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May 9, 2011

Raising Cancer Care
By Selena Chavis
For The Record
Vol. 23 No. 7 P. 10

It may require some heavy lifting, but improving cancer registry data can elevate quality care and patient outcomes to new heights.

Data collected by local cancer registries have long played a critical role in helping public health professionals understand and address the greater cancer epidemic. And while the industry at large recognizes the potential of cancer registry data to “do good” in the global scheme of the disease, experts stress that opportunities to tap into that potential within the framework of a hospital or a health system are often left lying on the table.

“Many times, [registry professionals] have their state registry in mind as a customer … but they need to remember that their own facility is a customer. You want the information to be useful to the organization,” says Dianne Cleveland, RHIA, CTR, national compliance manager for Kforce Healthcare.

Organizations such as Aurora Health Care are finding that while cancer registry data can help improve patient care, their ability to effect change, like any compilation of data, is only as good as the quality of information gathered. Lisa Robinson, RHIA, CTR, system director for clinical data registries at Aurora Health Care, points out that the organization’s registry data are scrutinized on a near-constant basis to maintain a level of quality that will benefit providers who access the information.

“Without quality in the cancer registry, you really can’t link it with other systems … unless you have solid core registry data,” she explains, pointing out that the integrated health system, with site locations in more than 90 communities throughout eastern Wisconsin and northern Illinois, sees potential in linking the data to outcomes in anticipation of quality assessment for pay for performance. “It’s important for the physicians to have confidence in the data. Engaging physicians to review information contained within the registry reinforces their faith as well as knowledge base regarding the accuracy, completeness, and depth of information contained within.”

Cancer registries have undergone sweeping reform over the past two years that many believe has the potential to vastly improve data quality. However, experts acknowledge there are growing pains that must be overcome. Couple the changes with an ever-evolving HIT landscape and the need for better physician documentation, and many registrars face an uphill battle to maintain accuracy and quality.

“The [opportunities and challenges] are rapidly evolving. We’re just going to have to continue to stay educated,” notes Laurie Hebert, RHIA, CCS, CTR, CCS-P, director of cancer registry services at Care Communications. “The key to all of this is education.”

A Day in the Life
For Aurora Health Care to maintain the quality needed for data use throughout its large network of providers and hospitals, Robinson says the cancer registry group must conduct scheduled random analyses. While the minimum requirement for a random sample review as a Commission on Cancer-accredited cancer program is 10%, Robinson says Aurora Health Care is reviewing more than 50% of the data collected.

“We get so many requests for data,” she says. “Being part of an integrated health system, many are looking at quality to make sure our physicians are complying with evidence-based best practices.”

Robinson says her department runs daily reports, sorting through information and passing problem areas back to abstractors as they are found. The ability to run reports that include abstractors’ initials is crucial to this process, she adds, because the information can be corrected in a timely manner, and the constant feedback ultimately improves future abstracted data.

“We just keep doing that over and over again. In some registries, it’s not possible to identify the abstractor on the reports, so it’s much harder to keep clean,” Robinson says.

The automated GenEDITS software tool provided by the North American Association of Central Cancer Registries (NAACCR) is invaluable for maintaining data accuracy, according to Cleveland, who points out that many managers also employ visual editing techniques. In fact, some states have enacted visual editing standards to use alongside the computer valuation checks.

In addition to GenEDITS, Robinson says the lines of communication between abstractors and physicians need to be open and productive to maintain high-quality data. For example, when problems arise with physician documentation, registry professionals can increase the likelihood of receiving a quick response if they make the process as straightforward as possible.      

“Look for ways to make it easy for the physician to review data,” Robinson says. “For example, provide a one-page synopsis of the issue rather than handing the physician a 4-inch [-thick] record.”

While the quality of physician documentation is key to maintaining proper data quality in the cancer registry, Hebert points out that it’s the job of the abstractor to identify and correct these issues. In fact, she believes one of the greatest challenges facing the daily operations of a cancer registry is the ability to find and retain qualified staff.

“You need to have highly qualified, trained staff who are capturing the information,” she says, pointing out that abstracting often entails sorting through multiple records to capture the complete picture of a patient’s journey with cancer. “You want to be able to track that patient no matter where they are. … It takes a highly qualified, trained individual to capture all that information.”

