PH+Reporting+User+Story+-+Birth+&+Fetal+Death+Registration

include component="page" wikiName="siframework" page="PHRI Header" =User Story: Birth / Fetal Death Registration=

Contact Info:
Michelle Williamson, BSN, MSIS (mwilliamson@cdc.gov, phone: 301.458.4618) -- Senior Health Informatics Scientist, CDC/National Center for Health Statistics Hetty Khan, BSN, MSN, MGA (hkhan@cdc.gov, phone: 301.458.4311) -- Health Informatics Scientist, CDC/National Center for Health Statistics (NCHS)

Date Received:
11/18/2011

The National Vital Statistics System (NVSS) is a program of the Centers for Disease Control and Prevention/National Center for Health Statistics (CDC/NCHS). The 57 U.S. vital records jurisdictions, the National Association for Public Health Statistics and Information Systems (NAPHSIS), and the CDC/NCHS have long collaborated to promote uniformity and consistency in vital records collection. State and jurisdictional laws require reporting of all births, deaths, and reportable fetal deaths to the jurisdiction where the event took place. Federal law obligates CDC/NCHS to produce national multipurpose statistics based on the state vital records information. CDC/NCHS closely collaborates with the states to develop standards for data collection, reporting and administrative purposes, as well as standardized procedures for data preparation and processing to promote a uniform national database.
 * Goal**

Two main goals of the Vital Records community are to:
 * Efficiently register records of birth and death, and reports of fetal deaths that are accurate and available quickly for issuance as certified copies and reports to meet the needs of families experiencing these vital events
 * Produce timely, accurate, high quality data based on birth, death, and fetal death records to inform public health at the local, state and national levels.

Vital statistics data (e.g., teen childbearing, prenatal care, cesarean, preterm and low birth weight rates, infant and maternal mortality) are essential for key national health and healthcare-related policy decisions and also influence programmatic and policy decisions for state agencies. The data are used to measure progress toward national and state health objectives, such as Healthy People 2000-2020 goals and are the basis for information relevant to the health of the public and for aiding decision makers in setting policies, directing resources, managing problems, and identifying emerging health trends.

Vital statistics birth and fetal death or stillbirth information has the greatest implications for women and families in their reproductive years. These data guide pre-pregnancy planning and pregnancy management, and inform appropriate interventions. Standardization of vital records data within the EHR could improve the timeliness and accuracy of these and other valuable data for improved patient care. This information serves as baseline measurements for a lifetime exposure to patient care.

Annually, over 6 million vital event records, including statistical information (demographic, medical, and geographic) are derived from over 4 million birth certificates and from about 2.4 million death certificates and fetal death reports. Currently, these data typically are gathered by hospital personnel from the hospital’s medical records and directly from the mother using paper worksheets.
 * Description of Data Reporting Events, Actors and Triggers**

This process has fostered redundancy in data entry which can slow transmission of birth, death and fetal death data to the federal government, impacting data accuracy, timeliness and usefulness.

Many data items required for birth and fetal death event reporting are captured in medical records. Indeed, medical records are recommended by CDC/NCHS to serve as the source for more than half of all data items collected on the 2003 US Standard Certificate of Live Birth and the 2003 US Standard Report of Fetal Death. The data items needed to record a birth or fetal death event are divided into two basic groups:
 * Demographic and personal information is provided by the mother. A data collection worksheet called the Mother’s Worksheet (for live birth) or Patient Worksheet (for fetal death) has been developed by CDC/NCHS and state colleagues.
 * Medical information, including prenatal care information, is derived from hospital medical and prenatal care records. A standardized Facility Worksheet is recommended for use by CDC/NCHS and NAPHSIS. Prenatal care and pregnancy history information is sent to the hospital by the prenatal care provider prior to the mother’s estimated delivery date. The remaining information needed to complete the Facility Worksheet may come from the labor and delivery log, the mother’s medical record and the newborn’s medical record. Fetal death records include a cause of death section which must be completed by the certifying physician.

