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- Leadership for a Healthy Arizona -
Fife Symington, Governor
State of Arizona
James B. Griffith, Acting Director
Arizona Department of Health Services
1740 West Adams Street, Phoenix, Arizona 85007
6021542- 12 16
This publication can be made available in alternative format.
Please contact the Office of Health Planning, Evaluation and Statistics,
at 542-1216 (voice) or call 1-800-367-8939 (TDD).
July 22, 1997
Lisa Block
House Research Staff
1700 W. Washington
Phoenix, AZ 85007
Dear Ms. Block:
Attached please find the Electronic Death CertGcate Advisory Committee Report to the Legislature prepared by the
Arizona Department of Health Services. In 1995, House Bill 2010 directed the establishment of an advisory committee
on electronic death certificates consisting of representatives from public and private stakeholder organizations to assist
the Department of Health Services develop and implement an electronic death certificate system. This report includes
the findings and recommendations of that advisory committee.
As the reports indicates: an electronic death registration system is a user-friendly tool designed to simplify the process
of registering deaths and improving customer service. However, the implementation of an electronic death certificate
system is a complex undertaking requiring a well conceptualized, well organized, and well developed partnership among
the numerous stakeholders. Without such a partnership, an electronic death certificate system could become a costly
alternative to a manual system but lacking the benefits anticipated by its stakeholders.
The ultimate success of an electronic death certificate system in Arizona will be measured by the accuracy of the
information, the improvements in productivity gained by the stakeholders, the improvements in customer service, and
the State's ability to utilize the data for more effective program development and evaluation. By implementing the plan
contained in this report, Arizona could become the model for other states desiring an electronic death registration
I hope this report provides direction with regard to the implementation of a unique system. If you have any questions
regarding the report, please contact Ms. Marti Lavis, Chief, Legislative Services, Arizona Department of Health
Services at 542-1032, or Merle Lustig, Chief, Office of Health Planning, Evaluation and Statistics, Arizona Department
of Health Services at 542-1216.
James B. Griffith
Acting Director
Leadership for a Healthy Arizona
Table of Contents
Introduction .......................................................... 1
Background/Overview .................................................. 2
ProceduralIssues ...................................................... 3
Physician Participation and Education ................................. 3
Demographic Data Entry Verses Electronic Death Certification ............ 4
Responsibility for the Entry and Accuracy of the EDC Data ............... 5
Fundingsources .................................................... 6
ZowaCaseStudy .................................................... 7
TechnicalIssues ....................................................... 8
Single Purpose Network Verses a Global Network ........................ 8
Arizona Specific Software Requirements ................................ 9
User-Friendly System That Provides Incentives for Physicians ............. 9
Residence of the Information and Integration with Existing State Systems ... 10
Time Constraints with Existing Systems ............................... 11
Potential EDC Cost Components ..................................... 11
Conclusions and Recommendations ...................................... 12
APPENDIX A: Electronic Death Certificate Advisory Committee Members List
APPENDIX B: Arizona Funeral Directors Association Report
APPENDIX C: Chart 1: EDC Process. Funeral Director On-line .Ce rtifying
Physician Manual
Chart 2: EDC Process. Funeral Director On-line .Ce rtifying
Physician On-line
APPENDIX D: Client/Server. Application Systems Strategy. Technical
Introduction -b ..... :.
Death care in Arizona, as in many states, has reached a critical crossroad. Arizona continues to
break its own record in recorded deaths each year and, with births on the rise and the beginning
of the baby boom generation reaching retirement age, this trend is projected to continue. In 1996
Arizona recorded over 36,500 deaths or more than 10 deaths per day. Moreover, Arizona citizens
requested and received 220,000 certified death certificates in 1996. As a result, the manual vital
records death registration system has become fraught with system and procedural inefficiencies,
delays in the processing of information and data integrity issues.
To address these issues, the legislature enacted HB 2010 that established an Advisory Committee
on Electronic Death Certificates to assist the Director of the Department of Health Services
develop and implement an electronic death certificate system. The Director of the Arizona
Department of Health Services (ADHS) has appointed an Electronic Death Certificate (EDC)
Advisory Committee consisting of representation from various public and private health care
organizations. The representatives on the EDC Advisory Committee come from the ADHS,
Arizona Funeral Directors Association, Arizona Medical Association, Arizona Osteopathic
Medical Association, medical examiners, hospitals, and county governments. A list of the EDC
Advisory Committee members is included as Appendix A of this document.
The problems with the existing manual death registration process have been discussed in a
previous report developed by the Arizona Funeral Directors Association that studied the re-engineering
of death registration. This report is included as Appendix B of this document to
provide background information and a more thorough understanding of the problems associated
with the existing process. The mission of the Arizona Funeral Directors Association Committee
was similar to the EDC Advisory Committee in that it focused on re-engineering the death
registration process. While the Arizona Funeral Directors Association Committee justified the
viability of automation, the EDC Advisory Committee focused on building a consensus among the
stakeholders and identifying the steps necessary for implementation of an electronic death
registration process.
The intent of this report is to clarify the issues surrounding the implementation of an EDC system,
develop conclusions based on the Committee's research, and make recommendations upon which
the individual organizations represented on the Committee can act.
The EDC Advisory Committee has studied the process of registering deaths in Arizona and
understands the impact this process has on the parties involved. It has engaged a consultant,
received information from specialized software vendors, and used other states' experiences to help
formulate an approach to automate the death registration process. The results of these efforts are
summarized in this legislative report. The problems with the existing process are clear, the
challenges of automating such a process are understood, the solutions are identified, and the
benefits of change are significant. It is this Committee's hope to receive the necessary fiscal and
statutory support from the legislature to move forward with this project.
Under the existing manual death certificate registration process, the funeral director maintains
responsibility for the certificate until all the data elements are gathered by the family, physician,
and county. In other words they act as a "hub" or central registry for the certificate. The family
provides basic demographic and personal information on the deceased. The attending physician
or medical examiner provides the cause-of-death and other required medical information. The
county issues the burial permit to the funeral director or the family depending on who has assumed
responsibility for the burial process of the deceased and conducts public health surveillance. The
State of Arizona is responsible for maintaining the central registry through which all certified
copies of death certificates are issued, preparing statistical reports on the health status of Arizona
citizens, and creating public health programs to address issues raised by the data.
Since the funeral directors serve as the hub for information and are unable to bury the deceased
until the death certificate is completed and the burial permit is in hand, a significant amount of
driving, faxing and phone calling needs to take place for each occurrence. This can cause the
obvious problems of delays in the burial process, poor customer service, data integrity and
redundancy issues for the State, increased operating expenses for the funeral directors, security
exposures for the families of the deceased, and several other issues that typically accommodate a
manual registration process. Each of these areas will be addressed and greatly improved upon by
the institution of an Electronic Death Certificate system.
Automation of death registration appears to be fairly straightforward. It could be assumed that
by replacing the manual forms and maillfax systems currently in use with a central "server" that
stores all the data in a single database, by utilizing one of the several software packages that are
available from specialized software vendors, and by selecting one of the many communications
options and/or the Internet, the death certificate could be routed through the information
superhighway until all the data elements for proper death registration have been completed.
So why then are no states able to lay claim to a successful EDC system? Several issues exist
within the death certificate process that make it unique. These issues can be categorized into two
groups, procedural issues and technological issues. The following sections detail each issue and
describe how the EDC Advisory Committee recommends each be addressed to arrive at a
functional solution. As will be illustrated in this report, some issues that exist will not be solved
by automation alone. A complete solution will require difficult process changes (possibly
legislatively mandated changes) in addition to technology to ensure that maximum benefits are
Embarking upon a project such as EDC involves the cooperation of all the organizations influenced
by such a project. This in-and-of-itself represents the core of the procedural issues facing the EDC
project. Unlike most systems where the data elements are all entered into a central server, EDC
requires data elements to be collected from many sites. Funeral home directors, physicians,
medical examiners, hospitals, nursing homes, the State of Arizona, and each county are involved
when someone dies. The diversity of the stakeholders creates issues within the data collection
process that need to be addressed in order to make an EDC functional.
• Physician Participation and Education
The paradox between the death registration process and the collection of the data elements is the
thorniest of the challenges facing an integrated, automated EDC. The Arizona Revised Statute
(A.R.S. 36-327) states that "The funeral director.. . who first assumes custody of a dead body or
dead human remains is responsible for executing and filing the death certificate." Furthermore the
statute states that the medical certification on the death certificate shall be completed and signed
within 72 hours by the physician in charge of the patient's care for the illness or condition resulting
in death. Adherence to this statute is necessary for an EDC system to work efficiently whether the
registration of the patient's death occurs manually or electronically.
Yet the funeral directors are often challenged by the effort to acquire cause-of-death and physician
signatures within 72 hours. They are concerned that they often spend many hours in pursuit of the
attending physician to acquire this information to complete the certificate and bury the deceased.
