Unlocking TxEVER: Experts Weigh in on Best Practices for Texas’ Death Records Registry
By Jessica Ridge Texas Medicine November 2024

“To be fair, I’m in and out of the system relatively frequently. It works fine for me because I know those nuances, I learned them, and I navigate them reasonably well,” said Dr. Young, chair of the Department of Family and Community Medicine at the Texas Tech University Health Sciences Center at Amarillo. “But for the people who are a once-in-a-while death certificate completer, then it’s not as user-friendly as it could be.”    

Though not without its idiosyncrasies, including state- and federal-mandated security controls that can make the registrar challenging to use for infrequent users, the system facilitates Texas physicians’ final act of care for patients and serves as a repository of critical public health data, which makes mastering its navigation as vital as the records it houses.  

Recognizing that, and physicians’ frustrations, the Department of State Health Services (DSHS) has developed numerous resources available to TxEVER’s 11,000 active physician users that are designed to ease and explain the process of certifying a death record – a record containing important data that Vital Statistics State Registrar Tara Das, PhD, says bears on the health of all Texans. (See “Where to Turn for TxEVER Help,” page 28.) 

“You cannot know what are the leading causes of death or any type of demographics are to help prevent deaths from occurring in the future through public health or clinical interventions if not for the information that’s collected on the death certificate,” she said. “The death certificate holds immense importance as a public health instrument, particularly for mortality statistics.” 

Though often viewed as a transactional legal or administrative document required to access insurance benefits, settle pension claims, or transfer property titles, death certificates represent the tangible product of death records, on which vital statistics are based that identify public health needs and inform research and the allocation of resources.   

“The death record is the data that underlies that death certificate,” added Chris Van Deusen, DSHS director of media relations, about the information submitted by medical certifiers, often physicians and medical examiners, in TxEVER, which moved to its current cloud-based system in 2019. “So it’s more than just filling in a PDF so you can print out and give to your insurance company or to the courts or something like that. It’s really all the data that’s behind that.”  

Guiding health initiatives  

Lauren A. Edelman, MD, deputy chief medical examiner at the Travis County Medical Examiner’s Office, who assesses TxEVER as an overall robust death certificate data entry system, has seen firsthand how the information collated in death records impacts public health. She notes that when TxEVER identified an increase over several years in Travis County deaths due to drug toxicity, local government was able to implement harm-reduction strategies such as the distribution of naloxone to high-risk populations.     

Developing the chain of circumstances that led to a death with the level of specificity (e.g., the specific histology of a type of cancer) that TxEVER requires can sometimes be challenging, though, particularly for physicians who work in hospice, who might see a patient only once — or maybe not at all, if the patient enters hospice late in their illness and dies hours later, says Dr. Young.  

“In that scenario, oftentimes the medical director wouldn’t even have seen them yet, directly,” Dr. Young said. “So I have to gather the information [from nursing staff] to tell that story. That information has proven extraordinarily elusive in many cases. That said, they [DSHS] don’t tell me I have to be perfect. I have to use my judgment as best I can to say what I believe led to death and what was the mechanism. So there’s some latitude in there.”   

In Dr. Young’s view, the delegation of tasks like assigning and deactivating users to thousands of individual practices statewide presents “a lot of opportunities to mess up” details by virtue of interfaces that can feel unintuitive or clunky to parse.   

Those nuances and perceived hurdles stem from federal controls that are meant to safeguard the quality of the data captured by death records, Dr. Das explains.  

“TxEVER contains births and deaths and other vital records for all Texans, which makes it one of our most mission-critical and confidential information security systems,” she said. 

Acknowledging users’ frustration with the policy, she notes that the information security measure to disable inactive users within 90 days is a specific Texas Health and Human Services control that is mapped to state and federal requirements, rules, and standards.    

Vital help  

“Additionally, we’re happy to provide any type of trainings or support that is needed for our communities,” Dr. Das said, adding the department encourages users to reach out about their experiences using state resources. “We’re always open to any kind of suggestions or feedback for improving those.” 

Those resources include a help desk reachable Monday through Friday by phone and help request form, user guides, YouTube tutorials, and a DSHS Handbook on Death Registration.  

Dr. Edelman appreciates the ease with which TxEVER users can contact the help desk to facilitate access to the system as well as the website’s training materials for clinicians who are unfamiliar with the system. 

“One of the biggest challenges with death certification is the general lack of training that clinicians receive,” she said. “This last act of patient care is essentially a black box for so many clinicians, and it generates a lot of anxiety.” 

TxEVER administrators at practices offer an avenue of technical assistance and might be able to fix a problem for a user more quickly than the help desk if, for example, an account lockout happens over the weekend. They too operate under the security control that dictates TxEVER account lockout after 90 days of inactivity, a caveat that Dr. Young’s co-local admin for TxEVER has experienced that requires Dr. Young to occasionally unlock her account as well. He cites insufficient automated notices and reminders to complete death certificates that can get buried in a physician’s email queue as additional sticking points. 

“This could be made better, and it would serve the physicians, the patients, and the bureau of vital statistics better, if we made a few changes,” he said. 

As a frequent user, on the other hand, Dr. Edelman says she’d like to have the option to disable instructional popups meant more for infrequent users, and to be able to review the certificate in its entirety in one step, but also finds moving through the screens to complete certification more intuitive since it moved to a cloud-based system.  

Resources from the Centers for Disease Control and Prevention (CDC) can further support TxEVER users, Dr. Das notes. The CDC’s National Vital Statistics System website offers training and instructional manuals for certifiers of death certificates, and the agency’s validation and interactive edits web service guidance informs the immediate feedback users receive as they proceed through TxEVER to certify a death record, to guard against ill-defined or nonspecific causes of death and to identify rare causes that might merit a second look. All to ensure the veracity of the data.  

“I understand that it takes time away from living patients, but it also serves as that final act of patient care and provides a great deal of valuable information that is used in Texas and across the country for designing interventions that could prevent similar deaths in the future,” Dr. Das said. “It’s more than just a piece of paper.”