The following use case provides a common scenario of how birth and fetal death events are recorded in a birthing hospital. For the birth record, prenatal care and pregnancy history information, such as the mother’s last menstrual period (LMP), are obtained from the mother’s prenatal records which are sent to the hospital by the prenatal care provider prior to the mother’s estimated delivery date. Information about the labor and delivery and the infant (e.g., a spontaneous vaginal delivery of a girl weighing 3,242 grams) is documented by the nurse in the hospital’s labor and delivery (L&D) log. Information about the labor and delivery and the newborn to be collected for the birth record is also documented by the nurse in the Facility Worksheet for the Child’s Birth Certificate. The Pediatrician documents the physical assessment in the newborn’s medical record and the nurse then completes the newborn information sections of the Facility Worksheet.

The Birth Information Specialist (BIS), the hospital staff person responsible for gathering and entering information for the birth certificate, checks the hospital’s information system for a list of all new births. She prints a copy of the list and takes it to the L&D unit where she picks up the Facility Worksheet completed by the Nurse. The BIS then goes to the Mother’s room and presents her with a packet of information and several forms to complete. One of the forms, called the Mother’s Worksheet for the Child’s Birth Certificate, collects important demographic information on the mother and father. The BIS helps the Mother complete the Mother’s Worksheet. The BIS reviews the Facility Worksheet for completeness. If a section has not been completed, she reviews the L&D log, mother’s prenatal care and other medical records for the required information. If necessary, she calls the prenatal care provider for more information.

The BIS then enters the information from the Mother’s and Facility worksheets into the State’s web-based Electronic Birth Registration System (EBRS). At the time of data entry, the EBRS performs field edits and cross-field edits that are pre-programmed into the system. Once the record “passes” all validations, the BIS submits the record to the state for registration. The birth record is then automatically transmitted over a secure Internet connection to the State Office of Vital Records.

The vital records registrar reviews a list of newly transmitted birth records received from birthing facilities around his state. If there are records that have not passed all edits, he contacts the hospital and requests that they correct and retransmit the birth record. The hospital corrects the birth record and retransmits. Once the birth record has passed all edits, the vital records registrar registers the baby’s birth and the mother is provided with a certified copy of the birth certificate on request.

The process of collecting information at the hospital for the fetal death report is similar to that for birth. The labor and delivery nurse enters information in the medical records and completes the Facility Worksheet. The BIS is responsible for gathering and entering information into the Electronic Fetal Death Registration System (EFDRS) for the fetal death report. She first checks the hospital’s information system and learns about the mother’s loss. She obtains the completed Facility Worksheet from the nurse and helps the mother complete the Patient’s Worksheet. She may also contact the prenatal care provider to obtain the Mother’s prenatal care information and the obstetrician to enter the cause of death in the system.

CDC/NCHS closely collaborates with the individual U.S. states/jurisdictions, the National Association for Public Health Statistics and Information Systems (NAPHSIS), and the World Health Organization on standardization. The CDC/NCHS, jurisdictions, and NAPHSIS collaborate to develop standard certificates and reports for data collection and administrative purposes, as well as standardized procedures for data preparation and processing to promote a uniform national database. The data that are currently reported are based on the national standards of the 2003 Revisions of the U.S. Standard Certificate of Live Birth and the U.S. Standard Report of Fetal Death. The following are supporting documents for the collection of live birth and fetal death data. These documents are available from the Centers for Disease Control and Prevention / National Center for Health Statistics / National Vital Statistics System website at: http://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm
 * Data**
 * 1) U.S. Standard Certificate of Live Birth: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf
 * 2) U.S. Standard Report of Fetal Death: http://www.cdc.gov/nchs/data/dvs/FDEATH11-03finalACC.pdf
 * 3) Birth Edit Specifications for the 2003 Revision of the U.S. Standard Certificate of Birth: http://www.cdc.gov/nchs/data/dvs/FinalBirthSpecs3-24-2005.pdf
 * 4) Fetal Death Edit Specifications for the 2003 Revision of the U.S. Standard Report of Fetal Death: http://www.cdc.gov/nchs/data/dvs/FinalFetalDeathSpecs2-22-05.pdf
 * 5) Facility Worksheet for the Live Birth Certificate: http://www.cdc.gov/nchs/data/dvs/facwksBF04.pdf
 * 6) Mother's Worksheet for the Child's Birth Certificate: http://www.cdc.gov/nchs/data/dvs/momswkstf_improv.pdf
 * 7) Patient’s Worksheet for the Report of Fetal Death: http://www.cdc.gov/nchs/data/dvs/patientwkstfetaldth.pdf
 * 8) Facility Worksheet for the Report of Fetal Death: http://www.cdc.gov/nchs/data/dvs/FacilityFetal04.pdf
 * 9) Guide to Completing the Facility Worksheets for the Certificate of Live Birth and Report of Fetal Death: http://www.cdc.gov/nchs/data/dvs/GuidetoCompleteFacilityWks.pdf

