MMRIA User Guide

MMRIA_User_Guide

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TABLE OF CONTENTS
A. What Is MMRIA? ..................................................................................................................................... 4
Additional Resources ................................................................................................................................ 4
B. HOSTING MMRIA .................................................................................................................................... 5
C. IMPORTING MMRDS DATA TO MMRIA ................................................................................................ 8
D. LOGGING IN .......................................................................................................................................... 10
User Roles............................................................................................................................................... 10
New User ................................................................................................................................................. 10
Returning User ........................................................................................................................................ 10
E. GETTING STARTED: BASIC FUNCTIONS .......................................................................................... 11
Saving Your Data .................................................................................................................................... 11
Deleting/Recovering Records ................................................................................................................. 11
Printing .................................................................................................................................................... 12
Data Dictionary ........................................................................................................................................ 14
View Aggregate Report ........................................................................................................................... 15
F. ABSTRACTING CASES INTO MMRIA ................................................................................................. 15
Field Types .............................................................................................................................................. 16
MMRIA Home Screen ............................................................................................................................. 16
1. Summary Page.................................................................................................................................... 17
2. Actions ................................................................................................................................................. 20
3. Print Blank ........................................................................................................................................... 21
Case Forms ............................................................................................................................................. 21
G. DATA ANALYSIS .................................................................................................................................. 44
Data Structure ......................................................................................................................................... 44
Forms and Grids...................................................................................................................................... 44
Core Elements Report ............................................................................................................................. 44
Data Export ............................................................................................................................................. 45
Relating Your Data: ................................................................................................................................. 46
H. REVIEWING CASES.............................................................................................................................. 49

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How to Use the Committee Reviewer Role ............................................................................................. 49
De-identified Fields.................................................................................................................................. 50
I. USER ADMINISTRATION ....................................................................................................................... 54
Add Users ................................................................................................................................................ 56
Remove Users......................................................................................................................................... 56
J. ADDING FIELDS AND FORMS ............................................................................................................. 57
K. FREQUENTLY ASKED QUESTIONS ................................................................................................... 58
APPENDIX: COMMITTEE DECISIONS FORM ......................................................................................... 59

A. WHAT IS MMRIA?
Created by the Centers for Disease Control and Prevention (CDC) and the CDC Foundation, in
partnership with maternal mortality review committees, the Maternal Mortality Review Information
Application (MMRIA or “Maria”) serves two purposes. First, it provides a repository for the medical and
social information needed for maternal mortality review committee (MMRC) case review. Second, MMRIA
provides standardized data that can then be used for the surveillance, monitoring, and research of
maternal mortality. MMRIA provides a common language that helps MMRCs collaborate in case review
and analysis.
MMRIA is the successor to the Maternal Mortality Review Data System (MMRDS). Based on lessons
learned from implementing MMRDS in 11 states, MMRIA was developed to be a user-friendly custom
application with flexible hosting options. Jurisdictions can select web-based, file-based network, or
desktop hosting.
MMRIA is a multi-user data entry system designed to flow like a case review. MMRIA’s abstraction forms
and tools help MMRC members understand the story of a woman’s life and the events leading to her
death. Devised to accommodate the scope of work and processes of MMRCs, the system supports
abstraction and captures committee decisions. MMRIA provides access to semi-automated case narrative
templates from which committee members can print easy-to-read case narrative details. Lastly, through
the geocoding of addresses, MMRIA captures socio-spatial information to expand case discussions and
analyses.
MMRIA also contains a RESTful API for importing data. Jurisdictions may choose to map data from other
systems to the MMRIA API to automate the import of data. In the future, a tool to map death certificate
and birth certificate data will be released to allow for automatic import of vitals data.

MMRIA user roles are assigned by a User Admin within your jurisdiction, based on the level of access
needed. Predefined user roles are: User Admin, Abstractor, Committee Reviewer, and Form Designer.

MMRIA is compatible with multiple operating systems and browsers; however, Google Chrome is the
recommended browser.

Additional Resources
The following tools complement MMRIA use and are available on ReviewtoAction.org:
Report from MMRCs, featuring data from four states
Committee Facilitation Guide
Model Purpose, Mission, Goals, and Vision for MMRCs
Overview of State Legislative Support for MMRCs
Model Case Identification Process
Model Abstractor Job Description
Tools for Case Abstraction
Model Committee Meeting Agenda

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Model Confidentiality Statement
Committee Decisions Form

B. HOSTING MMRIA
MMRIA is a custom application built on the following open source tools, including
CouchDB – central data store
OWIN/Katana – allows desktop and web-based hosting
Microsoft.NET core – enables compatibility with various operating systems
jQuery – user interface
Docker – container platform

With several options for hosting the system, MMRIA is designed to work flexibly with the various
environments in which review committees operate. In choosing which option will work best for your
jurisdiction, consider:
Who will enter data, and where are they located?
Who needs to view the data, and where are they located?
Who will analyze data, and where are they located?

T AB L E 1

crosswalks several options plus advantages and disadvantages of each option.

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T AB L E 1

OPTION

AD V AN T AG E S

D I S AD V AN T AG E S

1.
E X E C U T AB L E RUN FROM
DESKTOP

 Easiest setup

 Designed to support a single user from a
single location only

 Easily and quickly
supports single data
entry from a single
location (similar to
MMRDS)

 Upgrades require each user to take action
 Does not allow committee members to
access de-identified case information prior
to/during meetings direct from their machine
(MMRC will still rely on hard copies)
 Requires transferring data between
abstractor(s) and data analyst
 Requires downloading the following to each
user’s machine: Docker, Couch DB, Chrome
internet browser, MMRIA files

2.
E X E C U T AB L E RUN FROM
L O C AL
NETW ORK/
I N T R AN E T

 Supports multi-user data
entry from a single
location
 Upgrades require a
single user with admin
rights to take action

