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What is Applied Forensic Epidemiology and How Is It Related to Public Health? Each year, medical examiner and coroner (MEC) offices conduct medicolegal death investigations (MDI) of sudden or unexpected deaths, including suspicious or violent deaths, such as homicides and suicides, unintentional (accidental) deaths, and unexpected deaths from natural causes (about 600,000 deaths per year or approximately 20% of all deaths in the US). In this capacity, MECs are often considered “first responders” in identifying diseases and causes of death in the population. The findings from MDI data provide key information for public health planning, prevention efforts, and policy development. Larger MEC offices often employ epidemiologists or data analysts who use public health methods to analyze MDI data. These epidemiologists are called applied forensic epidemiologists (in contrast to other types of forensic epidemiologists who determine the probability of cause of death in potential criminal investigations or in disease-related litigation). Responsibilities may vary by jurisdiction, but in general, applied forensic epidemiologists analyze MDI data, track trends in causes of death, prepare jurisdiction-level reports on key conditions, prepare subsets of MDI or other data to share with law enforcement and public health entities, and support research efforts as needed. Applied forensic epidemiologists act as key liaisons between MEC offices and public health entities, by providing analysis results and interpreting the findings from aggregated MDI data. This information is essential for identifying the populations at risk for various causes of death, as well as the locations and circumstances associated with these deaths – information that is critical for the development and implementation public health interventions. How has CSTE Supported Applied Forensic Epidemiology? In recognition of the important epidemiology functions that occur in MEC offices, CSTE partnered with the Centers for Disease Control and Prevention/National Center for Health Statistics (CDC/NCHS) in early 2022 to convene the CSTE Forensic Epidemiology Workgroup. This group supports the work of applied forensic epidemiologists and other professionals who perform data analysis duties in MEC offices. The group aims to better understand the challenges and needs of applied forensic epidemiologists in the US. Focus areas and activities include:
Applied forensic epidemiologists act as key liaisons between MEC offices and public health entities, by providing analysis results and interpreting the findings from aggregated MDI data. This information is essential for identifying the populations at
risk for various causes of death, as well as the locations and circumstances associated with these deaths – information that is critical for the development and implementation public health interventions.
Find out more:Why you need an Applied Forensic Epidemiologist In addition to the resources curated by CSTE, many national organizations provide helpful resources. Partner Resources
Partner Resources
Medical examiner and coroner (MEC) offices often use software-based case management systems (CMS) to manage cases more efficiently. These systems help to streamline data collection, enhance case tracking, and improve reporting practices across jurisdictions. In addition to the resources curated by CSTE, many national organizations provide helpful resources:
Coroner and Medical Examiner Systems
Coroner and Medical Examiner Systems
The head medicolegal officer can be either a coroner or medical examiner. Together with investigators, support staff, and sometimes consultants, they work as a team to form an investigative system. A coroner system has an elected or appointed chief medicolegal officer who is responsible for overseeing death investigations in a given jurisdiction, but who is not usually the person who performs autopsies. Coroners are not usually required to be physicians. In this type of system, forensic pathologists are hired to be either in-house or are contracted consultants to perform autopsies at the request of the coroner as part of the coroner’s investigation. Being elected, coroners do not typically operate within public health agencies or departments. Some coroners have their own dedicated autopsy facilities while others do not. A medical examiner system has a chief medicolegal officer who is a physician with specialized training in forensic pathology to determine cause and manner of death. This person is responsible for overseeing death investigation in a given jurisdiction and whose duties include not only administrative oversight but may also include the performance of autopsies. Medical examiners are usually forensic pathologists appointed by a governing authority of the jurisdiction. Both systems have the same goals: to investigate the circumstances surrounding certain deaths and to determine the cause and manner of death. Both maintain legal documentation of death investigations, provide testimony at court, and advocate for victims and families. Both systems adhere to the same code of ethics and apply the same investigative procedures and guidelines established by the main governing organizations. As part of either system, most cases sent to an autopsy facility undergo a full internal and external examination by a pathologist, and toxicological tests are initiated. There are occasions, however, when full autopsies don’t occur. If an investigator is unsure of the next steps to take in an investigation, the decedent may be sent to the autopsy facility where only an external examination is completed and toxicological samples can be drawn until the next steps in the investigation are determined. If the decedent is in an advanced state of decomposition or otherwise unrecognizable, an in-house or contracted anthropologist, rather than a pathologist, may perform the examination. Investigation in Medical Examiner and Coroner Offices