//Data Sets for Birth and Fetal Death Registration// COUNTY OF DELIVERY; PLACE WHERE DELIVERY OCCURRED; FACILITY NAME; FACILITY ID || LOCATION; STREET AND NUMBER; APT. NO.; ZIP CODE; INSIDE CITY LIMITS? || PREGNANCY? ||
 * = **U.S. Standard Certificate of Live Birth** ||=  ||= **U.S. Standard Report of Fetal Death** ||=   ||
 * = Item 1 ||= CHILD’S NAME* ||= Item 1 ||= NAME OF FETUS* ||
 * Item 2 || TIME OF BIRTH || Item 2 || TIME OF DELIVERY ||
 * Item 3 || SEX || Item 3 || SEX ||
 * Item 4 || DATE OF BIRTH (INFANT) || Item 4 || DATE OF DELIVERY ||
 * Items 5-7, 17, 26 || FACILITY NAME; CITY, TOWN OR LOCATION OF BIRTH; COUNTY OF BIRTH; FACILITY ID; PLACE WHERE BIRTH OCCURRED || Items 5-9 || CITY, TOWN OR LOCATION OF DELIVERY; ZIP CODE OF DELIVERY;
 * Item 8a || MOTHER’S CURRENT LEGAL NAME* || Item 10a || MOTHER’S CURRENT LEGAL NAME* ||
 * Item 8b || DATE OF BIRTH (MOTHER) || Item 10b || DATE OF BIRTH (mother/patient) ||
 * Item 8c || MOTHER’S NAME PRIOR TO FIRST MARRIAGE* || Item 10c || MOTHER’S NAME PRIOR TO FIRST MARRIAGE* ||
 * Item 8d || BIRTHPLACE (STATE, TERRITORY, OR FOREIGN COUNTRY) || Item 10d || BIRTHPLACE (state, territory, or foreign country) ||
 * Item 9a-g || RESIDENCE OF MOTHER: STATE; COUNTY; CITY, TOWN OR LOCATION; STREET AND NUMBER; APT. NO.; ZIP CODE; INSIDE CITY LIMITS? || Item 11a-g || RESIDENCE OF MOTHER/PATIENT: STATE; COUNTY; CITY, TOWN OR
 * Item 10a || FATHER’S CURRENT LEGAL NAME* || Item 12a || FATHER’S CURRENT LEGAL NAME* ||
 * Item 10b || DATE OF BIRTH (FATHER) || Item 12b || DATE OF BIRTH (father) ||
 * Item 10c || BIRTHPLACE (FATHER)* || Item 12c || BIRTHPLACE (father)* ||
 * Item 11 || CERTIFIER’S NAME* || Item 13 || METHOD OF DISPOSITION ||
 * Item 12 || DATE CERTIFIED* || Item 14 || ATTENDANT’S NAME, TITLE, AND NPI ||
 * Item 13 || DATE FILED BY REGISTRAR* || Item 15 || NAME AND TITLE OF PERSON COMPLETING REPORT* ||
 * Item 14 || MOTHER’S MAILING ADDRESS* || Item 16 || DATE REPORT COMPLETED* ||
 * Item 15 || MOTHER MARRIED? || Item 17 || DATE RECEIVED BY REGISTRAR* ||
 * Item 16 || SOCIAL SECURITY NUMBER REQUESTED FOR CHILD?* || Item 18a || INITIATING CAUSE/CONDITION ||
 * Item 18 || MOTHER’S SOCIAL SECURITY NUMBER* || Item 18b || OTHER SIGNIFICANT CAUSES OR CONDITIONS ||
 * Item 19 || FATHER’S SOCIAL SECURITY NUMBER* || Item 18c || WEIGHT OF FETUS ||
 * Item 20 || MOTHER’S EDUCATION || Item 18d || OBSTETRIC ESTIMATION OF GESTATION AT DELIVERY ||
 * Item 21 || MOTHER OF HISPANIC ORIGIN? || Item 18e || ESTIMATED TIME OF FETAL DEATH ||
 * Item 22 || MOTHER’S RACE || Item 18f || WAS AN AUTOPSY PERFORMED ||
 * Item 23 || FATHER’S EDUCATION || Item 18g || WAS A HISTOLOGICAL PLACENTAL EXAMINATION PERFORMED ||
 * Item 24 || FATHER OF HISPANIC ORIGIN? || Item 18h || WERE AUTOPSY OR HISTOLOGICAL PLACENTAL EXAMINATION RESULTS USED IN DETERMINING THE CAUSE OF FETAL DEATH ||
 * Item 25 || FATHER’S RACE || Item 19 || MOTHER/PATIENT’S EDUCATION ||
 * Item 27 || ATTENDANT’S NAME, TITLE, AND NPI || Item 20 || MOTHER/PATIENT OF HISPANIC ORIGIN? ||