 Requires IT involvement to configure and to
download application to each user’s machine
 Does not allow committee members to
access de-identified case information prior
to/during meetings, unless committee
members have access to local network and
executable file installed
 Some transfer of files is required if users
exist both within local network and outside of
network
 Requires downloading the following to each
user’s machine: Docker, Couch DB, Chrome
internet browser, MMRIA files

3.
E X E C U T AB L E RUN OVER
INTE RNE T

 Supports multi-user data
entry from multiple
locations
 Committee members
can view de-identified
cases from any location
(if MMRIA is downloaded
to their PCs/tablets)

 Requires IT involvement to configure
deployment over web server
 Some costs may be associated with use of a
web server (estimated needs = 2G memory,
two core processors, 40G disk space)
 Requires downloading the following to each
user’s machine: Docker, Couch DB, Chrome
internet browser, MMRIA files

 Upgrades require a
single user with admin
rights to take action
4 . V I R T U AL
M AC H I N E V I A
DESKTOP OR
F I L E - B AS E D
NETW ORK

 Supports multi-user data
entry from multiple
locations

 Upgrades require each user to take action

 Committee members
can view de-identified
cases from any location
via a web browser

 Some costs may be associated with use of a
web server (estimated needs = 2 to 5G
memory, two core processors, 40G disk
space)

 Requires IT involvement to configure
deployment over web server

 Upgrades require a
single user with admin
rights to take action
 Fewer files to download
and easier setup:
Chrome, Pouch DB and
MMRIA packaged into
one file
5 . V I R T U AL
M AC H I N E V I A
INTE RNE T/W EB
SERVER

 Supports multi-user data
entry from multiple
locations
 Committee members
can view de-identified
cases from any location
via a web browser
 Upgrades require a
single user with admin
rights to take action
 Fewer files to download
and easier setup:
Chrome, Pouch DB and
MMRIA packaged into
one file
 Upgrades require a
single user with admin
rights to take action
 Easiest setup and
upgrade process for IT

 Requires IT involvement to configure
deployment over web server
 Some costs may be associated with use of a
web server (estimated needs = 2 to 5G
memory, two core processors, 40G disk
space)

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If your MMRC will have multiple abstractors entering data, The MMRIA Team recommends hosting the
system on the internet or intranet. Option 5 enables maximum functionality for abstractors, data analysts,
and committee members.
To access any new updates to MMRIA, please consult: http://mmria.org.

C. IMPORTING MMRDS DATA TO MMRIA
The MMRIA Importer is a tool that automatically imports data from MMRDS into MMRIA. Before
importing, you will need to install the Microsoft data drivers available at: https://www.microsoft.com/enus/download/confirmation.aspx?id=23734.
To run the import, you will need 4 pieces of information:





username – a MMRIA username for an abstractor role
password – MMRIA abstractor password
database_file_path – file path to the location of your MMRDS Maternal_Mortality.mdb file
url – your MMRIA URL

To locate the Maternal_Mortality.mdb file that is generated from MMRDS:
Go to your Windows File Explorer and locate MMRDS 0.3.3. When you have found MMRDS 0.3.3., click
on it and open up the folder titled Projects. Within the Projects folder, you will find a Maternal_Mortality
folder. Inside that folder is the file called Maternal_Mortality.mdb. (The file path will look similar to:
C:\Users\username\Desktop\MMRDS 0.3.3\Projects\Maternal_Mortality)
Note that if you have more than one Maternal_Mortality.mdb file on a single user’s computer, you
need to be very careful not to overwrite data. Contact mmriasupport@cdc.cov for step-by-step assistance
with importing multiple mdb files.

1. Open up Notepad and copy and paste the following information:
mmria.exe import user_name:user1 password\:password
database_file_path:c:\temp\Maternal_Mortality.mdb url:http://localhost:12345
2. Replace the words in bolded red with your specific information.
3. Highlight and copy the text in Notepad.
4. Next, open a MMRIA command line function by locating your MMRIA folder in your Windows File
Explorer, and then typing “cmd” in the path line.

5. Right-click in the dialog box and select Paste.
6. Press Enter and the Import will begin.
The import may take up to 30 seconds per case. When finished, a message will appear that says, "Import
is finished." You can then log in to MMRIA to view all imported cases.
The import can be run as many times as needed. You can import separate mdb files from several users’
computers, and with several different usernames. The Importer will overwrite existing cases with the latest
data from MMRDS.
If you see an error message like the following, make sure you have installed the Microsoft data drivers,
available at: https://www.microsoft.com/en-us/download/confirmation.aspx?id=23734.

D. LOGGING IN
Your jurisdiction will configure a URL, or web address, for MMRIA. You will need to reach out to your local
User Admin to receive the URL and your user name and password. Open Chrome internet browser, enter
the web address for MMRIA, and enter your user name and password.

User Roles
Access levels are based on roles:
User Admin – assigns user roles, user names, and passwords
Abstractor – has data entry and editing privileges. This role may be assigned to abstractors
and data analysts, or anyone who needs full read/write access.
Committee Reviewer – can view de-identified cases
Form Designer1 – has all access of an abstractor and also the ability to add forms and fields
via the Metadata Editor

New User
If you are a new user, you will need to contact the person on your MMRC with the User Admin role to
receive your login information. If you do not know who your User Admin is, contact
mmriasupport@cdc.gov.

Returning User
Select the “Login” button in the upper right-hand corner to enter your user name and password. Once you
enter your information into the fields, click “LOG IN.”

1. Contact mmriasupport@cdc.gov for additional guidance

FIGURE 2

E. GETTING STARTED: BASIC FUNCTIONS
Saving Your Data
There is a save button available on each form within a record that you may choose to use. However,
MMRIA automatically saves all data that is entered. For example, if you enter text and then navigate to
another screen, it will automatically have saved your text. You do not need to prompt the database to
save your file or any changes made to the data entered. The save button is available for those who
choose to use it.