To the physicians the existing process is time-consuming and cumbersome. In addition, the process
requires a knowledge of coding and other related factors that are often so unclear as to require
several attempts before accurate completion. Physicians frequently avoid the inevitable process of
registering their patient's death because engaging in this problem-laden process takes away from
their productive time of healing and attending to their patients. Furthermore, they are concerned
with the accuracy of the data collected, the inability to do research or access information relating
to their deceased patients, and the need to include additional information on the death certificate
form. The physicians hold the key to the completion of the death certificate. No one else involved
in the process is qualified or legally obliged to identify cause-of-death other than the physicians.
A report published in the March 13, 1996 edition of the Journal of the American Medical
Association (JAMA. 1996;275:794-796) entitled '2ccuracy of Death Certz3cate Completion - The
Need for Formalized Physician Training1'references a study that was done to test the theory that
cause-of-death education is needed at all levels of the medical community. This study involved
analyzing 6 typical death cases and asked each participant (consisting of general internists, internal
medicine residents, and senior medical students) to determine the underlying cause-of-death each
of which were coded by a professional nosologist. Each case was measured for different degrees
of accuracy using certified methods published in the New England Journal of Medicine
(1985;3 13 : 1263-1269); 'The autopsy as a measure of accuracy of the death certifcate '< The
agreement percentage, when compared to the official cause-of-death for each case, ranged from a
low of 14.7% in one case study to a high of 98.5% in another case study. The overall accuracy
percentage for the study measured 72.7%. It was concluded that training on death certificate
completion needs to be included as an integral part of physician education.
If ADHS is to achieve the objectives of creating public health programs that are meaningful based
on vital records data, it is critical that the proper cause-of-death be identified by the attending
physician in a timely manner. Without the proper education of the physicians on ICD-9 and
National Center for Health Statistics coding requirements for the physicians, it is unlikely that high
levels of accuracy will be maintained in a death registration system.
Physician participation is essential, whether having to fill out a form manually or electronically.
A move to an electronic system will not, in-and-of-itself, provide incentive nor encourage
participation in the death registration process by the physicians. People die in hospitals, nursing
homes, their own homes, and many other places. Clearly these dynamics make certifying deaths
a challenging issue. Despite this challenge, it is necessary for the physicians to attend to the matter
of registering their patients with the State of Arizona after they die both for completion of patient
care as well as statutory reasons.
Demographic Data Entry Versus Electronic Death Certification
The issue arises as to the level of participation needed in order to ensure an optimal return on an
EDC investment. The taxpayers of Arizona deserve a cohesive system that returns to them the
benefits of an automated process. The greater the participation in an EDC system by each
stakeholder, the greater the benefits.
Chart 1 (Appendix C) describes a process where funeral directors use an EDC system but
physicians do not. This scenario is a typical implementation of a so-called EDC system in other
states. When funeral directors enter the demographics of a deceased person into a computer and
transmit that information to the State electronically, some benefits are realized. These benefits
include .- -..-.. - -CC:-:----- --A --.--
~ I I I ~ L U VCLCII~L ICI~LYa iiu auaracy of the demographic information. Under this scenario
however, the funeral directors must still pursue the key medical information related to the cause-of-death
manually from the doctors. The primary issue of timely medical information continues to
exist as with a completely manual system. Consequently, Chart 1 is a demographic data entry
system that is fairly easy to implement, has a relatively low cost, requires no statutory changes, and
offers little benefit to the stakeholders and the general public. An automated means of transmitting
the demographics of the general public from the medical community to the State of Arizona already
exist in other public health networks. The demographics are not the key piece of information in
an EDC system. The medical information tied to the patient is the critical element necessary to
complete the certificate.
Chart 2 (Appendix C) describes an EDC system in which all stakeholders participate in the EDC
process. This arrangement depicts the full impact and benefits that can be realized through the
electronic transmission of accurate medical data associated with the deceased. Full participation,
however, does not mean that each physician must buy a computer system specified by the State of
Arizona. Full participation simply means the enforcement of the existing State statute requiring
registration of death within 72 hours of occurrence. It is the EDC Advisory Committee's belief
that the EDC system would be utilized by physicians without any additional legislation if a system
was in place that made it simpler to enter cause-of-death and authorize the certificates. Re-designing
the process and eliminating its inefficiencies might create enough incentive and offer the
benefits necessary to encourage the physicians to participate in an automated alternative. Although
the flow of information looks similar to Chart 1, Chart 2 describes a comprehensive medical
information network that demands participation from each stakeholder. With this participation, not
only are the problems associated with the current process eliminated, but each stakeholder receives
substar;:ia! be~ef;l:~T. hc F~~crdai!r ectors benefit from a more co~i-eff~cipir~oece ss. The
community and the State of Arizona have the tremendous benefit of accurate and timely medical
information. The general public benefits from a streamlined process that shortens the
administrative burden currently accompanying the death of a loved one. To implement a full EDC
system requires significant research and investment. The characteristics of this solution involve
carefully designed networks (some of which may already be in place), possible statutory changes,
and education of the stakeholders to ensure each of their roles are understood and accurately
Automated systems are only as good as their weakest link. If a physician or funeral director
continue to register deaths the "old way" by manually completing cause-of-death, the fact that one
or the other has an automated means of entering the information into a computer system offers little
benefit to anyone including the general public. The benefits physicians are looking for including
improved efficiencies, better information in a central registry to develop meaningful public health
programs, and an improved research database that is easy to access and that contains up-to-date
information are not accomplished under this scenario.
The key to full participation is the benefit realized by the stakeholders, enforcing the statutes
currently in place and making proper death registration an integral component of physician training.
The importance of the cause-of-death data is summarized in the JAMA article referenced earlier
in this report.
Responsibility for the Entry and Accuracy of the EDC Data
Under the existing manual process, the County Registrars are the first to receive the completed
death certificate forms. These manually processed forms are subjected to several edits and checks
by the counties. Initial edit checks have identified an error rate of thirty-three to forty-eight percent
(33 %-48%) in some counties. Once the data elements of the death certificate have been gathered,
edited and checked, and the burial permit issued, the completed form is mailed to the ADHS'
Office of Vital Records. The information is then entered into the ADHS' main computer system
where the central registry is maintained by the State of Arizona. Facilitating the collection of all
the needed data elements is the responsibility of the funeral directors. They currently collect all
data elements within and outside their control. In an automated system, each stakeholder would
take ownership of their data elements to ensure timeliness and accuracy. In an EDC environment,
the hardware and software are simply mechanisms to assist the participants in adhering to the time
and accuracy requirements of the death registration process.
Using this approach, it is no longer necessary to route the death certificate to a County Registrar
prior to certification. However, it is critical to the counties to continue to be able to issue and
charge for death certificates to its county residents. All required information can be collected from
the family, funeral director, and attending physician. By providing an EDC system in which the
central server is located at ADHS, funeral directors and physicians can enter necessary information
from a series of easy-to-use screens and menus. As the funeral directors will attest, coordinating
the necessary data to complete death registration presents a challenge. However, by centralizing
this function at the Office of Vital Records, using technology, and enforcing existing state statutes,
the procedural change of empowering each stakeholder with the responsibility of entering their
respective data elements should reap substantial benefits.
e Funding Sources
There are several phases of this project that involve network design and procurement of computer
hardwarelsoftware applications. Funding alternatives to support these phases were discussed by
the Committee. The benefits of an EDC system are primarily directed at the general public in the
form of improved customer service. However, significant benefits also exist for funeral directors,
the State of Arizona, physicians and the federal government. Funeral directors will be able to
lower their operating expenses. The State of Arizona should have better quality information to
report to the federal government agencies requiring this data. Physicians will have access to a
network filled with valuable information for research and analysis, and will save resources through
the use of a more efficient system. The federal government will be able to access death information
sooner facilitating better public service and optimizing the ever-depleting Social Security fund.
The value realized from an EDC helps determine the funding alternatives for this project.
Discussions with other states suggest several ways automation projects pertaining to vital statistics
are funded. Following are examples of four possible funding sources for this project and a case
study from Iowa.
o Apply a surcharge to each certified copy of a death certificate. Currently
there is a $1.00 surcharge applied to each certified copy to fund the Child
Fatality Review Board. A similar surcharge could be applied to fund EDC
that could begin immediately in order to generate revenue to offset initial
capital expenditures for hardware and software.
CI Arizona Legislative appropriation for the necessary capital expenditures and
operating expense to ADHS for the server component of an EDC system.
o Apply for federal grants (specifically, Social Security).
o Obtain financial assistance from the private sector (i.e. funeral directors,
hospitals, nursing homes, etc.) for personal computers.
More than likely, a combination of some or all of these options will be needed to properly fund this
project. Initial capital expenditures for the main system and ongoing expenses could be handled
through a combination of legislative appropriation, a surcharge and federal grants. The private
sector has the expense of procuring the necessary equipment and software licenses in order to
participate in the new EDC system. The issue of funding needs to be discussed further by all the
affected parties. This is the type of project that requires a commitment to change and investment
by everyone involved.
Iowa Case Studv:
Iowa's Vital Statistics office has been a completely manual operation since inception. Slight
progress was made with the advent of microfilm and microfiche as a way to store and retrieve birth
and death certificates. Yet the process continued to be cumbersome and prone to errors.
Furthermore, each request for certified copies of birth and death certificates required two days to
process. The charge for certificates was six dollar ($6), regardless of the type.
