics channel between the two organizations that allows mortality surveillance data to be analyzed in near real time. This is a vast improvement over mortality surveillance that relies on vital statistics data. If this practice is similar to an existing model practice in NACCHO's Model Practice Database (www.naccho.org), how does your practice differ? It is not similar to other programs in the database.

The Health Department operates the surveillance system and analyses the data. The Coroner’s Office collects data in the field and provides it to the system. The existence of the system represents a formal channel of communication between the two agencies, which reinforces the need for and desirability of interagency information sharing.

Implementation required the commitment of sufficient time, effort and technical expertise to establish a working relationship with the Coroner’s Office and to enhance their data and informatics infrastructure to make it compatible with the surveillance system and establish connectivity. Funding for the purchase of 10 laptop computers for field data collection by deputy coroners was also required (approx. $15,000). This project was funded, in part, by a grant from the University of Louisville’s Center for the Deterrence of Biowarfare and Bioterrorism.

In this system, deputy coroners input data from death investigations in the field using laptop computers. This data is uploaded to a master database upon completion of the investigation. Every 24 hours, an updated copy of the database is uploaded to a LAN folder that is shared with the Health Department. The data is downloaded by the Health Department each morning for daily analysis. Two different methods are used in the analysis of daily case counts to detect significant departures from baseline mortality, the epidemic threshold and Cusum methods. When a significant increase in mortality is signaled by the system, further epidemiologic analyses are performed using data already available from the coroner’s database, including analyses of the presumed cause and manner of death and geographic as well as age, sex and race stratified analyses. Such analyses are intended to determine whether further data collection and investigation is warranted. In some cases, these intermediate analyses may rule out the need for further follow up, by identifying excess deaths as the result of a multiple vehicle traffic crash, for example. In cases where further follow up is required, they will define or narrow the focus of the epidemiological field investigations to be undertaken.

The surveillance system has been operating for over two years, without the need for additional funding beyond the start up costs. Because the elements of the system have been built into the routine business practices of both agencies, its operation does not impose additional burdens on either deputy coroners or health department personnel. In fact, both agencies realize secondary benefits from the operation of the system. The Coroner's Office benefits from an improved data infrastructure and improved field data collection capacity, which allows for more efficient nonsurveillance record keeping, data analysis and report writing.

The surveillance system has been operating successfully for over two years, providing near real time mortality surveillance and health situational awareness.