Deleting/Recovering Records
Records can be deleted from the database via the summary page (F I G U R E 3 ). Click on the “Delete”
button. Once the “Delete” button is pressed, the record will be highlighted in gray. If you are sure you wish
to delete the case, press “Delete” again.
The deleted case will be excluded from data exports and from aggregate standard reports created within
MMRIA. If a case needs to be recovered after being deleted, contact MMRIAsupport@cdc.gov.

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FIGURE 3

Printing
You have the option to print a blank copy of all 11 forms, a single record, or an entire case. The print
dialog opens in a separate browser window.
You may wish to print only the Case Narrative form for a given case. Using the case narrative templates,
your Case Narrative form should contain all of the information your committee needs to review a case.
You may also want to print the Core Elements report, which contains additional data that your review
committee may need. For select cases, you may wish to print graphs from the Prenatal Care and ER
Visits/Hospitalizations forms or other forms as appropriate. To print any forms besides the Case Narrative
and Core Elements for committee review, be aware that within the abstractor role, you will be printing fully
identified forms. To print these other forms, you should log in with a committee reviewer to ensure
information is de-identified. In the future, the option to print de-identified forms will exist within the
Abstractor role.

Steps for Printing a Case
1. Locate the record on the Summary Page.
2. Click directly on the case to open its Home Record page.
3. Select the “Print Version” drop-down to see a menu listing all forms.
4. Select an individual form to print or select “All” to print all of the case’s forms.

Steps for Printing Blank Forms
1. You can print blank forms from the “Summary”
page (F I G U R E 4 ) or from within a case (F I G U R E 5 ).
2. Select the “Print Blank” drop-down (F I G U R E 4 ) to
see a menu listing all blank forms.
3. Select an individual blank form to print or select
“All” to print all of the blank forms.

FIGURE 4

Note: if you would like a set of blank
forms with all drop-down values
displayed to help you take abstraction
notes on paper, contact
mmriasupport@cdc.gov

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FIGURE 5

Data Dictionary
The data dictionary is a dynamic dictionary that automatically updates; any changes to the forms will be
reflected in real time. You can navigate to the data dictionary from the summary page (F I G U R E 6 ) and
from within a case (F I G U R E 7 ). The data dictionary will open in a separate window. You may also choose
to export the data dictionary to Excel for easy viewing. To export to Excel, “Select All,” then copy and
paste into a spreadsheet.

FIGURE 6

FIGURE 7

View Aggregate Report
To view a snapshot of information on the cases you have entered, click the “Actions” button and select
“View Aggregate Report” to launch a new window (1). Click the “generate report” button (2) and data will
be populated below the table (3) (F I G U R E 8 ).
FIGURE 8

You will see a disclaimer that this report is currently in progress. More fields, and further reports, will be
added in the future.

F. ABSTRACTING CASES INTO MMRIA
MMRIA is designed to capture your abstraction notes and help you to write a comprehensive case
narrative. You may wish to abstract on paper and then enter the data into MMRIA, but it is ideal to enter
case data into MMRIA before you present a case to your committee. Why?
1. The templates contained in the Reviewer’s Notes sections of each form and the Case
Narrative form itself will aid you in writing and printing a case narrative that can be easily
printed for presentation to your committee.
2. Throughout the different forms in MMRIA, you will see fields marked with an asterisk.
Fields with asterisks denote core data elements. These fields are not required but were
identified by review committees and subject matter experts as important information for
both committees and analysts to have accessible. All of the core elements are brought
into a Core Elements Report that you may print for presentation to your committee. If you
have this data available, make sure you complete the field. If it is not available, you may
wish to note that in the Reviewer’s Notes text box at the bottom of each form.

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3. If your committee members have MMRIA access, they can view de-identified case
information prior to or during committee meetings.

Field Types
What types of fields are in MMRIA?
 Single select drop-down lists
 Multi-select drop-down lists
 Checkboxes
 Editable lists – allow you to enter an option from a dropdown menu, or type another value if the value is
not listed
 Free text fields
 Date and Date+Time Fields
o

Note that dates and times are de-identified when viewed by Committee Reviewers, to
protect anonymity. Thus, it is important to enter not only dates and times but also
gestational age or days postpartum for all events, which are visible to Committee
Reviewers.

 Reviewer’s Notes boxes – these are found at the bottom of each form. They can be expanded by
clicking and dragging the bottom right corner of the box.

 Grids – used to capture related pieces of information in a table format, e.g. the Routine Monitoring Grid
in the Prenatal Care Record

Note: Be sure to exclude any personal identifiers from the Reviewer’s Notes
sections of each form. Any identified information entered into Reviewer’s Notes
sections of forms will NOT be de-identified for the Committee Reviewer role.

MMRIA Home Screen
As shown in F I G U R E 9 , the MMRIA Home Screen has three main menu options: Summary (1), Actions
(2), and Print Blank (3).

17
FIGURE 9

1. Summary Page
The Summary Page is where you add new cases, edit cases, or delete cases.
FIGURE 10

Add a New Case
1. To add a new case, click the “Add New Case” button located under the “Summary”
heading.
2. After clicking on the “Add New Case” button, you will be taken to the Home Record
screen. However, you can start data entry on any form. To proceed from one form to the
next, select the “Case Forms” (T AB L E 2 ) drop-down menu.
3. Select the appropriate form to begin entering data.
FIGURE 11

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FIGURE 12

T AB L E 2

C AS E F O R M T Y P E S

Home Record

Other Medical Office Visits*

Death Certificate

Medical Transport*

Birth/Fetal Death Certificate – Parent Section

Social and Environmental Profile

Birth/Fetal Death Certificate – Infant/Fetal
Section*

Mental Health Profile

Autopsy Report

Informant Interviews*

Prenatal Care Record

Case Narrative

ER Visits & Hospitalizations*

Committee Review

*Indicates that for a case, you can enter multiple forms

Note: You may not have information to complete each of these forms for every
case. You will have fields within forms that you cannot complete. It is okay to
leave fields blank. It is recommended that you note in the Reviewer’s Notes box at
the bottom of each form if information was not available. This will help you write
your Case Narrative and help you to justify incomplete information to your
committee.