Several years ago, the Iowa legislature approved a four dollar ($4) surcharge on all certificates
raising the total cost to ten dollar ($10). This surcharge went into an automation fund setup to pay
for a fully integrated vital statistics system including births and deaths. The four dollar ($4) were
available to the automation fund for four years. Since this fund was established, Iowa has made
tremendous strides in improving customer service, staff efficiencies, and data integrity. Most
applications have come online with the exception of death registration which is currently in process.
Iowa's Office of Vital Statistics recently received approval for a two-year extension on their
surcharge fund and assumed full ownership of the monies collected. The Office of Vital Statistics
in Iowa determined that the four dollar ($4) surcharge was adequate to completely fund their office
including staffing, other operating expenses, and capital expenditures. In exchange for the control
of the four dollar ($4) surcharge, Iowa's Office of Vital Statistics gave up all state appropriations
during the two-year extension. This four dollar ($4) surcharge generates approximately one million
dollars annually. It is their hope that the Iowa legislature will continue to allow them to be a fully
fee-funded organization.
Technical Issues
Unlike the Electronic Birth Certificate implementation which included the State Office of Vital
Records, eighty (80) hospitals, and several county registrars, the number of potential participants
involved in implementing the EDC may well exceed several thousand. These stakeholders include
physicians and funeral homes statewide, numerous county registrars, medical examiners, hospitals,
nursing homes and the State Office of Vital Records. Furthermore, the EDC project is ongoing
in that new users of the system will continually be coming online. As new doctors, funeral homes,
medical examiners and others establish businesses in Arizona, they will have to use and interface
with the EDC system. With the advent of managed care, large medical providers will come and
go, affecting a significant number of patients. All these issues need to be understood prior to the
implementation of EDC. EDC is a user friendly tool designed to simplify the process for the
private sector, provide a better information foundation for the public sector, and provide
improved customer sewice for the general public. In order to implement electronic death
registration in the State of Arizona, the following technical issues will need to be resolved.
0 Single Purpose Network Versus a Global Network
When several organizations are connected together to contribute to a single database, it is important
to determine the characteristics of the network by which these organizations will disseminate their
information. The network design is critical to the overall success of a project such as EDC where
data elements are collected from a variety of sources. Two general categories of networks were
considered as possible options for the EDC network.
Single Duipose network: This type of network is the kind that is typically used to link a collection
of users needing to access or contribute to the same database. Under this design, a main computer
system (or in today's vernacular -"server") provides the application(s) needed for people within a
department or organization. These users can be connected directly to the server if they are in the
same building, or, they can be connected remotely to the server with dedicated or dial-up phone
lines from another facility. Regardless of the location of the users, the network and its components
are established for the sole purpose of utilizing a single set of applications across a finite, static user
base. Electronic Birth Certificates and Newborn Screening are two examples of existing single
purpose networks in use at ADHS.
Global network: A global network is established to provide a more dynamic and flexible computing
environment for its users. Not only does a global network accomplish the same objectives of a
single purpose network, it also provides controlled access to other networks such as existing public
health networks and the Internet. A main server is still required to store the data and applications.
However, instead of running cables and setting up phone lines directly from the users of the system
to the server, users are connected using technologies specifically designed for a hybrid computing
environment. This is done by connecting the server to the global information superhighway. Users
then tap into the applications either through locally established "addresses" or remote service
providers. With the understanding that there are complex issues to work out under this scenario
such as security, confidentiality, standardization, and access, global networks provide the users
access to more information and, with its large number of potential users, simplifies the
implementation of a project such as EDC. Existing public networks such as the Internet or the
phone systems can be utilized for the different stakeholders to participate in EDC. Access to these
networks already exists in many cases so no new dedicated connections to a server would have to
be established for a stakeholder to begin to utilize an EDC system.
Each of these alternatives has connectivity and telecommunications issues that will need to be
addressed. Several network topologies exist, each having different implementation considerations.
Furthermore, bandwidth and other technology limitations exist on most global networks limiting
access and causing performance problems. However, pent-up demand for high speed networks and
access to the Internet are driving technology improvements that address these issues.
Determining which network design is best suited for an EDC application in Arizona is critical.
These alternatives need to be defined further in a detailed systems plan. The security and access
issues are the main concerns associated with a global network. However, it is evident that global
computing is here to stay. In order to be positioned for the new millennium, it is important for the
medical community to participate and utilize the resources made available through these networks.
Arizona Specific Software Requirements
In surveying other states, software vendors, and consultants about these issues, it became evident
that EDC implementation differs from state to state. Of the very few software solutions available,
each requires significant modifications to conform to Arizona specific requirements. Software
vendors in this marketplace offer data entry screens complete with very robust edits and checks to
ensure the integrity of the death registry. However, each field needs to be evaluated by Arizona
to determine proper field lengths, whether or not a field needs to be made optional or mandatory,
and the addition of fields specific to Arizona such as tribal affiliation for the Native American
population. Each of these items is unique to Arizona and would need to be programmed into the
new EDC system. The magnitude of these changes will directly impact the cost of the project and
are largely dependent on the selected software vendor. Most of these changes are very simple and
some are even included in the license fees of the software vendors. However, it is necessary to
identify these changes and assign time frames and costs before entering into a contract with a
selected software vendor.
User-Friendly System That Provides Incentives for Physicians
In order to optimize the use of an EDC system, it is important to insure that EDC is easier and
more convenient to use than filling out today's manual forms. Special features that aid the
physician in assigning the proper cause-of-death need to be included in order to provide incentives
for the physicians to use the system. These features may include:
o Multiple comment lines, prompts, and lists of possible conditions to assist
physicians to enter accurate information that leads to the official cause-of-death;
A field on the EDC system to record the deceased's health plan number;
Electronic signatures using a personal identification number (PIN);
~1 Menu-driven cause-of-death information.
Residence of the Information and Integration with Existing State Systems
The physical location of the EDC application server needs to be determined since the Vital Records
Office and the ADHS Information Technology Services (ITS) office are in two separate locations
in Phoenix. Currently, the ITS department maintains the vital statistics database. An electronic
death registration system will distribute the data entry across multiple stakeholders including the
Vital Records Office. There are several network and hardware configurations that will satisfy these
requirements. Each of these alternatives needs to be analyzed to assess risks, costs, and
efficiencies. The resulting costlbenefit analysis will be used to determine the final network
ADHS is in the process of re-engineering all of its applications into a clientlserver environment.
With most of the applications having been legacy programs written and developed in outdated
technology, initiatives such as EDC were technologically difficult to implement. With the advent
of clientlserver and open computing, technology now facilitates projects that allow multiple
organizations to collaborate and share information in a single virtual system such as EDC. The
Information Technology Services (ITS) Department within ADHS is currently on schedule to
eliminate all legacy programs and move fully into clientlserver by the end of 1998. Several
programs are migrating to clientlserver including birth certificates and immunization. Appendix
D details the "Application Framework adopted by ADHS to implement new applications such as
EDC. It is within this framework that an EDC solution will be expected to fit in order to meet the
clientlserver initiative currently underway at ADHS.
In order to support an EDC system, ADHS must upgrade its clientlserver infrastructure to handle
the additional workload and capacity brought on by EDC. ADHS' role in projects such as EDC
is geared towards the "server" side of clientlserver environment. There are multiple "clients" with
EDC (e.g. funeral directors, physicians and medical examiners) but there is only one "server,"
ADHS. ADHS is the custodian of the data ensuring its integrity, security and accessibility.
The software applications used at Vital Records are closely integrated and extremely
interdependent. When one application changes, several interfaced programs are impacted.
Defining these interfaces will be critical to the implementation of an EDC system.
The most critical interface to be established is the one between the birth registry and death registry.
The interface is known as birthldeath matching and is used for many applications. One of these
applications is called B . D. S .I. or Birth Death Social-security Interface. This program is invoked
each night and records all the deaths registered with ADHS. The output from this program
provides a list of those deaths that occurred in Arizona that have a corresponding Arizona birth
record. This program then flags each of the birth files and marks them as "deceased". According
to ITS, this program is one of the most critical with various elements being reported to the National
Center for Health Statistics (NCHS). This program and the interface between the birth and death
registry provide the sole protection from birth certificates and social security numbers being issued
to a deceased person. Consequently, this interface needs to be included as a part of the EDC
project since a change to the death registration process and programs that support it directly impact
the interface programs to the birth registry.
Time Constraints with Existing Systems
Existing legacy systems that support the death registry at ADHS are scheduled to be eliminated
by January 1, 1999. Consequently, the evaluation of the most appropriate approach needs to be
completed. The alternatives include identifying and purchasing a pre-written EDC software
solution that meets Arizona's requirements or building a custom application through a combination
of contractors and/or existing ITS staff. Even with an off-the-shelf solution, preliminary
investigation indicates that a significant amount of modifications to an EDC application will be
. . necessary.
Furthermore, the overall coordination of an EDC project that addresses each of the technical and
procedural issues discussed in this report represents a challenge within the time constraints
described above.
Potential EDC Cost Components
Following is a list of potential system components and staffing requirements related to an EDC
system. These are typical capital and operating elements incurred when implementing a computer-based
application. Actual costs and proposed budgets will be determined once the Project
Investment Justification is completed.