Investigation in Medical Examiner and Coroner Offices
Medicolegal death investigations (MDIs) are conducted in both coroner and medical examiner offices. These investigations seek to identify decedents and determine their cause and manner of death. Conclusions from such investigations are then formally recorded on death certificates for vital records. Individual jurisdictions have their own standards, but most require medicolegal investigations for deaths that are unexpected, unexplained, suspicious, violent, unnatural, unattended, or where the deceased was not treated by a physician within a certain time period before death. Death investigation systems and processes in the United States are determined at a state-wide, regional, or county level. See additional resources below:
The same processes used by death investigators for the identification and determination of cause and manner of death for a single individual can also be applied to mass fatalities and instances of disaster. Deaths resulting from natural disasters or human-induced mass fatalities such as terrorist attacks, large-scale structural disasters, etc., require medicolegal investigation. Some jurisdictions may have the capacity to work mass fatality scenes on their own, while others may require logistic assistance from federal sources depending on the size and scale of the disaster. COMEC - Disaster and Preparedness Mass fatality and disaster response preparedness across medical examiner and coroner offices in the United States. National Association of Medical Examiners Position Paper Recommendations for the Documentation and Certification of Disaster Related Deaths. Role of Applied Forensic Epidemiologists Coroner and medical examiner offices have collaborated with public health for years as outlined in the review, *Medical Examiners, Coroner, and Public Health: A Review and Update*. This collaboration was not well known until recently, and data generated by death investigators was viewed as only serving the criminal justice system. The COVID-19 pandemic initiated a rapid shift in perspective, as death investigation data became paramount in the development of local, state, and federal efforts to address the public health emergency. Death certificate data proved critical in tracking the number of fatalities as well as demographic trends, which guided the development of preventive safety measures and the direction of resources to areas most in need. Other public health crises further underscore the importance of using data resulting from death investigations to inform public health efforts. Policy development and funding allocation decisions for the current opioid crisis, for example, are now largely informed by data collected and recorded by coroners and medical examiners. This increased need for medicolegal data among stakeholders at all levels has in part led to the embedding of Applied Forensic Epidemiologists in coroner and medical examiner offices and local public health agencies. These individuals act as key liaisons between death investigation offices and public health entities as they provide analytical results and interpretations of aggregated data. Data System Flows and Lifecycles
Data System Flows and Lifecycles
At first glance, the data flow from medical examiners and coroners (MECs) to a completed and processed death certificate appears to be straightforward. Death scene investigators collect circumstantial and scene data, ensure the body is transported for examination, and the MEC decides on what type of examination to conduct (a full or partial autopsy, an external examination only, or radiographic options such as computed tomography [CT] scans). They then write a report of their findings, which is submitted to the state’s vital records office as part of the death certificate. After other parties (funeral homes, etc.) fill out any needed additional data (marital status, occupation, veteran status) on the death certificate, it is submitted to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) for International Classification of Disease (ICD) coding, and then returned to the issuing state for registration. Considering this basic outline, however, raises numerous questions regarding what additional data constitute a complete and thorough medicolegal death investigation (MDI). For example, are medical records or law enforcement reports needed? What supplemental testing, such as toxicology or histology, is