Edit a Case
1. Once you enter data into MMRIA, cases will be listed on the Line Listing Summary Page
(F I G U R E 1 3 ).
2. To view or edit a case, click directly on it to open the case’s Home Record page.
3. You can navigate to the form for review or revision by clicking on the “Case Forms” dropdown menu.
FIGURE 13

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FIGURE 14
3

Tip: At any point, you can return to the Home Screen by clicking “Summary” on the tool bar.

2. Actions
Clicking on the “Actions” button will display a drop-down menu displaying: Show Data Dictionary, View
Aggregate Report, and Export Data (F I G U R E 1 5 ). You can view a snapshot of all case information
entered via the Aggregate Report. Navigating to Show Data Dictionary, View Aggregate Report, or Export
Data will open a new window or tab in your browser.
FIGURE 15

Refer to the Data Dictionary and View Aggregate Report sections above for more information.

3. Print Blank
You have the option to print blank case forms (F I G U R E 1 6 ).

Steps for Printing Blank Forms
You can print blank forms from the “summary” page (F I G U R E 1 6 ) or while in a case
(F I G U R E 1 7 ).
Click on the “Print Blank” button in the tool bar to reveal the drop-down options
(F I G U R E 1 7 ).
Select individual forms or select “All” to print all of the blank forms.
FIGURE 16

FIGURE 17

Case Forms
The following sections will highlight the 11 case forms within MMRIA. Data may be entered in any order.
You will be directed to the Home Record after selecting “Add New Case” or selecting a previously entered
case for review or edit.

Menu Options
The menu options at the top of the page are different than those on the preceding forms. You will now
view the subsequent options:
Summary – returns you to summary page
Case Forms – displays a drop-down list of forms
Print Version – enables you to print a completed case or specific completed forms
Actions – enables you to populate core elements, show data dictionary, or view aggregate
report
Print Blank – enables you to print all blank forms or specific forms
FIGURE 18

Home Record Form
The Home Record form is divided into three components: Record ID, Date of Death, and Case Progress.

Record ID
The Record ID is automatically generated once you complete the Last Name, Year of Death and State of
Death fields and click in the Record ID field (F I G U R E 1 9 ). The Record ID consists of your 2-letter state
acronym + the year of death + a random 4-digit number.

FIGURE 19

2
3

Agency-Based Case Identifier
The Agency-Based Case Identifier field, (F I G U R E 2 0 ), is for internal reference and is based on your
jurisdiction or state system. If your jurisdiction does not use an internal reference number, you can leave
this field blank.
FIGURE 20

Case Progress Report
The Case Progress Report (F I G U R E 2 1 ) allows you to track your abstraction progress as you fill out each
form in MMRIA. You are presented with the following options:
Not Started
In Progress
Completed
Not Available
Not Applicable

FIGURE 21

Death Certificate Form
To navigate to the Death Certificate form, click on “Case Forms” and select “Death Certificate” (F I G U R E
2 2 ).

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FIGURE 22

Place of Last Residence and Geocoding
This section of the Death Certificate is specific to the address of the deceased, not the location of death,
i.e. name of the medical facility where the woman died. The full address, along with other identifying
information will not be visible to the Committee Reviewer role. MMRIA uses geocoding to support social
and health system context for case discussion and analysis and to enable distance calculations. A
complete address is required to successfully geocode an address. MMRIA’s “Get Coordinates” button is
linked to Texas A&M’s Geoservices geocoding system.
1. Enter the full address
2. Click on “Get Coordinates.”
3. Latitude and longitude values will appear.

FIGURE 23

Birth/Fetal Death Certificate – Parent Section Form
To navigate to the Birth/Fetal Death Certificate – Parent Section form, click on “Case Forms” and select
“Birth/Fetal Death Certificate- Parent Section” (F I G U R E 2 4 ). This form collects information only on the
parents, not the infant or fetus. Infant and fetus information is collected on the Birth/Fetal Death
Certificate – Infant/Fetal Section form.
FIGURE 24

Race and ethnicity of both parents (F I G U R E 2 5 AN D F I G U R E 2 6 ) are captured in the data system just as
they are recorded on the source document.

27
Note: Race Recode. Click on the “Recode” button to code race in accordance with the standards set by
the Office of Management and Budget (OMB) Race and Ethnic Standards for Federal Statistics and
Administrative Reporting2. This is used for analysis and aggregate reporting.
FIGURE 25

FIGURE 26

2. “Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity” is available from the OMB website at
http://www.whitehouse.gov/omb/fedreg/1997standards.

28
Complete addresses are required to populate the latitude and longitude fields; this information is used to
calculate distance in miles from Residence to Place of Delivery (F I G U R E 2 7 ). Place your cursor in the
field to generate the Distance from Residence to Place of Delivery.
FIGURE 27

Birth/Fetal Death Certificate – Infant/Fetal Section Form
To navigate to the Birth/Fetal Death Certificate – Infant/Fetal Section form, click on “Case Forms” and
select “Birth/Fetal Death Certificate- Infant/Fetal Section” (F I G U R E 2 8 ). To add a new record, click on
“View Record 1” (F I G U R E 2 9 ). To add information for more than one birth or fetal death, click on “add
new Birth/Fetal Death Certificate- Infant/Fetal Section form.”

29
FIGURE 28
1

FIGURE 29

After you click on “View Record 1,” the form below will appear on the screen (F I G U R E 3 0 ). If another birth
or fetal death should be added, click on “Case Forms,” navigate to “Birth/Fetal Death CertificateInfant/Fetal Section,” and repeat steps.

30
FIGURE 30

Autopsy Report
To navigate to the Autopsy form, click on “Case Forms” and select “Autopsy Report” (F I G U R E 3 1 ).
F I G U R E 3 2 illustrates the sections of the Autopsy Report form.
You may wish to copy and paste sections of the actual Autopsy Report into the Reviewer’s Notes section
at the bottom of the form. Remember to always exclude any identifying information about people or
facilities from Reviewer’s Notes text areas.

