their presentations, birth certificates are administrative and legal documents with well-defined civil registration and identification purposes. Madans noted that early certificates were more focused on those needs but, over time, the number of items on the certificates grew. There were good reasons to add more public health data items to meet real public needs. Madans noted that the U.S. certificate may be unusual in the number of data items; by comparison, for example, Canadian birth certificates stick closely to the civil registration model and are limited to the most basic items (name, sex, and date and place of birth). The question is whether the U.S. certificate (with its 60 data items in the 2003 revision; see Appendix D) is now too large: What is known about the usefulness and quality of all that information, and what are the real cost implications of adding another item to the collection? To be clear, Madans said, this is not to say that the data items are unimportant by any means—just to question whether the birth certificate is the best vehicle for getting high-quality data efficiently.

More generally, Madans spoke of four issues for the future of vital statistics that all need to be dealt with, simultaneously, in choosing a future direction:

  • Infrastructure: Current investments at the state and local levels have been geared to the electronic infrastructure of data processing and collection: indeed, the objective in the general category of infrastructure is to use information technology to achieve a faster, more efficient structure. Among the developments to date have been work on electronic verification of vital events, development of transmission standards, and creation of web-based systems for local practitioners to use in completing certificate information. Madans noted that these are all important advances, and advances that have to continue, but it has to be recognized that the “payoff” of these developments to date has not been as great as hoped. The phased nature of the implementations has been disruptive for trend analysis and overall comparability; Madans commented that it is possible that there might have actually been more rapid adoption of the 2003 standard birth certificate among the states if not for the difficulty of retooling electronic birth certificates. Madans also referred to statements made earlier in the workshop in commenting that infrastructure alone cannot solve all problems; even with the fastest and most efficient infrastructure, vital statistics are only as fast as the slowest state.

  • Content: Picking up on her earlier theme—and taking care to note that suggesting changes to data content is often unpopular but nonetheless necessary—Madans said that the system needs to carefully consider what items are on the birth and death certificates and why. Is there some limited, core set of public health statistical data items that are



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