Potential Components of an EDC Solution
Capital Components Operating Components
ADHS server hardware ADHS technical staff
Systems and database software licenses Stakeholder training
EDC application software licenses Telecommunication expenses
EDC Application modifications Server hardware and system software
ADHS implementation and training maintenance
Cabling and networking equipment EDC application software maintenance
Consulting services, as necessary
The original intent of the EDC Advisory Committee was to develop a detailed design of an
electronic death certificate system and to identify the costs associated with its implementation. The
overall objective was to take a tedious data entry process and automate it to improve productivity
among those participants in the process. As the Committee progressed through the project it
became evident that, before the detail work could begin, significant issues associated with death
registration that have existed for decades needed to be understood by each of the Committee
members. Moreover, by highlighting these issues and attempting to address them, greater benefits
could be realized from resolving these issues than were part of the original scope of this
Committee. After developing an appreciation for the other concerns, the Committee began to
discuss the importance of fully integrating each of the stakeholder organizations into a single death
registration network. The consequences of doing this reach well beyond a hardware and software
solution. It became evident that system design, cost, and implementation issues would have to be
studied further in order to remove the inefficiencies associated with the existing process. The scope
of the Committee subsequently changed with the focus moving away from technical products
toward procedural issues.
The Electronic Death Certificate Advisory Committee recommends to the Legislature that it
continue to pursue the development of an EDC system. Like other state-wide programs ADHS has
implemented, EDC requires detailed analysis and significant procedural changes. It is not a system
that can be immediately bought, installed, and implemented. Moreover, the most challenging
issues to address are not related to technology. Physician education on proper death certificate
completion and legislative enforcement policies are examples of the issues that need to be dealt with
in order to realize the benefits of an EDC system.
To facilitate the continued pursuit of an EDC system, we recommend that the EDC Advisory
Committee be retained through the January, 1998 legislative session. The Committee has strong
representation from both the public and private sectors all of whom are committed to making the
changes and investment necessary for an EDC system. In addition, the Committee recommends
the establishment of three subcommittees who would address specific aspects of the EDC
implementation and make recommendations to the EDC Advisory Committee who, in turn, would
make recommendations to the ADHS Director, the Governor, and to the Legislature. The three
subcommittees are as follows:
0 EDC Project Application Subcommittee: This subcommittee should be chaired
by the Information Technology Services (ITS) Department of ADHS and will include representation
from all stakeholders. The objective of this subcommittee is to develop a detailed system plan that
outlines the necessary technology components of a userfriendly EDC system. This detailed system
plan should take approximately three months to develop and include the following components:
o Cost benefit analysis of networking alternatives;
o Analysis of hardware and equipment needed for each stakeholder;
o Application software analysis including specific vendor's packages;
o Preliminary cost projections;
o Implementation schedule to complete the project;
o Project Investment Justification.
0 EDC Legislative Subcommittee: This subcommittee should be chaired by the
Legislative Services Office of ADHS. The objectives of this subcommittee are: (1) to study existing
statutes and recommend additional policies or legislation that would encourage participation in the
EDC process and; (2) to propose recommendations on funding sources. The time table to complete
these tasks should be approximately three months and can happen simultaneous to the detailed
system plan developed by the EDC Project Application Subcommittee.
0 EDC Phvsician Implementation Subcommittee: This subcommittee should be
chaired by the Arizona Medical Association (ARMA). The objective of this subcommittee is to
develop a physician implementation plan that will make technological, educational, and process
recommendations related to the physicians which can be incorporated in an EDC system.
Recommendations should be made to the EDC Advisory Committee within the same three-month
window given to the other two subcommittees.
Each subcommittee will report to the EDC Advisory Committee monthly to insure that objectives
and time tables are met. The EDC Advisory Committee will present their findings and
recommendations during the January 1998 Legislative Session. The findings will include specific
capital and operating budget requirements, required legislative changes, and a comprehensive
implementation schedule.
It is important to keep the EDC project focused on achieving measurable objectives and benefits.
Each subcommittee must stay focused on the aspects of EDC for which they are responsible. For
example, the subcommittee responsible for developing a detailed system plan needs to ensure their
plan facilitates communication between all stakeholders of the process and to optimize the
investments in hardware and software. The subcommittee responsible for legislative changes needs
to leverage state statutes to encourage full participation by the stakeholders. And, the subcommittee
responsible for physician implementation needs to develop a plan for their medical constituents that
facilitates accurate recording of critical medical information. The EDC Advisory Committee is
responsible for providing direction to the subcommittees, summarizing their research to the
legislature, clarifying funding sources, addressing other issues, and identifying an implementation
Developing a schedule and tracking progress to this schedule are critical to the project's success.
Although a comprehensive implementation schedule can only be developed in a detailed system
plan, the EDC Advisory Committee recommends that the following milestones be addressed by the
EDC Advisory Committee with input from the subcommittees.
Milestones for EDC Implementation
Kev Milestones
Complete and present legislative report
Establish EDC subcommittees
Subcommittees present final plans to EDC Advisory Committee
EDC Advisory Committee recommends plan to the ADHS Director, Governor and Legislatul
Budget approved by Legislature and Governor
ADHS issues RFPs for EDC hardware & software
ADHS selects EDC application software vendor
Software vendor and/or ADHS make software changes
Stakeholder implementation
The ultimate success of an EDC system in Arizona will be measured by the accuracy of the medical
research database it creates, the improvements in productivity gained by the participating stakeholders,
the improvements in customer service, and the resulting public health programs developed by ADHS.
The procedural changes needed to facilitate an EDC solution pose the biggest challenge. Without a
well conceptualized, well organized, and well developed partnership among all of the stakeholders,
an EDC could become a costly alternative to a manual system lacking the benefits anticipated by its
supporters. By achieving the milestones and implementing the plan contained in this report, Arizona
could become the model for other states desiring a new death registration process centered around the
implementation on an EDC system.
Director's Designee
Arizona Department of Health Services
Director's Office
Director's Designee
Arizona Department of Health Services
Director's Office
Manager of Vital Records
Arizona Department of Health Services
Office Chief, OHPES
Arizona Department of Health Services
Office of Health Planning, Evaluation & Statistics
Urban Medical Examiner
Office of the Medical Examiner
Maricopa County
Rural Medical Examiner
Urban Hospital
Good Samaritan Regional Medical Center
Health Information Management Department
Rural Hospital
Casa Grande Regional Medical Center
Urban Funeral Home
Arizona Funeral Director's Association
Rural Funeral Home
Simes Mortuaries
Arizona Medical Association (AZMA)
Osteopathic Physician
Local Registrar - Urban County
Maricopa County Department of Public Health Services
Local Registrar - Rural County
Yavapai County Health Department
Marti Lavis
Rosalie Lopez
Renee Gaudino
Merle Lustig
Frank Ciaccio
Sharon Sanford (Resigned
1 /22/9 7)
Joy Crawford
Tracy Calvert
Bill Proctor
Gail Simes
Thomas Ross, M.D. 411 8/97
Jan Zieren, D.O.
Sarah Santana
Evelyn Wilson
A uto mated
Re-engineering Death Reg istrcltion
for the
November 8, 1995
Dear Ms. Lavis:
On behalf of the Arizona Funeral Directors Association and the Committee
For Re-engineering Death Registratrion in Arizona, I thank you for
attending today's meeting.
It has been very heartening to find such broad and enthusiastic support for
this project among the many potential users of the proposed system.
The impetus for such projects is usually some immediate problem which
affects oneself or ones industry or, as in this case, the customers of that
industry. However, as we progressed in our research, we found that the
process of gathering and compiling vital statistics has appreciable impact
on many more professions and entities than our own.
Finally, we began to appreciate the vast benefits of automated vitals
registration to the ultimate users of statistics. Federal, state, and
county governments, health care planners, public health agencies, and a
host of others whose missions are truly matters of life and death, need
better and more timely data on which to base decisions. Automated vital
statistics systems can result in more focused allocation of scarce
resources to public health imperatives so that those who supply and use the
information, as well as those who ultimately must pay the bill for it, will
Again we thank you for your interest and support for this important
project, and for attending today.
Mary V: Melcher, CPA
AFDA Committee
The collection and compilation of birth, death, and marriage
statistics in the United States is important to all of us,
indeed the term vital statistic is a very apt one in more than
one sense.
Disease detection, tracking, and coitrol; health care planning
and funding decisions, and myriad other important functions of
both the public and private sectors depend on accurate and
timely information about births, deaths, and marriages.
For all the years it has been done, the process of this
collection has been an arduous and labor intensive one. As
the country has grown in numbers and as needs for data have
increased, so has the complexity of the data collected. As a
nation and as a state, we can no longer afford lengthy delays
between the event and the transmission of data to users---
changes occur too fast now for manual systems to suffice.
Birth certification is slowly being automated across the
country, with both Oregon and Washington online with
completely paperless systems and many other states embarking
on similar birth certification projects. Development of
automated death certification systems is underway in several
states as well. New Hampshire has had both an automated birth
and death certification program for several years and it has
proved to be efficient, fast, cost-effective, and accurate.