31
FIGURE 31

FIGURE 32

Prenatal Care Record Form
To navigate to the Prenatal Care Record form, click on “Case Forms” and select “Prenatal Care Record”
(F I G U R E 3 3 ). F I G U R E 3 4 displays the sections of the Prenatal Care Record form.

32
FIGURE 33

FIGURE 34

PR E N AT AL C AR E R E CO R D G R AP H S
Below the Routine Monitoring Grid, you will see three graphs: Blood Pressure, Weight Gain, and
Hematocrit. If you enter data for these values in the Routine Monitoring Grid, you can view it in these
graphs. To generate the graphs: enter values in the Routine Monitoring Grid above the graphs. Navigate
to any other form in MMRIA, and then navigate back to the Prenatal Care Record. Values will be
displayed in the graphs.
Note: If any line within a grid is blank, a default x-axis value of 1/1/1970 and y–axis values of 0 will
appear in the graphs. You can correct the graph by deleting the blank line in the grid, navigating to
another form, and navigating back to the Prenatal Care Record.

ER Visits and Hospitalizations Form
To navigate to the ER Visits and Hospitalizations form, click on “Case Forms” and select “ER Visits and
Hospitalizations” (F I G U R E 3 5 ). To add a new record, click on “View Record 1” (F I G U R E 3 6 ). To add
information for more than one ER visit or hospitalization, click on “add new ER Visits and Hospitalizations
form” (F I G U R E 3 6 ).
FIGURE 35

FIGURE 36

After you click on “View Record 1,” the ER Visits and Hospitalizations form will appear on the screen
(F I G U R E 3 7 ). If there were multiple ER visits or hospitalizations, click on “Case Forms,” navigate to “ER
Visits and Hospitalizations,” and repeat steps.

34
FIGURE 37

FIGURE 38

ER VI S IT S AN D HO S P IT AL IZ AT I O N S FO RM G R AP H S
Below the Vital Signs Grid, you will see four graphs: Temperature, Pulse, Respiration, and Blood
Pressure. If you enter data for these values in the Vital Signs Grid, you can view it in these graphs. To
generate the graphs: enter values in the Vital Signs Grid above the graphs. Navigate to any other form in
MMRIA, and then navigate back to the ER Visits and Hospitalizations form. Values will be displayed in the
graphs.

Note: If any line within a grid is blank, a default x-axis value of 1/1/1970 00:00:00 and y–axis values
of 0 will appear in the graphs. You can correct the graph by deleting the blank line in the grid,
navigating to another form, and navigating back to the ER Visits and Hospitalizations form.

Other Medical Office Visits Form
To navigate to the Other Medical Office Visits form, click on “Case Forms” and select “Other Medical
Office Visits” (F I G U R E 3 9 ). To add a new record, click on “View Record 1” (F I G U R E 4 0 ). To add
information for more than one Other Medical Office Visit, click on “Add New Other Medical Office Visits
form” (F I G U R E 4 0 ).
FIGURE 392

FIGURE 40

After you click on “View Record 1,” the form below will appear on the screen (F I G U R E 4 1 ). If there were
multiple Other Medical Office Visits, click on “Case Forms,” navigate to “Other Medical Office Visits,” and
repeat steps.

36
FIGURE 41

Location of Medical Care Facility
Remember that within the Reviewer Committee role, complete addresses will be de-identified – only the
state will appear.
Enter the full address.
Click on “Get Coordinates.”
The “Get Coordinates” button (F I G U R E 4 2 ) helps with geocoding for mapping. This is a two-step process
involving collecting latitude/longitude and FIPS block level information. The latitude and longitude can aid
analyses.
FIGURE 3

Medical Transport Form
To navigate to the Medical Transport form, click on “Case Forms” and select “Medical Transport”
(F I G U R E 4 3 ). To add a new record, click on “View Record 1” (F I G U R E 4 4 ). To add information for more
than one Medical Transport, click on “Add New Medical Transport form” (F I G U R E 4 4 ).
FIGURE 43

FIGURE 44

After you click “View Record 1,” the form below will appear on the screen (F I G U R E 4 5 ). If there were
multiple Medical Transports, click on “Case Forms,” navigate to “Medical Transport,” and repeat steps
above.

38
FIGURE 45

Social and Environmental Profile Form
The Social and Environmental Profile should be completed for each case that you abstract and
review. To navigate to the Social and Environment Profile form, click on “Case Forms” and select “Social
and Environment Profile” (F I G U R E 4 6 ).
FIGURE 46

Mental Health Profile Form
To navigate to the Mental Health Profile form, click on “Case Forms” (F I G U R E 4 7 ) and select “Mental
Health Profile” (F I G U R E 4 8 ).
FIGURE 474

40
FIGURE 48

Informant Interviews Form
To navigate to the Informant Interviews form, click on “Case Forms” and select “Informant Interviews”
(F I G U R E 4 9 ). To add a new record, click on “Record 1” (F I G U R E 5 0 ). To add information for more than
one Informant Interview, click on “Add New Informant Interview form” (F I G U R E 5 0 ).
FIGURE 49

FIGURE 50

After you click on “View Record 1,” the form below will appear on the screen (F I G U R E 5 1 ). If there were
multiple Informant Interviews, click on “Case Forms,” navigate to “Informant Interviews,” and repeat steps
above.
FIGURE 51

Case Narrative Form
To navigate to the Case Narrative form, click on “Case Forms” and select “Case Narrative.”
HO W T O US E T H E C AS E N AR R AT I VE FO R M
Within the Case Narrative form, you will see the Reviewer’s Notes from the various forms carried over into
one place. At the very bottom is a text box labeled Case Narrative – this is where you can write your case
narrative to print for your committee. You may use the template provided and edit it as needed.