 * Item 28 || MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY? || Item 21 || MOTHER/PATIENT’S RACE ||
 * Item 29a-b || DATES OF FIRST AND LAST PRENATAL CARE VISIT || Item 22 || MOTHER/PATIENT MARRIED? ||
 * Item 30 || TOTAL NUMBER OF PRENATAL CARE VISITS FOR THIS PREGNANCY || Item 23a-b || DATES OF FIRST AND LAST PRENATAL CARE VISIT ||
 * Item 31 || MOTHER’S HEIGHT || Item 24 || TOTAL NUMBER OF PRENATAL CARE VISITS FOR THIS PREGNANCY ||
 * Item 32 || MOTHER’S PREPREGNANCY WEIGHT || Item 25 || MOTHER/PATIENT’S HEIGHT ||
 * Item 33 || MOTHER=S WEIGHT AT DELIVERY || Item 26 || MOTHER/PATIENT’S PREPREGNANCY WEIGHT ||
 * Item 34 || DID MOTHER GET WIC FOOD FOR HERSELF DURING THIS PREGNANCY? || Item 27 || MOTHER/PATIENT’S WEIGHT AT DELIVERY ||
 * Items 35a-c, 36a-b || NUMBER OF PREVIOUS LIVE BIRTHS- NOW LIVING, NOW DEAD; DATE OF LAST LIVE BIRTH; NUMBER OF OTHER PREGNANCY OUTCOMES; DATE OF LAST OTHER PREGNANCY OUTCOME || Item 28 || DID MOTHER/PATIENT GET WIC FOOD FOR HERSELF DURING THIS
 * Item 37 || CIGARETTE SMOKING BEFORE AND DURING PREGNANCY || Items 29a-c, 30a-b || NUMBER OF PREVIOUS LIVE BIRTHS- NOW LIVING, NOW DEAD; DATE OF LAST LIVE BIRTH; NUMBER OF OTHER PREGNANCY OUTCOMES; DATE OF LAST OTHER PREGNANCY OUTCOME ||
 * Item 38 || PRINCIPAL SOURCE OF PAYMENT FOR THIS DELIVERY || Item 31 || CIGARETTE SMOKING BEFORE AND DURING PREGNANCY ||
 * Item 39 || DATE LAST NORMAL MENSES BEGAN || Item 32 || DATE LAST NORMAL MENSES BEGAN ||
 * Item 40 || MOTHER’S MEDICAL RECORD NUMBER* || Items 33, 34 || PLURALITY; IF NOT SINGLE BIRTH- BORN FIRST, SECOND, THIRD, ETC. (specify) ||
 * Item 41 || RISK FACTORS IN THIS PREGNANCY || Item 35 || MOTHER/PATIENT TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS FOR DELIVERY? ||
 * Item 42 || INFECTIONS PRESENT AND/OR TREATED DURING THIS PREGNANCY || Item 36 || RISK FACTORS IN THIS PREGNANCY ||
 * Item 43 || OBSTETRIC PROCEDURES || Item 37 || INFECTIONS PRESENT AND/OR TREATED DURING THIS PREGNANCY ||
 * Item 44 || ONSET OF LABOR || Item 38 || METHOD OF DELIVERY ||
 * Item 45 || CHARACTERISTICS OF LABOR AND DELIVERY || Item 39 || MATERNAL MORBIDITY ||
 * Item 46 || METHOD OF DELIVERY || Item 40 || CONGENITAL ANOMALIES OF THE FETUS ||
 * Item 47 || MATERNAL MORBIDITY ||  ||   ||
 * Item 48 || NEWBORN MEDICAL RECORD NUMBER* ||  ||   ||
 * Item 49 || BIRTHWEIGHT ||  ||   ||
 * Item 50 || OBSTETRIC ESTIMATION OF GESTATION ||  ||   ||
 * Item 51 || APGAR SCORE ||  ||   ||
 * Items 52, 53 || PLURALITY; IF NOT SINGLE BIRTH- BORN FIRST, SECOND, THIRD, ETC. (specify) ||  ||   ||
 * Item 54 || ABNORMAL CONDITIONS OF THE NEWBORN ||  ||   ||
 * Item 55 || CONGENITAL ANOMALIES OF THE NEWBORN ||  ||   ||
 * Item 56 || WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? IF YES, NAME OF FACILITY INFANT TRANSFERRED TO ||  ||   ||
 * Item 57 || IS INFANT LIVING AT THE TIME OF REPORT? ||  ||   ||
 * Item 58 || IS INFANT BEING BREASTFED? ||  ||   ||
 * Item is not part of the NCHS data set.