required for death certifiers to conclude the cause and manner of death? Further, who is responsible for completing each step of the process, and what do they need to ensure accurate reporting? To help understand the complexities of MDI data flows, a multidisciplinary panel of forensic experts in the Medicolegal Death Investigation Data Exchange Working Group (MDI-Data-WG) mapped MDI data, identified needed data elements, and recommended ways to improve the flow of data between recipients and providers throughout the investigative process. This group produced a report, Data Exchange Practices of Medicolegal Death Investigation, that provides excellent explanations and graphics of the MDI data elements and MDI data flow between agencies and institutions. Refer to this comprehensive report for guidance in understanding MDI data collection and exchange. For additional guidance on the effective use of MDI data in certifying drug overdose deaths and the substances responsible for them, epidemiologists should refer to Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose . MDI Data Modernization
MDI Data Modernization
Medical Examiner and Coroner (MEC) offices serve as a vital hub for comprehensive data on the deaths they investigate. To determine the cause and manner of death, MECs collect detailed information from a wide array of sources, including emergency medical services, healthcare providers, witnesses, law enforcement, and more. This rich data resource helps in understanding mortality patterns within their jurisdictions and plays a crucial role in public health surveillance and policymaking. Furthermore, MEC offices distribute data to families, legal systems, state vital record offices, and various public health surveillance systems, such as the National Violent Death Reporting System (NVDRS), the State Unintentional Drug Overdose Reporting System (SUDORS), and the Medical Examiners and Coroners Alert Project (MECAP). To bolster their data capabilities, MEC offices are undergoing significant modernization. Traditionally reliant on manual data entry, these offices are moving towards electronic case management systems and advanced informatics tools that automate and accelerate data flows. By adopting standards like Fast Healthcare Interoperability Resources (FHIR), MEC offices are enhancing their interoperability with statewide death registration systems and other public health databases. Additionally, some MEC offices are implementing data science initiatives to streamline data transfer and integration with key surveillance systems like SUDORS and NVDRS. These modernization efforts ensure that data from MEC offices is not only more efficiently shared with relevant agencies, but is also accurate and timely, enabling faster responses to public health threats and more effective injury and violence prevention programs. See additional resources below: Death Certification Guidance
Death Certification Guidance
A key component of a death certificate is the cause-of-death statement. These fields outline the sequence of events leading to death. While guidelines for who can legally certify a death vary by jurisdiction, the duties of the certifier remain the same: determine the cause(s) of death and accurately report it on the death certificate. Although terms may be colloquially interchanged, for purposes of death certification, it is important to note the difference between cause and manner of death. Cause of death is defined as the disease or injury that led directly to death. Manner of death refers to the circumstances by which the cause of death occurred. There are only five manners of death: Natural, Accident, Suicide, Homicide, and Undetermined. Though state statutes vary, in general, Medical Examiners and Coroners (MECs) investigate sudden and unexpected deaths, deaths in which there is no attending physician, and suspicious or violent deaths, including homicides, suicides, accidents, and unexpected natural deaths. The certifier uses the information from the death investigation to complete the medical portion of the death certificate. The MECs report this information to authorities such as the state vital registrar. The Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS) have prepared several guidance documents to help standardize how death certificates are completed. Consistency in the information and language used to complete the medical portion of the death certificate helps improve data quality and comparability. The links below provide recommendations and guidance for completing death certificates for all deaths and for specific types of deaths:
The links below provide recommendations and guidance for completing the death certificate for specific types of deaths:
Case Management Software
Case Management Systems
Medical examiner and coroner (MEC) offices often use software-based case management systems (CMS) to collect, organize, and store case-related data. MEC office staff enter case-related data using standardized variables or forms to create a uniform data set that can be queried or analyzed. Depending on the features of the software, these systems can also be used to facilitate data sharing with stakeholders, such as law enforcement or public health.