42
You can copy and paste from the Reviewer’s Notes boxes into the Case Narrative box at the very bottom
to write a comprehensive Case Narrative. To copy and paste from the Reviewer’s Notes boxes, highlight
the text you wish to copy, right-click, and select Copy. Then place your cursor in the Case Narrative box
at the very bottom of the form, right-click, and select Paste.
You can also copy and paste text from Word, Notepad, or other documents outside of MMRIA. Text may
be copied into MMRIA; however, formatting will not be maintained (e.g. bold, italics, and underlines).
Pasting images or other file types is not currently supported in MMRIA
When you have completed your case narrative, you can preview or print it by going to Print Version and
clicking “Case Narrative.” You will see the Case Narrative displayed there (F I G U R E 5 2 ) .
FIGURE 52

Committee Decisions Form
To navigate to the Committee Decisions Form, click on “Case Forms” and select “Committee Decisions.”
HO W T O US E T H E CO M M I TT EE D E CI S IO N S FO RM
The Committee Decisions Form is perhaps the most important form within MMRIA, because it captures
the findings of your committee and helps your committee prioritize action. It is crucial to assign a person
to take notes on the “paper” version of the Committee Decisions Form (Appendix) BEFORE each case
goes for review. This person may or may not be the same person who abstracted the case. You can also
give copies of the form to each committee member for each case and collect the forms at the end of each
meeting in order to capture all possible input on a case. Once the meeting has finished and a case is
closed, an abstractor or other assigned data entry person should enter the findings into the system as
soon as possible.
Though the formatting differs, the content of the “paper” version of the form matches the content of the
Committee Decisions Form within the system (F I G U R E 5 3 ) .

FIGURE 53

G. DATA ANALYSIS
Data Structure
The MMRIA data structure is a hierarchical database with two levels in the hierarchy. The first level is
comprised of forms for which you can have only one per case (Single Forms) and forms for which you can
have more than one per case (Multiple Forms). The second level is composed of grids that exist within
the Single and Multiple Forms.

Forms and Grids

SINGLE FORMS

Death Certificate
Birth/Fetal Death
Certificate- Parent
Section
Autopsy Report
Prenatal Care Records
Mental Health Profile
Social and Environmental
Profile

M ULTIPLE FORM S

Birth/Fetal Death
Certificate- Infant/Fetal
Section
ER Visits and
Hospitalizations

GRIDS

Grids exist within single
and multiple forms. See
Field Types for more
details.

Medical Transport
Informant Interviews
Other Medical Office
Visits

Committee Decisions
Case Narrative

The data is stored by MMRIA in JSON (JavaScript Object Notation) format. While it is possible to import
JSON-formatted data directly into some data analysis tools, MMRIA also has a data export function that
provides CSV files for analysis. These data files are structured like a relational database.

Core Elements Report
The Core Elements Report is now a report rather than a data entry form as it was in MMRDS. The data
used to create this report comes from the other forms in MMRIA. You can print this report to support case
review processes and export it as a data table to support MMRC analyses.

Data Export
Data tables are exported from MMRIA as CSV files. All 1st-level Single Forms are merged and put out as
one file, named mmria_case_export. The Core Elements report is exported as a separate CSV file,
named core_mmria_export. A separate CSV file is also created for each of the five 1st-level Multiple
Forms and each of the 53 grids. The CSV files are named to reflect the forms from which they originated
and the contents of the grid.
In addition, there are two mapping files that are exported with the CSV files. One is for the forms and
grids (field_mapping) and the other is for the Core Elements (core_field_mapping). These mapping files
are a reference tool for you, providing the File name, the Path, and the Variable name.
All files are exported into a folder called “Export,” which is located at C:\temp\mmria-export. Once
exported, these files are ready for analysis. Some analyses may require you to merge two or more of the
exported CSV files.

Export Data
1. On the top menu bar, navigate to Actions  Export Data. A new tab will open in your browser
titled “Submit Export Data Request.”

2. Choose either “Export Core Data to csv format” or “Export All Data to CSV format.”
3. A new line item will appear in the Export Request History with “Confirmation Required” in the
Status column. Confirm your request by selecting the “Confirm” button.
4. The “In Queue” message will appear. This process can take several minutes and may be slower
or faster depending on the number of cases you have in MMRIA. The core export is generally
faster than the export of all data.
5. When the “Download” button appears, click Download and a zip file will be generated.* The
name of the zip file is formatted as an ISO Date and Time String: YYYY-MM-DD T hh:mm:ss Z.
*It may be necessary to clear your browsing history prior to downloading the files. To do so in
Google Chrome, select Settings. Under Advanced, select Privacy and Security, then select Clear
Browsing Data.
6. Open the zip file to view the individual csv files.
7. Save the zip file to your local computer for offline access. You can also re-run the download of
any export at a later date.

46
You may wish to delete previous exports from your Export Request History. This is recommended to
improve the speed of future exports. Save copies of any previous data exports to a secure location, and
then use the “Delete” button to remove them from your Export Request History.

Relating Your Data:
Any of the csv files can be imported into the software of your choice for analysis. There will be times that
you will want to relate two or more of the csv files.
Single-Single
Single-Multiple
Single-Grid
Multiple-Multiple
Multiple-Grid

1st level to 1st level
1st level to 1st level
1st level to 2nd level
1st level to 1st level
1st level to 2nd level

1 key used
1 key used
1 key used
1 key used
3 keys used

Key is _id in both sources
Key is _id in both sources
Key is _id in both sources
Key is _id in both sources
Keys in Multiple Form Files are _id and
record_index, and in the Grid Files are _
id and parent_record_index.