 * Other information**

//U.S. Standard Certificate Use//

The CDC/NCHS and NAPHSIS recommend standardized data items, worksheets, edits, certificates and reports for collecting, recording and reporting birth and fetal death events. The most current version release of the U.S. Standard Certificate of Birth and U.S. Report of Fetal Death was in 2003. Most jurisdictions have revised to the 2003 standard or will be revised by January 2014, when compliance becomes mandatory.

//Electronic Vital Record Systems//

All U.S. jurisdictions have automated the birth registration process, with the exception of a few territories. Most of the automation platforms have been upgraded to web or web-enabled Electronic Birth Registration Systems (EBRS), EBR systems are owned and operated by each jurisdiction and are used by trained hospital staff for the purpose of recording and filing birth records with the jurisdiction. At the time of data entry, the EBRS performs field edits and cross-field edits recommended by CDC/NCHS and NAPHSIS and which are pre-programmed into the system. Usually, a record must pass this validation step before it can be transferred electronically from the hospital to the jurisdiction for official registration.

Most jurisdictions have not yet automated fetal death registration. Others have developed Electronic Fetal Death Reporting Systems (EFDRS) that are integrated with the EBRS. EFDRS often allow electronic certification of the cause of fetal death by authorized and trained hospital physicians.

//Standards Development for EHR-Vital Record Exchange//

Many data items required by birth and death certificates and fetal death reports are captured in medical records. For example, the mother’s and infant’s medical records are recommended by CDC/NCHS and NAPHSIS to serve as the source for more than half of all data items collected on the 2003 US Standard Certificate of Live Birth and the 2003 US Standard Report of Fetal Death, Currently, these medical items are typically gathered by hospital personnel from the hospital’s medical records using paper worksheets and are data entered directly into the jurisdiction’s Electronic Birth Registration System (EBRS).

The vital statistics community has been collaborating on developing standards for EHR medical data exchange with jurisdictional vital record systems. Once implemented, the standardized transmission of medical information on a hospital birth or fetal death should improve the overall efficiency of hospital data collection and reporting. CDC/NCHS has been collaborating with NAPHSIS and other vital records stakeholders to develop vital records standards that are supported by the standards development organization (SDO), Health Level Seven International (HL7) and the standards organization, Integrating the Healthcare Enterprise (IHE).

The CDC/NCHS sponsored a project that was approved and supported by the HL7 Public Health and Emergency Response Work Group (PHER WG) to develop an HL7 Vital Records Domain Analysis Model (VR DAM). The VR DAM identifies and describes the activities and data required for processing birth, death and fetal death records in compliance with the 2003 Revision of the U.S. Standard Certificates of Birth and Death, and the 2003 Revision of the U.S. Standard Report of Fetal Death. The model depicts vital records stakeholders who are involved in exchanging data within the context of each activity. The model also includes descriptions of each of the data elements required for vital registration as defined by the national standard. The VR DAM was published as an HL7 standard in April 2011. The model is serving as a framework to guide additional design and implementation efforts to standardize electronic vital records exchange.