The Steering Committee For Re-engineering Death Registration
is a coalition of people from all parts of the public and - -
private health care sectors, from government, from private
sector businesses, and from federal agencies, such as the
Centers For Disease Control and the National Center For Health
Statistics. The Committee's objective is a paperless system
of death certification in the United States by the year 2,000.
Rapid population growth, particularly in urban areas of Pima
and Maricopa Counties, has slowed the collection, compilation,
and transmission of vital statistic information, especially
death certification, very seriously.
At the same time, needs of county, state and federal
authorities for more and more detailed information has added
to the complexity of the task.
In peak winter months, consumers are waiting 30 to 40 days
(total turnaround), just to obtain this needed legal document.
Some duplication exists in the present processing systems, and
responsibility and lines of accountability are not clearly
fixed for the basic parts of the death certificate. The
system has grown inefficient and costly. Finally, the storage
of voluminous paper records uses enormous financial and
physical resources at the present time---resources which could
be applied to other, more vital governmental functions.
We propose that, rather than waiting until the present system
totally breaks down, or until a nationally mandated system is
imposed upon us, that Arizona move forward to develop and
implement a system that fulfills the needs of users and
public alike, while producing high quality, timely statistical
The technological challenge for today's equipment and software
is elementary. If ever a task was suited to computerization,
it is this. The system needed is a very economical, PC based
one, using a central server which can be accessed by the three
inputting parties to the process---medical (physicians,
medical examiner, hospitals) governmental (county and state) ,
and the funeral director.
A series of prompts and edits will ensure that the correct
information is entered and will even screen causes of death
for acceptability and logic. Information which appears in
more than one place, will only have to be entered once.
In the New Hampshire experience, errors were reduced from over
18% to less than 1% and the time to create the master file
from six months to six weeks. The state's computer is
available for entry of data around the clock, 365 days a year.
Burial transit permits are available to the funeral home
within minutes rather than hours or days, thus improving
service to the public.
New Hampshire's Bureau of Vital Records secured a federal
grant which helped them get started on their project. In
addition, a surcharge was-levied on the first certified copy
which completely paid for all the equipment, software, an3
training necessary and which in fact has now produced a
sizable surplus. Officials are actually considering reducing
or eliminating the surcharge.
Ms. Rene Gaudino, Administrator and Registrar of Vital Records
for Arizona, has been successful in securing a Social Security
Administration grant in the amount of $ 96,000 for development
of the automated birth certification program. Because of the
enormous monetary impact on the Social Security System of even
small delays in transmission of death data, we are confident
that a similar grant could be obtained for automating death
registration as well. From a practical and economic
standpoint, it would be well to begin now on the death
certification phase so that the systems are compatible, since
some users will be common to both the birth and death
certification systems.
A small surcharge on the first, or even all, certified copies,
added to a grant, would pay for the system.
Consumers now pay $ 6.00 per certified copy ($1.00 of which is
a surcharge for a Child Fatality Review Fund established
pursuant to ARS 36-3504). There has been no resistance to the
$6.00 charge. There is however, a great deal of
dissatisfaction with the very long delays which are
encountered in peak months, by consumers waiting for these all
important documents. A modest additional charge would not
encounter opposition, due to the relative importance of the
need. Overall, enhanced consumer satisfaction with government
services would result simply by virtue of the fact that final
arrangements could be expedited, as well as settlement of
estates, accessing of funds, and the multitude of other tasks
which attend every death.
November 8, 1995
AFDA Committee For Re-engineering Death Registration
Mary V. Melcher
William Proctor
Paul Gabriel
[l!z!E!K) COMPLETE VITAL PARTIAL VITAL
Ms. Kathleen Frawley
Ph: (202) 73621 55
Fax (202) 296-9480
Ms. Patricia J. Brown, RRA
Ph: (301) 7908131
Fax: (301 ) 790-81 29
Sona Kalousdian, M.D., M.P.H.
Ph: (31 2) 464-5919
Fax: (312) 464-5841
Mr. Mlchael R Lavoie
Ph: (404) 6569298
Fax: (404) 651 -9427
Lorne A. Phillips, Ph.D.
Ph: (913) 296-1415
Fax: (91 3) 2968075
Daniel J. Friedman, Ph.D.
Ph: (61 7) 727-6452
Fax: (61 7) 727-6584
Mr. George Van Arnburg
Ph: (51 7) 335-9975
Fax: (51 7) 335-951 3
Mr. Hebert Buzbee
Ph: (309) 6840200
Fax: (309) 689-0260
John E. Smlalek, M.D.
Ph: (41 0) 333-3225
Fax: (41 0) 333-3063
Director, Washington D.C. O W
American Health Information Management Association 1919 Pennsylvania Avenue, NW, SuRe 300
Washington, D.C. 20006
Director, Medlcal lnformation Management Dep. American Hospltal Association
President, Maryland Health lnformation Manag.
Senlor Scientist, Department of Preventive
Medicine and Public Heath
American Medical Associatlon
President, Association for Vial Records and Association for Vial Recordsand Health Statistics
Health Statlstlcs. And
Director, Vial Records Unit
President-Elect, Association for Vnal Records
and Health Statistics
Assistant Commissioner Bureau of Health
Statistics, Research and Evaluation
State Registrar and Chief Office of the State
Registrar and Center for Health Statistics
Executive Secretary-Treasurer
International Association of Coroners and
Medical Examiners and Coroner, Peoria County
Washington COUntY Hospital association
251 East Antietam Street
Hagerstown, Maryland 21740
515 North State Street
Chicago, Illinois 60610
Center for Heaith Information, Dhrision of Public Hearth
47 Trinity Avenue, SW., Room 217-H
Atlanta, Georgia 30334
State Department of Health and Environment
900 SW Jackson Street, Room 152
Topeka, Kansas 6661 2-2221
~assadhusetts Department of Public Health
150 ~r2monSt treet, 8th Floor
Boston, Massachusetts 021 11
Center for Health Statistics
3423 North Logan Street. P.O. Box 301 95
Lansing, Michigan 48909
International Association of Coronem and Medical Examiners 5401 Knoxville Avaure, Sulk Bt
Peoria, Illinois 61614
Federal Llaslon RepresentatNe National National Association of Medical Examiners
Association of Medical Examiners and Chief
Medical Examiner, Maryland
11 1 Pennsylvania Street
Baltimore, Maryland 21 201-1020
Mr. Grover Tasker
Ph: (603) 742-4961
Fax: (603) 742-0283
Tasker Funeral Home National Funeral Directors Association Tasker Funeral Sewbe
621 Central Avenue
Dover, New Hampshire 03820
Chief, Technical Services Branch Division of National Center for Health Statistics
Vlal Statistics
P.O. Box 1221 4
Research Triangle Park, North Carolina 27709
Mr. Ronald F. Chamblea
Ph: (919) 541-0985
Chief, Registration Methods Branch Division of
Vtal Statistics
Natlonal Center for Health Statistics
6525 Belcrest Road, Room 890
Hyaltsville, Maryland 20782
Mr. George A. Gay
Ph: (301) 4368815
Fax: (301) 436-7066
Mr. Peter L. Hurley
Ph: (301) 436-7106
Fax: (301) 4366668
Associate Director, Offifice of Vital and Health
Statistics Systems
National Center for Health Statistics
6525 Belcrest Road, Room 11 20
Hyaltsville, Maryland 20782
Harry M. Rosenberg, Ph. D.
Ph: (301) 436-8884
Fax: (301) 436-7066
Chief, Mortality Statistics Branch Division of
Vlal Statistics
National Center for Health Statistics
6525 Belcrest Road, R m84 0
Hyattsville. Maryland 20782
National Center for Health Statlstlcs
P.O. Box 12214
Research Triangle Park, North Carollna 27709
Mr. Charles E. Sirc
, Ph:(919)541-0134
Fax: (91 9) 541 -4098
Acting Deputy Director, Dlvislon of Data
Mr. Robert K. Hall Deputy Director, Policy Integration Staff Social Security Administration
Ph: (41 0) 965-2866
Fax: (41 0) 966-1 328
Office of Policy
Attmeyer Bldg., Room 500, ti401 Security Blvd.
Baltimore, Maryland 21235
Randy L. Hanzlick, MD
Ph: (404) 488-7060
Fax: (404) 4887044
Forensic Pathologist Centers for Disease Control and Prevention DIvlslon of Environmental Hazards and Health Eflects
4770 Buford Highway, NE Mail Stop F35
Atlanta, Georgia 30341
Dlvislon of Environmental Hatards and Health Effecb
4i70 Buford Highway, NE Mall Stop F35
Atlanta, Georgia 30341
Gib Panish, MD
Ph: (404) 4887060
Fax: (404) 488-7044
Chlef, Surveillance and Programs Bmnch
Division of Surveillance and Epidemiology
1600 Clifton Road, NE Mail Stop C08
Atlanta, Georgla 30333
Scott Wetterhall, Sc.D.
Ph: (404)6394Xm
Fax: (404) 639-1 546
Assistant Director for Science
State of Arizona
Electronic Death Certificate Process
~uneraDl irector Online - Certifying Physician Manual
Automation Characteristics
Funeral Director enters
o Low cost Funernl Director: Some assistance with
Low value physicians from State.