Data Export: Grids
Grids are used to capture data in cases where users have more than one entry per form and the entry
has related fields. One example is the Toxicology Grid on the Autopsy Report form.
You can input multiple substances and indicate characteristics for each substance, such as
concentration, unit, and level, as illustrated below.
T O XICO LO G Y G R ID O N T H E AUT O PSY R E P O RT FO RM

Substance

Concentration

Unit of Measure

Level

Comment(s)

A
B
C

Below is a list of each form that contains at least one grid, and the numbers of grids contained within that
form.
SI NG L E FO RM S:
Death Certificate [1 Grid]
Autopsy Report [4 Grids]
Prenatal Care Record [13 Grids]
Social and Environmental Profile [5 Grids]

47
Mental Health Profile [2 Grids]
Committee Decisions [3 Grids]
M ULT IPLE FO RM S:
Birth/Fetal Death Certificate – Infant/Fetal section [1 Grid]
ER Visits and Hospitalizations [13 Grids]
Other Medical Office Visits [10 Grids]
Medical Transport [1 Grid]

Analysis of MMRIA Data: Considerations
You are most likely to use only one to three forms, with their associated grids, during data
analysis. The Core Elements, Committee Decisions Form, and Death Certificate, along with
their associated grids, together provide the data an analyst would need to support both
routine and topic-specific analyses.
Some forms and grids may never be used in analysis. This is because they are there for
other purposes, such as case narrative development.
Variables in the CSV output data files were named using the following convention:
o
o
o

The first three letters of the first three words of the form name +
The first letter of each word in the MMRIA path +
The first five letters of the last word in the MMRIA path

For example: the variable for place type of the medical care facility on the Other Medical
Office Visits form would be: path:
other_medical_office_visits/medical_care_facility/place_type) is omovmcf_p_type)
The path and variable names are located in the field_mapping csv file.
If there is a duplicate variable name based on this algorithm, MMRIA creates a unique
alphanumeric name. In future releases of MMRIA, these alphanumeric names will be
replaced with a descriptive name.

Example Analyses
Below are some examples of questions that you might pursue, along with the required data files.
What proportion of pregnancy-associated deaths are pregnancy-related?
Data file: Core Elements
What are the leading underlying causes of pregnancy-related death? How do they vary?
Data file: Core Elements
What are the most and least preventable underlying causes of pregnancy-related death?
Data file: Core Elements
What are the common contributing factors of the leading and most preventable causes of
pregnancy-related death?
Date files: Core Elements merged with Contributing Factors Grid
What recommendations for action were made for the leading and most preventable causes of
pregnancy-related death?
Data files: Core Elements merged with Committee Recommendations Grid

48
What recommendations for action for the leading and most preventable causes of pregnancyrelated death would have the largest impact?
Data files: Core Elements merged with Committee Recommendations Grid

H. REVIEWING CASES
If you are a Committee Member wishing to view cases in MMRIA, you will need to contact your User
Admin(s) to receive access to MMRIA. Refer to the Logging In section for guidance.

How to Use the Committee Reviewer Role
Once you have logged in, you will see a Line Listing Summary page displaying all cases that have been
entered into MMRIA by your committee’s abstractors. Note that the first and last names have been
redacted and replaced with “de-identified” for each case.

Note: As a committee reviewer, you can only view cases. You cannot edit or delete cases.
To view a case, click directly on a case to open its Home Record page. To learn more about the contents
each case form, refer to the Case Forms section of this User Guide.

De-identified Fields
Within each case, you will see all of the forms that your committee’s abstractors can access. However,
you will see that the following fields are de-identified:

Form

Fields

Home Record

First Name, Middle Name, Last Name
Month and Day of Death
Agency-Based Case Identifier

Death Certificate

Time of Death
Local File No.
State File No.
Place of Last Residence- Street, City, Zip Code, County, Latitude, Longitude
Month and Day of Birth
City of Birth
Month and Day of Injury
Time of Injury
Place of Injury (Place Name)
Location Where Injury Occurred- Street, City, Zip Code, County, Latitude,
Longitude
Place of Death- Facility Name, Street, City, Zip Code, County, Latitude,
Longitude

Form

Fields

Birth/Fetal Death
Certificate- Parent
Section

Delivery Facility NPI Number, Delivery Facility Name
Attendant's NPI
Name of Facility Mother Transferred From
Facility of Delivery Location Street, City, Zip Code, County, Latitude,
Longitude
Father's First Name, Middle Name, Last Name
Father’s Month and Day of Birth
Father’s City of Birth
Mother’s First Name, Middle Name, Last Name, Maiden Name, Medical
Record Number
Mother’s Month and Day of Birth
Mother’s City of Birth
Location of Residence- Street, City, Zip Code, County, Latitude, Longitude
Month and Day of Last Live Birth, Last Other Pregnancy Outcome, Last
Normal Menses, First Prenatal Care Visit, Last Prenatal Care Visit

Birth/Fetal Death
Certificate- Infant/Fetal
Section

Newborn/Fetus First Name, Middle Name, Last Name
State File No., Local File No., Medical Record No.
Facility- Name, City and State

Form

Fields

Autopsy Report

Month and Day of Autopsy
Jurisdiction

Prenatal Care Record

Prenatal Care Record No.
Location of Primary Prenatal Care Facility- Street, City, Zip Code, County,
Latitude, Longitude
Month and Day that Birth Control was Discontinued
Month and Day of: Last Normal Menses, Estimated Date of Confinement
(Estimated Date of Delivery), First Prenatal Visit, First Ultrasound, Last
Prenatal Visit
Name, City and State of Intended Birthing Facility
Dates of: Routine Monitoring Other Laboratory Tests, Diagnostic
Procedures, Problems Identified, Medications/Drugs and Adverse Reactions
During Pregnancy, Pre-Delivery Hospitalizations or ER Visits, Medical
Referrals, Prenatal Care Other than the Primary Provider

ER Visits and
Hospitalizations

First Name, Middle Name, Last Name, Maiden Name
Medical Record Number
Month and Day of Arrival at Hospital/ER, Admission to Hospital, Discharge
from ER/Hospital
Facility Name
Facility NPI Number