Data Visualization and Dashboards
Data Visualization and Dashboards
Many medical examiner and coroner (MEC) offices use data visualization techniques and dashboards to enhance the use of medicolegal death investigation (MDI) data. These resources allow users to learn about the patterns of the different types of deaths occurring in their jurisdiction. Users of the dashboards are often able to make selections and submit queries to see the number of deaths by cause and manner of death, demographic characteristics of the decedent, trends over time, and locations where deaths occur. There exists a wide variety of software programs that can be used to create dashboards and data visualizations. Traditionally, static data visualizations for presentations and reports have been created in programs like Microsoft Excel or statistical analysis software like SAS. The mid-2000s and 2010s saw the rise in data visualization programs like Tableau, Microsoft Power BI, and others. These new programs allow for the creation of more interactive data representations, leveraged for Business Intelligence and further data exploration. They can also support more direct data connections for automated updates and real-time information. In the work of an applied forensic epidemiologist, these tools can be very helpful in disseminating data both to the public and within your organization. The most common use of data visualization software is often to create interactive dashboards. A data dashboard is a graphical interface that typically provides summary data relevant to a particular subject or process through a combination of visualizations and tables. It is designed to give quick and digestible insights related to a key topic. Due to the flexibility of most data visualization programs and the wide variety of data within a medical examiner and coroner office, dashboards can become powerful tools for deeply exploring your data and providing actionable insights within your organization. Incorporating data filters on dashboards empowers users to explore data that is interesting or relevant to their specific work. The links below highlight examples of dashboards and data visualizations from MEC offices or other agencies that use MDI data by the data visualization platform used:
More information on Data Visualization Software: Reports
Reports
Many medical examiner and coroner (MEC) offices produce annual reports describing the work of the office and highlighting the types of deaths occurring in their jurisdiction. Annual reports are required for accreditation by the National Association of Medical Examiners (NAME) and by the International Association of Coroners and Medical Examiner (IACME).
The links below highlight the NAME and IACME annual report requirements for accreditation:
The links below highlight examples of annual reports:
Fatality Review Teams
Fatality Review Teams
Fatality review is a process that involves a multidisciplinary team that reviews the details of individual deaths to help communities understand why the death occurred and to identify possible interventions to prevent similar fatalities in the future. The multidisciplinary teams include members from many disciplines, such as public health, the medical profession, coroners and medical examiners, law enforcement, social services, schools, pharmacists, traffic safety, prevention specialists, and others, depending on the types of deaths being reviewed. Fatality review teams often focus on a particular group of deaths, such as those involving children or the elderly, maternal fatalities, deaths resulting from domestic violence, suicide, homicide, deaths involving firearms, fatal overdose or drug intoxication, etc. Because coroners and medical examiners are responsible for the investigation of sudden and unexpected deaths to determine the cause and manner of death, they are essential contributors to fatality review teams. The links below provide information on recommendations from national organizations regarding fatality review for various types of deaths:
The links below provide examples of reports and dashboards from fatality review teams: Death Certificate Coding and Case DefinitionsDeath Certificate Coding and Case Definitions
Drug Overdose
Drug Overdose
Suicide
Suicide
Suicide is a leading cause of death in the United States for adolescents and adults. Medical examiners and coroners (MECs) play a key role in these cases, as they investigate suspicious deaths to determine the cause and manner of death. A large portion of death investigation procedures involve the MEC interviewing the family, law enforcement, neighbors/roommates, and other sources of information to inform the manner and cause of death determination. Additionally, a thorough scene investigation by the MEC allows local and national databases to gather and understand suicide risk factors, which can help prevent future deaths. The reasons for suicide are complex and intersectional, and in some cases, remain unknown. Information learned by studying these complex cases can be leveraged to increase safety and help prevent future loss by suicide. The links below provide recommendations and guidance related to the classification and analysis of deaths from suicide:
Training DatasetReal-world data for training forensic epidemiologists can be cumbersome to obtain outside of the working environment. Jurisdiction rules and regulations and the time required to generate such datasets are often prohibitive for all parties. Linked below are two datasets for training purposes. The structured dataset is a straightforward, clean sample dataset; while the real world dataset includes known errors and missing information. A data dictionary is included separately. See synthetic validation resource for more information on dataset development methods |