Electronic interfaces w/C ounty .- *- Physician: No change to existing process
Manual interfaces w/ Medical Exatniner and no additional incentive,
Manual interfaces tvl other physicians State: Significant workload increase -
Manual interfaces td l~ospitals tnostly manual,
Hardwadr~ oAwarep roject Counties: No longer involved in the death
Data ent~ys ystem certificate process. Still have abilG70 1
issue certified copies and generate
.D.s takes steps to obtain Physician notifies F.D.
certification from
physicians until they completed certificate
receive the info. needed and delivers to V.R.
I State Vital Records State Vital Records
transmits burial permit transmits burial permit
certification number to certification number to
I Funeral Director Funeral Director
State of Arizona
Electronic Death Certificate Process
Funeral Director Online - Certifying Physician Online
- - - . -- -
Automation Characteristics How parties are imnacted
* High cost Fi~neraDl irector enters Funeral Director: Significant relieffivm '
High value gathering info. from physicians. Can
Electronic interfaces \v/ County srrvice clients faster and better.
Electronic interfiices wl Medical Examiner Physician: Easier to adhere to state statute
Electronic interfaces \v/ other physicians and better service to patient's family.
Electronic interfaces \ni/ hospitals State: Enhanced data integrity, facilitates
Systems integ~;:icn aod networking project move to ClientlServer and away from -,
I Complete EDC system transmits demographic legacy systems.
Counties: No longerinvolved in the death
certificate process. Still have ability to
issue certified copies and generate
status of the certificate and
what needs to be done for
certification tlutnber to
Funeral Director
Physician completes
certificate which is
automatically sent to
State Vital Records
State Vital Records
transmits burial permit
Application Systems Strategy
Technical Framework
revised June 3, 1997
This document was prepared by the Arizona Department of Health Services
(ADHS), Office of Information Technology Services (ITS). The information
contained within is the property of ADHS and should not be duplicated in any
form without the written permission of the Arizona Department of Health
Comments, suggestions and questions regarding this document should be
forwarded to Mark Manson, ITS Office of Technical Services.
The information and content of this document is subject to change without
The Arizona Department of Health Services (ADHS) develops and manages
programs to serve the public health needs of all Arizonans. These programs
involve administration, regulation, prevention and intervention. All aspects
require the collection, management and distribution of information.
As part of the agency's continuing efforts to improve the delivery of services
to the citizens of Arizona, ADHS continually evaluates new methods,
programs and technologies. A primary strategy of the agency, is the move
from legacy based information systems (traditional Main Frame, Host based,
proprietary environments) to a more "open" distributed environment. As part
of this strategy, the agency is currently engaged in the development and
deployment of client/sen/er based application systems. The Office of
lnformation Technology Services is ultimately responsible for the
transformation of the agency's information systems.
Office of lnformation Technology Services
The Office of lnformation Technology Services (ITS) is responsible for
management of the agency's information resources. This responsibility
includes the evaluation of new technologies.
Recently, ITS evaluated several popular and current technologies to better
deliver information to those most in need within and outside the agency. This
evaluation has led ITS to recommend the development and deployment of
clientlserver based information systems. This recommendation is based on
the following premises:
- Accessibility to information
- Integration with existing software products
- Modularity of application and data components
- Scalability of application systems
- Faster response to information needs
- Better development tools
- Strategic direction of primary and industry vendors
To facilitate the development and purchase of software solutions for the
agency, ITS has developed a Technical Framework providing an outline for
the development, selection or evaluation of software based application
solutions. The purpose of this technical framework is to ensure that both
internally developed and externally acquired software solutions can be
integrated at an acceptable level and perform effectively within the agency's
computing platform, and as required, be supported by ITS staff.
Current Operating Environment
The agency currently supports information systems and services on five
1. IBM platform and associated devices
2. Bull HN platform and associated devices
3. Sun Microsystems platform
4. Local/Wide Area Networks (Novell)
5. Personal Computers
The Bull HN system is targeted for removal by December of 1998 after all
current legacy systems are migrated to another platform or replaced by
acquired software solutions.
The IBM platform is targeted for specific application systems within the
agency, with limited plans for expansion.
The Sun Microsystems platform is the preferred choice for data management
and warehousing of critical agency information. The agency's LocalNVide
Area Network, based on Novell Netware 3.x, provides departmental and
enterprise functions such as word processing, spreadsheet analysis,
electronic mail and local information processing.
Personal Computers, in most cases, provide the desktop interface to the
various platforms. The agency is gradually replacing (almost complete at this
time) all non-intelligent workstations connected to the IBM, Bull HN or Sun,
with personal computers to better utilize the agency's array of information
resources, and allow for a more desired graphical user interface (GUI).
Technical Framework
The technical framework exists to help formalize the agency's strategic
hardware and software objectives. This framework will ensure acceptable
levels of integration among the various application systems and databases,
and define the minimum and optimum environments for application solutions
deployed within the agency. Adopting a technical framework in no way
negates a solution that might function outside the defined scope.
The technical framework is categorized by functional area:
User lnterface
Operating System
Development Tools
User l nterface
The User Interface is that portion of the application which manages the way
an end-user interfaces with the application. The agency currently encourages
the following presentation services:
1. Microsoft Windows 3.11 and Win-95 (full graphical interface)
2. DOS (character mode, and graphical emulation)
3. ASCII Terminals (character mode)
Data base
As part of the agency's overall strategy to better manage data resources and
provide improved access to information, a central data repository is critical.
The agency has selected Oracle as the primary data management facility.
The following database services are supported:
1. Oracle 7.x (Enterprise)
2. Paradox (Departmental)
3. ODBC (Open Database Connectivity) compliant database
The network infrastructure provides the middleware through which all other
components communicate. The agency's Wide Area Network (WAN) is
based on Novell Netware 3.12. A SUN Sparc2000 and individual servers are
connected through various routers, gateways and communication services.
The pre-dominant protocols include Ethernet, SPX/IPX, and TCPIIP.
The agency supports the following network components:
1. Novell Netware 3.12 (moving to 4.1 1 )
Operating System
The agency supports the following operating environments:
Client Side
1. Microsof? Windows 3.1 1 and Win-95
2. Novell 2.12 (moving to 4.1 1 )
3. DOS 6.x
Server Side
1. UnixISolaris (2.5)
2. Microsoft NT 4.0 (in Beta)
Development Tools
The selection of development tools can play a significant role in the
productivity, management, flexibility and performance of an application
system. With this in mind, the agency has selected development tools that
compliment a clientlserver strategy using Oracle as the primary database.
These tools include:
1 Oracle Designer12000 CASE tool
2. Oracle Developer12000 (Forms 4.5, Reports 2.5)
3. Borland Paradox for Windows
4. Borland Delphi for Windows
5. MlTl SQR Report Writer
Minimum and Optimum Configurations
The applications within the agency should, at some level, accommodate the
development, deployment and management requirements of the agency. As
a further definition of these requirements, the following Optimum and
Minimum frameworks are provided for reference when considering an
application project or solution. The Optimum solution best compliments the
agency's current and future objectives. A Minimum solution provides the
minimum necessary to accommodate data sharing and application integration.
User Interface
Operating System
Development Tools
Client Workstation
User Interface
Data base
Operating System
Development Tools
Microsoft Windows 3.1 1 / 95
Oracle 7.x
TCP/IP, Novell Netware
Microsoft Windows 95, SUN Solaris
Designer/2000, Developer/2000, Delphi
Personal Computer, Intel Pentium
SUN (Unix/Solaris)
DOS, ASCII Terminal
ODBC compliant relational database
DOS, SUN Solaris
Borland Delphi for windows,
Client Workstation
Borland Paradox for Windows
ASCII Terminal
PC-Server (Novell)
There is never a "one-size-fits-all" solution to any information systems
problem. Often, several possible solutions are identified for a given situation.
These solutions must be balanced with the needs of the application and the
needs of the agency as an organization
. .
This Technical Framework provides a general guideline through which the
selection or evaluation of software based application solutions for the agency
can be addressed. Those application solutions accommodating the
framework described, best fit the agency's goals and objectives.
Sirsgie copies of the following public health surveillance reports are available f m
the Arizona Center for Health Statistics
- -
. *
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text:
Kekkei GenkaiTalk173
this wiki
Kekkei genkai (血継限界; Literally meaning "a technique limited to inheritance by blood" or "Bloodline Limit") are abilities passed down genetically within specific clans. It's possible for a ninja to have more than one of these abilities. Kekkei genkai abilities that work via the user's eye are called dōjutsu. Other kekkei genkai include mixing one type of elemental chakra with another, creating a new one unique to the users, which is usually impossible for normal ninja.