Form

Fields

Facility Street, City, Zip Code, County, Latitude, Longitude
Date/Times of: Internal Transfers, Physical Examinations and Evaluations,
Psychological Examinations and Assessments, Laboratory Tests, Pathology,
Vital Signs, Medications, Surgical Procedures, Blood Transfusions or Blood
Products, Diagnostic Imaging and Other Technology, Referrals and
Consultations
Month and Day of: Onset of Labor, Rupture of Membranes,
Birth Attendant(s) NPI Numbers

Other Medical Office
Visits

Month and Day of Medical Office Visit

Medical Record No
Location of Medical Care Facility- Street, City, Zip Code, County, Latitude,
Longitude
Date/Times of: Vital Signs, Laboratory Tests, Diagnostic Imaging and Other
Technology, Physical Exams, Referrals and Consultations, Medications

Medical Transport

Month and Day of Medical Transport
Date/Times of: Transport Vital Signs, Departure, Arrival, Patient Contact
Place of Destination

Social and Environmental
Profile

Date/Times of: Social and Medical Referrals

Form

Fields

Names of Sources of Social Services Information

Mental Health Profile

Date of Screening

Informant Interviews

Informant Name
Month and Day of Interview

Note on Display:
All de-identified Times display as “12:00 AM.”
All de-identified Dates within grids display as “2001-01-01.”
All de-identified Date/Time fields within grids display as “0001-01-01 00:00:00.”
All de-identified text fields display as “de-identified.”

Note: because dates are de-identified, it is important that your committee’s abstractor(s) enter
gestational ages or days postpartum for all events.

I. USER ADMINISTRATION
MMRIA utilizes the CouchDB security system for user administration. The User Admin role assigns user
names and passwords to each MMRIA user within a jurisdiction. Through the MMRIA interface, the User
Admin can assign any of three user roles to a user: Abstractor, Committee Reviewer, or Form Designer.

For information on who should be assigned what user role, refer to the User Roles section above.

Note: The initial User Admin role is created during the setup of the MMRIA database through the
CouchDB interface. Additional User Admins can be assigned through the CouchDB interface as
needed. It is recommended that one or two trusted people within your jurisdiction have User Admin
roles assigned.

If you are a User Admin, log in with your user name and password. From the Home Screen, click on
“Actions,” then “Manage Users.”

Within the “Manage Users” page, you will see a list of all users and the option to add new users, remove
users, and add or remove roles for users.

Add Users
To add a new user, scroll to the bottom of the page and enter a username (recommended: use emails as
usernames). Then click the “Add New User” button.

The new user will appear. You must then add a role or multiple roles for the user. For information on user
roles, refer to the User Roles section above.
Once you have added a user role, click the “save user changes” button. Currently, each time you make a
change and click the “save user changes” button, you must reset the password. Changes to user roles
will take effect immediately.
The MMRIA Team recommends the User Admin configure usernames to be users’ email addresses. In
the future, the system will generate automatic emails to notify users of account changes. Currently, the
User Admin needs to provide each user with his or her username and password outside of the system.
The User Admin also must manually reset any user passwords as needed. In the future, users will be
able to reset their own passwords and will have usernames sent to them through email.
Passwords must be at least eight characters. There are no other inherent password restrictions.
Usernames must be at least five characters; again, using email addresses as usernames is
recommended.

Remove Users
The functionality to remove a user does not yet exist in the user interface. To disable a user account, you
must change the user’s password. Changing the password will immediately take effect, preventing the
user from logging in.

A Note on Users with Multiple Roles
It is best to assign each user one role. If a user is assigned to a committee reviewer role along with an
abstractor role, the user will see the system as a committee reviewer (de-identified values in fields).

J. ADDING FIELDS AND FORMS
The Form Designer role allows you to customize forms with a tool called the Metadata Editor. With Form
Designer access, you can add, edit, and delete fields and forms. The MMRIA Team cautions against
adding or editing forms or fields, because MMRIA aims to standardize a national system and because
maintaining any changes to the “core” MMRIA forms requires effort within your jurisdiction. Before
choosing to add or edit fields, you should consider:
Can the information be captured in a Reviewer’s Notes field?
Is it data that other states should also be capturing?
If you decide that a new field or form is needed please reach out to MMRIAsupport@cdc.gov, for
guidance on using the Form Designer role and the Metadata Editor.

K. FREQUENTLY ASKED QUESTIONS
I accidentally deleted a record – can it be recovered?
Deleted records do not get exported to a data set and are marked for deletion; contact
MMRIAsupport@cdc.gov if you need assistance to recover a deleted record.

Will I see other abstractors’ cases?
Yes, if your jurisdiction is hosting MMRIA on a file network or web server. However, if MMRIA is hosted
on a desktop you will see only your own cases.
How should I handle a “false positive” case?
False positives, or cases where a woman was not in fact pregnant within one year of her death, should
be entered into MMRIA. They can help your state monitor the number of false positives you encounter
and analyze the characteristics of these false positives. To enter a false positive, complete all of the data
on the Home Record and the Death Certificate form. Then, on the Committee Decisions Form, select “Not
Pregnancy-Related or Associated (i.e. False Positive).”
Can CDC or other states see my state’s data?
No, CDC and other states cannot view your data unless you choose to share it.

Can we divide a case among multiple abstractors?
If MMRIA is hosted on a desktop, it cannot be divided among multiple abstractors. If MMRIA is hosted
centrally, it can be divided among multiple abstractors providing they do not work in the same case at the
same time.

Why does MMRIA ask for the same information multiple times on various forms (i.e. death
certificate, birth certificate, and prenatal care)?
Names and demographic information are often inconsistent across source documents. Names can also
change from event to event. Names may be misspelled or get reversed – this can be especially true with
uncommon names. Inconsistencies in names and demographic information, or missing demographic
information, across source documents can provide context around an event in a woman’s life. For this
reason, CDC recommends that information should always be abstracted exactly as it is on the source
document. Do not cut and paste from previous entries.

APPENDIX: COMMITTEE DECISIONS FORM

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