Building on this collaborative relationship, NCHS, NAPHSIS and other vital records stakeholders developed an HL7 Electronic Health Record System (EHR-S) Vital Records Functional Profile (VRFP). This activity was supported by the HL7 Electronic Health Records Work Group. The VRFP was derived from the HL7 EHR-S Functional Model (FM), which provides a reference list of functions that may be present in an electronic health record system. Functional profiles are a subset of the EHR-S FM that provide a standardized description and common understanding of the functions that are needed or required for a specific care setting or subject area. The VRFP profile defines the functional requirements needed to capture selected vital records data at the point of contact or care with a patient and supports messaging between EHR systems and states, local registrars, and federal agencies. The VRFP is intended to ultimately serve as a reference for potential certification of EHR systems that include functionality to support vital records requirements. The profile is slated to be published as an HL7 standard by early 2012.

Recent CDC/NCHS standards activities, in partnership with other vital records stakeholders, have been focused on developing HL7 technical messaging implementation guides as draft standards for trial use (DSTU) for birth, death and fetal death reporting that are based on the HL7 Version 2.5.1 standard. An HL7 V2.5.1 IG: Reporting Death Information from the EHR to Vital Records, R1 was balloted and approved for publishing in October 2011. Current work is in progress to develop an HL7 V2.5.1 IG: Reporting Birth and Fetal Death Information from the EHR to Vital Records, R1. The development of these guides represents an initial effort to provide implementation guides for transmitting live birth, fetal death and death-related medical and health information from a clinical setting to the jurisdictional vital record electronic registration systems.

Standards activities for vital records within Integrating the Healthcare Enterprise (IHE) have been supported by the IHE Quality, Research and Public Health (QRPH) Committee. CDC/NCHS and NAPHSIS collaborated with QRPH to modify the IHE Maternal and Child Health (MCH) Technical Framework Supplement. The MCH Technical Supplement describes the content to be used in automating the data captured for vital records purposes such as for the U.S. Standard Certificate of Live Birth and the U.S. Standard Report of Fetal Death. The U.S. currently limits the data that may be pre-populated from an EHR for vital records purposes to a subset of vital records’ medical/health data requirements, that is, primarily those items included in the U.S. Standard Facility Worksheet for the Live Birth Certificate. To clarify, these items are collected for medical and health use only, and are not the legal items included on a certified copy of the birth or fetal death record. Demographic and personal data items collected from the mother (using the U.S. Standard Mothers Worksheet for the Child’s Birth Certificate (excepting the two items “Mother’s prepregnancy weight” and “Mother’s height”) are to be entered directly into the EBRS or EFDRS. The IHE MCH technical supplement describes how these select information may pre-populate the vital records systems and potentially other stakeholder information systems for birth and fetal death events via the mechanism provided by the Request Form for Data Capture (RFD) integration profile. The MCH profile uses transactions and content modules defined in other IHE profiles to provide interoperable data exchange. Additionally, CDC/NCHS facilitated the development of the IHE Birth and Fetal Death Reporting (BFDrpt) Profile that describes the content and format to be used within the pre-population data part of the Retrieve Form Request transaction from the RFD Integration Profile. This profile describes the content to be used in automating the data captured for vital records while adhering to the Birth Edit Specifications for the 2003 Revision of the U.S. Standard Certificate of Birth and the Fetal Death Edit Specifications for the 2003 Revision of the U.S. Standard Report of Fetal Death.

CDC/NCHS has been collaborating with NAPHSIS and other vital records stakeholders to lay the foundation for the electronic exchange of vital records information. Based on fiscal year 2011 funding, CDC/NCHS is planning to pilot test in several states interoperability between EHR and Vital Record systems utilizing the HL7 and IHE developing standards listed above. Should this initiative be selected by the S&I framework, CDC/NCHS, NAPHSIS and the vital records community stand ready to participate because the successful pilot testing will be crucial for the acceptance of States and NAPHSIS in moving forward on a larger scale.
 * Stakeholder Commitment**

Supporting Files:

 * **Description** || **File** ||
 * This document contains the initial draft user story submission. || [[file:Initial Draft Submission - Birth & Fetal Death Registration - November 18 2011.docx]] ||  ||

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