Kekkei genkai and their related techniques cannot be taught to or copied by others. However, kekkei genkai can be given to others. Dōjutsu, or other kekkei genkai isolated to a single organ, can be transplanted into the body of another, as was done with transferring Obito's Sharingan to Kakashi. Use of these organs requires much more chakra than someone born with the kekkei genkai. Chakra elements can also be passed down to people outside of the clan, such as Yamato being subjected to DNA re-modification by Orochimaru who wanted to acquire the Wood Release kekkei genkai. However, Yamato's skill in using it is not nearly as powerful as the originator: Hashirama Senju, and the risk of such process was that Yamato was the only one of the sixty test subjects to survive.[1][2]
Although kekkei genkai are usually genetically shared within a specific clan, sometimes it is unique to one person alone, and that even family relatives do not share it, such as the Wood Release and Shikotsumyaku. Yet other kekkei genkai seem to appear in individuals with no known relation, such as the Lava Release, which has appeared in ninja from Kirigakure, Iwagakure, and Kumogakure, while Magnet Release, which has appeared in ninja from both Kumogakure and Sunagakure.
There is an advanced variant of kekkei genkai known as kekkei tōta, which is a combination of three different nature transformations.
List of Kekkei Genkai
Blaze Release
Main article: Blaze Release Blaze Release (炎遁, Enton; Viz "Inferno Style") is an advanced chakra nature kekkei genkai that produces black flames (黒炎, Kokuen). Known to have been employed by at least two members of the Uchiha clan, this chakra nature can be used in a variety of ways. Sasuke has gone as far as to add shape transformation to the black flames, fashioning them into various weapons and defences.[3] Besides being cast by means of Amaterasu, Sasuke can create this chakra nature with his Susanoo as well and even in his own palm.[4][5]It is the only known chakra nature that is used through a dōjutsu. C stated that Sasuke manipulates the flames with his right Mangekyō Sharingan whereas he casts Amaterasu with his left.[6] It is unknown what other basic nature Blaze Release entails aside from Fire Release.
Boil Release
Main article: Boil ReleaseBoil Release (沸遁, Futton; Viz "Vapour Style") is one of the two advanced nature kekkei genkai of Mei Terumī and is made up of techniques that combine fire and water-based chakra to create a powerful corrosive vapour capable of dissolving anything. The user is also able to control the range and level of the vapour's acidity. Not only is it dangerous to be near, but as being gaseous, it can cover a considerable range shortly, and go through small spaces. It also stays in the air, so it can potentially deal continuous damage if the enemy is trapped or knocked back into its range.
Main article: Byakugan The Byakugan (白眼; Literally meaning "White Eye", Meaning (Viz) "All Seeing White Eye") is the dōjutsu kekkei genkai of the Hyūga clan. Its power first appeared, alongside the Rinnegan, in the oldest known ancestor of the Hyūga: Kaguya Ōtsutsuki.[7] It has become known as one of the Three Great Dōjutsu (三大瞳術, San Daidōjutsu; Literally meaning "Three Great Eye Techniques"), along with the Sharingan, and the Rinnegan.[8] This dōjutsu is manifested as very distinctive eyes, characterised by their enlarged and featureless white irises with no visible pupils. When the Byakugan is activated, the user's pupils become more distinct, and the veins near their temples bulge. It also appears that unlike the other two great dōjutsu, all members of the clan possess, and can use this kekkei genkai from birth, as opposed to needing to awaken, or else not inheriting it at all.The primary ability of the Byakugan gives the user a near 360º field of vision, except for one blind spot at the back of the neck above the first thoracic vertebra.[9] Upon activation of the dōjutsu, the wielder is granted an automatic 50 metre field of vision around themselves which can be extended through training[10][11] as Hinata Hyūga's range in Part II stretches to at least as far as 10 kilometres.[12]The Byakugan is also able to see through solid objects and smokescreens,[13] even through most barriers as only a particularly strong barrier such as the Four Black Fogs Formation is able to somewhat distort the Byakugan's perception.[14] It can also differentiate between non-corporeal clones and see through techniques that would otherwise hide an opponent from normal sight.[15] The dōjutsu also has the ability to follow high-speed movement.[16]
Crystal Release
Main article: Crystal ReleaseThe Crystal Release (晶遁, Shōton; English TV "Crystal Style") is a rare and specialised field of elemental ninjutsu that can create crystal as well as manipulate already-existing crystals and crystalline structures.
Dark Release
Main article: Dark ReleaseThe Dark Release (冥遁, Meiton; Viz "Shade Style") is an advanced nature kekkei genkai that can be used to absorb, manipulate, and release chakra taken from an opponent. Hiruko used techniques of this nature through a mark on his left hand. This mark resembles two diamonds, one overlapping the other. Chakra is absorbed through the upper square, while it is released and manipulated through the lower.
Dust Release
Main article: Dust ReleaseDust Release (塵遁, Jinton; Viz "Particle Style") is an advanced nature kekkei tōta, an advanced version of kekkei genkai, which is created through simultaneous use of the earth, wind, and fire natures. The techniques of this nature initially form as a small three-dimensional object (e.g. a cube, a cone, etc.) composed of chakra that forms between the user's hands. When the technique is released, the form expands and surrounds the target. This nature allows the user to manipulate molecules, giving them the ability to disintegrate anything on a molecular level within the boundaries of the three-dimensional form.
Explosion Release
Main article: Explosion ReleaseExplosion Release (爆遁, Bakuton; Viz "Explosive Style") is an advanced chakra nature kekkei genkai. This chakra nature seems to give the wielder the ability to utilise explosive chakra in combat, allowing them to cause explosions in objects they come into contact with.
Iburi Clan's Kekkei Genkai
Main article: Iburi Clan's Kekkei GenkaiThis unique kekkei genkai is possessed by the members of the Iburi clan, which allows them to turn their bodies, either partially or fully, into smoke to serve various purposes. While in their smoke form the user becomes impervious to damage and can use this trait to gain an opportunity in battle, for example by allowing weapons to slip through them without any effects. However, if needed, they can still interact with physical objects.
Ice Release
Main article: Ice ReleaseIce Release (氷遁, Hyōton; Viz "Ice Style") is the advanced nature kekkei genkai of the Yuki clan, and allows the users to combine wind and water-based chakra to create and manipulate ice, forming it into various structures. When the user releases their chakra, the surrounding vicinity becomes cold enough to cause snow to fall.[17] The ice Haku could create was extremely resistant to fire-based attacks, only melting slightly when coming into contact with Sasuke's flames.
Jūgo's Clan's Kekkei Genkai
Main article: Jūgo's Clan's Kekkei GenkaiMembers of Jūgo's clan have unique bodies, which allow them to passively absorb natural energy. However, due to the constant intake of natural energy, they are mentally unstable, sporadically feeling sudden, uncontrollable urges to kill, causing them to go on a rampage. Their bodies also secrete special fluids, which through means of Senjutsu chakra allow them to transform parts of their bodies for several purposes.
Kurama Clan's Kekkei Genkai
Main article: Kurama Clan's Kekkei GenkaiEvery few generations a member of the Kurama clan will be born with an incredible talent for genjutsu. The clan member's talent in that field is such that their genjutsu is overwhelming. Furthermore, the genjutsu is so powerful that it causes the brain to believe anything that happens to the victim within the genjutsu physically harm their body. This fearsome ability allows the clan member to potentially kill their opponents with genjutsu.
Lava Release
Main article: Lava ReleaseLava Release (熔遁; 溶遁, Yōton; Viz "Corrosion Style" or "Lava Style") is an advanced nature kekkei genkai that combines fire and earth-based chakra to create lava and related substances that can serve multi-faceted purposes.
Magnet Release
Main article: Magnet ReleaseMagnet Release (磁遁, Jiton; Viz "Magnet Style") is an advanced chakra nature kekkei genkai which allows the user to convert chakra into magnetic forces and magnetise an object. It is unknown where it originates from but both Sunagakure and Kumogakure possessed users of this kekkei genkai in the past.[18]
Mangekyō Sharingan
Main article: Mangekyō Sharingan The Mangekyō Sharingan is awakened by a Sharingan user when they suffer from trauma after witnessing the death of someone close to them. With the user normally having to witness or experience this first hand, Uchiha throughout history have killed those closest to them in order to expedite this process.[19]It is distinguished from a normal Sharingan by its appearance, which changes the form of the tomoe seal. Unlike the Sharingan, the appearance of the Mangekyō Sharingan differs from user to user with all known wielders of the dōjutsu having eyes that resemble variations of pinwheels; one variation is a rare form known as the "Straight Tomoe" (直巴, Choku Tomoe), which seems to grant the user fluidity in their movements when fighting.[20]
Ranmaru's Kekkei Genkai
Main article: Ranmaru's Kekkei Genkai Ranmaru possessed a dōjutsu kekkei genkai which, when activated, causes his eyes to glow red in colour. It grants him abilities such as penetrative vision as well as the ability to hinder other dōjutsu such as the Byakugan which his own dōjutsu has been likened to.This dōjutsu grants the wielder many abilities that include penetrating vision, disruption of other dōjutsu, and unique healing through life-force energy manipulation.With his kekkei genkai, Ranmaru has the ability to see and hear things from long distances. With this ability, Ranmaru was able penetrate the walls of his shack to view the outside world. Although the range of his kekkei genkai is similar to the range of the Byakugan, it actually has the ability to counter and negate that trait. His abilities also allow him to perform irresistible genjutsu, which can fool even the "all-seeing" Byakugan. Ranmaru's vision also lets him locate and track others by sensing chakra, picking up chakra from long distances, and noticing changes in an individual's chakra. It is also able to sense how many individuals are present.
Rinha Clan's Kekkei Genkai
Main article: Rinha Clan's Kekkei GenkaiThe kekkei genkai of the Rinha clan allows them to absorb a person's chakra and duplicate their appearance and memories.
Main article: RinneganThe Rinnegan (輪廻眼; Literally meaning "Saṃsāra Eye") is reputed as the most exalted eyes amongst the Three Great Dōjutsu (三大瞳術, San Daidōjutsu; Literally meaning "Three Great Eye Techniques").[21] It is characterised by a ripple-like pattern which spreads over the eyeball, with either light purple or red sclerae and irides, some also containing a pattern of several tomoe. It is said that in times when the world is in disorder, a person is sent down from the heavens to become either a "God of Creation" who will calm the world, or a "Destroyer" who will reduce everything to nothingness.[22] This dōjutsu was first manifested by Kaguya Ōtsutsuki after eating the Shinju's fruit, and later by the Ten-Tails, the combined entity of Kaguya and the Shinju. Kaguya's son, Hagoromo, came to be revered as the Sage of the Six Paths by using his own Rinnegan to create the groundwork that brought forth all modern ninjutsu.[23]
Ryūzetsu's Kekkei Genkai
Main article: Ryūzetsu's Kekkei GenkaiThis unnamed kekkei genkai apparently allows the user to perform Reincarnation Ninjutsu as it allowed Ryūzetsu to perform the Dragon Life Reincarnation technique. It was seen only in Naruto 5: Blood Prison and Ryūzetsu was the only known user. Other details, such as whether it was common or rare and whether any other technique could be performed using it, are unknown.
Sakon and Ukon's Kekkei Genkai
Main article: Sakon and Ukon's Kekkei GenkaiSakon and Ukon's unnamed kekkei genkai gives them the unique ability to break their bodies down to a molecular level. The two brothers usually use this ability to share the same body but can also use it to merge with the bodies of others and destroy the host's cells from the inside. When Sakon is in need of assistance, Ukon can bring out some of his body parts to aid Sakon in blocking or attacking. Ukon's arms and legs can emerge from those of Sakon's to increase the force and quantity to his physical attacks.
Scorch Release
Main article: Scorch ReleaseScorch Release (灼遁, Shakuton; Viz "Scorch Style") is an advanced chakra nature kekkei genkai. This nature creates chakra that is capable of heating up an enemy to the point where all the liquid inside their body evaporates, killing the victim and leaving them a desiccated corpse.
Main article: SharinganThe Sharingan (写輪眼; Literally meaning "Copy Wheel Eye", Meaning (Viz) "Mirror Wheel Eye") is the dōjutsu kekkei genkai of the Uchiha clan that selectively appears in some of its members.[24] While its powers were first seen in Kaguya Ōtsutsuki, its true form first manifested in Indra, the earliest ancestor of the Uchiha clan, and later became regarded as one of the Three Great Dōjutsu (三大瞳術, San Daidōjutsu; Literally meaning "Three Great Eye Techniques"), along with the Byakugan and the Rinnegan.[25] The Sharingan is also called "Heaven's Eye" (天眼, Tengan), because of the many abilities it grants the user.[26] The Sharingan's abilities consist of two parts: the "Eye of Insight" (洞察眼, Dōsatsugan) and the "Eye of Hypnotism" (催眠眼, Saimingan).[27] The first of the Sharingan's powers is being able to see chakra flow. The Sharingan itself gives colour to chakra, allowing the wielder to differentiate them.[28] They are also able to tell if a person is under a genjutsu because the person's chakra flow would be irregular. The Sharingan's second-most prominent ability grants the user an incredible clarity of perception, allowing them to easily recognise genjutsu and different forms of chakra, though not to the same extent as the Byakugan.
Main article: ShikotsumyakuShikotsumyaku (屍骨脈; Literally meaning "Dead Bone Pulse", Meaning (Viz) "Macabre Bone Pulse") is a kekkei genkai which gives its wielder the ability to manipulate their own skeletal structure (their osteoblasts and osteoclasts). By infusing their calcium with chakra, they could manipulate the growth and properties of their bones to their liking.[29] The ability first manifested from Kaguya Ōtsutsuki which later inherited into a rare few amongst her descendants in the Kaguya clan, Kimimaro being the only other known inheritor of this power.
Steel Release
Main article: Steel ReleaseThe Steel Release (鋼遁, Kōton; Viz "Steel Style") is an advanced nature kekkei genkai that can be used to make one's body virtually indestructible by turning it into black steel.
Storm Release
Main article: Storm ReleaseStorm Release (嵐遁, Ranton; Viz "Gale Style" or "Storm Style") is an advanced nature kekkei genkai that combines lightning and water-based chakra to create energy beams that can be guided towards the enemy.
Swift Release
Main article: Swift ReleaseThe Swift Release (迅遁, Jinton; Viz "Quick Style") is an advanced nature kekkei genkai that can be used to move with instantaneous speed, granting the user an advantage over opponents with more strength than speed, such as users of Chakra Enhanced Strength. This nature therefore renders the user invulnerable against most taijutsu.
Wood Release
Main article: Wood ReleaseWood Release (木遁, Mokuton; Viz "Wood Style") is an advanced nature kekkei genkai formed through simultaneously combining earth-based chakra in one hand and water-based chakra in the other.[30] The Wood Release can create wood as well as various plants, from simple seeds to even flowering trees.[31] Wood and plants can be produced from any surface, including the user's own body, as the user's chakra is literally converted into a source of life. Wood Release Techniques (木遁の術, Mokuton no Jutsu) are commonly affiliated with the Snake seal.
The concept of special ninja techniques limited by bloodline inheritance may have been inspired in part by the works of Futaro Yamada, which strongly influenced later depictions of ninja in fiction. In particular, The Kōga Ninja Scrolls (甲賀忍法帖, Kōga Ninpōchō), published in 1959, featured a pair of warring ninja clans that, through selective breeding, had produced ninja with a variety of deformities, mutations, and special abilities, even dōjutsu.
- Kekkei genkai can be preserved through the creation of Human Puppets. This allows them to retain the special traits of the users when they were still alive.
- When a person is brought back to life via the Summoning: Impure World Reincarnation technique, they also retain any kekkei genkai they possessed before their death.
- A kekkei genkai should not be confused with hiden techniques. Hiden techniques are exclusive to a certain person or clan, but only because they have kept others from learning how to perform those techniques.
- ↑ Naruto chapter 291, pages 15-16
- ↑ Naruto chapter 297, page 9
- ↑ Naruto chapter 415, pages 7-9
- ↑ Naruto chapter 574, page 10
- ↑ Naruto chapter 585, page 7
- ↑ Naruto chapter 464, page 7
- ↑ Naruto chapter 671, page 6
- ↑ Third Databook, page 313
- ↑ Naruto chapter 196, page 8
- ↑ Naruto chapter 172, page 10
- ↑ Naruto chapter 195, page 9
- ↑ Naruto chapter 396, page 5
- ↑ Naruto chapter 188, pages 7-8
- ↑ Naruto chapter 186, page 5
- ↑ Naruto episode 149
- ↑ Naruto chapter 85, page 18
- ↑ Naruto chapter 522, page 7
- ↑ Naruto chapter 546, page 1
- ↑ Naruto chapter 386, page 13
- ↑ Naruto chapter 657, page 8
- ↑ Naruto chapter 373, page 2
- ↑ Third Databook, page 313
- ↑ Naruto chapter 425, page 9
- ↑ Naruto chapter 12, page 7
- ↑ Third Databook, page 313
- ↑ First Databook, page 193
- ↑ Naruto chapter 26, page 13
- ↑ Naruto chapter 361, page 17
- ↑ Naruto chapter 212, page 2
- ↑ Naruto chapter 316, page 6
- ↑ Naruto chapter 575, pages 4-5

subset: commoncrawl


text:
This page contains Super Pokemon Rumble Video Walkthroughs for 3DS called "Walkthrough Part 92 - Battle Royale EX-2" and has been posted or updated on Dec 7, 2011 by giancarloparimango11. Let us know what you think of this Video by thumbs voting.
- Developer: Ambrella
- Publisher: Nintendo
- Genre: Action Beat-'Em-Up
- Release Date: Oct 24, 2011
- ESRB: Everyone 10+
Video Walkthroughs
Walkthrough Part 92 - Battle Royale EX-2
Watch this step-by-step Video Walkthrough for Super Pokemon Rumble (3DS), which will help and guide you through each and every level part of this game and also assist you to find all secrets and solutions to complete this game.
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text:
The Market in Defense of Markets: The Impact of the New Technology
Recorded 03-19-2005 at the Austrian Scholars Conference, Mises Institute, Auburn, Alabama [48:43]
Recorded at the Mises Institute on March 19, 2005; Auburn, Alabama. The video version includes a post-lecture Question and Answer session. [52:25]
From: Austrian Scholars Conference 2005 , Monday, March 21, 2005 by Alberto Mingardi
This stream is available from http://direct.mises.org:88/Mingardi.
Available for download as Mp3 .