Technology: The Good, Bad, and Ugly
Herman R. Menck, BS, MBA, CPhil, FACE, project manager with the Cancer Surveillance Program of Los Angeles, recently conducted an informal survey of 30 registrars who are considered leaders in the field to garner their thoughts on how the use of EHRs will affect cancer registry data.

“The responses I got were mostly positive. People are finding EHRs help greatly with efficiency and quality,” he notes, adding that a similar survey he conducted in 2007 yielded a much more negative response. “It’s true, though, that in the responses, there is a lot of information to suggest that the devil is in the details. One person said they had to log on eight different times to get all the information.”

While the HIT movement has created efficient access to information that previously might have been located in numerous locations, industry professionals point out that EHRs are clearly not customized for the cancer registry. Plus, registrars often face the added challenge of having to access information from multiple facilities or sources—all of which may or may not have an EHR in place.

“Some comes electronically and on paper. A lot of times, physician offices have paper records or hybrid records,” Cleveland explains. “It can be such a variety of places to go for information as well as formats for delivery.”

Cancer registrars need to get involved in the EHR implementation process early, if at all possible, to ensure that the needs of the registry are out on the table, according to Hebert, who notes that sometimes an EHR may be poorly organized, leading to holes in information gathering.

“In organizations where the EHR is not fully implemented, the cancer registry needs to step up to the plate and become part of the implementation team,” she says. “If we are sitting at the table, sometimes we see information other departments don’t because we are so encompassing.”

Cleveland believes Health Level Seven International (HL7) standards have the potential to help create efficiencies for capturing data. “Hopefully, in the next five years, we will see that change occur,” she notes, adding that while HL7 is a much-anticipated standard, it is still limited when considering the needs of the cancer registry.

“Right now, there are challenges to getting a broader picture of the patient. The data elements are limited and don’t include everything needed. Not everyone [other departments] collects data like the registry does,” she says.

Robinson notes that while EHRs will certainly address some of the issues surrounding data accessibility, registrars should be wary of accepting the information as completely accurate. “Technology will help in terms of pulling down data from various areas, but there’s still going to be a need for data registrars to ensure the data is correct,” she explains. “What we’ve seen is that physician and nursing documentation in the EHR isn’t audited for accuracy as much as it should be.”

As PHRs continue to evolve, Cleveland believes tapping into their information could greatly benefit data quality and accuracy. “Patients are going to create their own personal records more. This could be a reliable method for obtaining information because it comes directly from the patient,” she says.

A Clear Understanding
Industry experts agree that the sweeping changes made to cancer registries over the last two years have impacted productivity as registry professionals continue to get up to speed on new procedures. While growing pains exist, many in the industry recognize the potential of these changes.

“On the one hand, the registrars are a little overwhelmed, but on the flip side, we are really happy those new data elements are there,” Robinson says. “It’s what the physicians have wanted, and it’s raised the awareness of the registry.”

To make use of these expanded elements, the data quality has to exist and the registrars have to be able to capture it—putting education at the forefront, according to Hebert.

“When all the changes came, if organizations didn’t train their staff, they may not be aware of the need to document certain things,” she explains. “There is more opportunity to gather more information, but it’s an all-encompassing thing. The physicians have to be educated about what needs to be in there.”

Offering an example of potential holes that may exist in physician documentation and education, Hebert poses this question: “Have your physicians been educated that we are now capturing the actual multigene signature methods and scores through our Collaborative Stage Data Collection System efforts?”

The Collaborative Stage Data Collection System Coding Manual and Instructions notes that “multigene testing is usually done for node-negative patients to predict risk of recurrence within a specified time period or to predict the likelihood that the patient will respond to specific types of chemotherapy. Multigene testing helps tailor treatment for the woman’s specific cancer characteristics. The most common and best known multigene test method is the Oncotype DX Breast Cancer Assay.”

“Proper collection of this data now can lend itself to being incorporated into future quality studies,” Hebert says. “If physicians are performing these tests and are aware that we are capturing this data, then they can ensure that the documentation is available to us for entry into the cancer registry database.”

Establishing good relationships with physicians is crucial to success, according to Cleveland, who points out that “it can be challenging but, a lot of times, physicians are on the cancer committee and understand why the information is needed.”

As the role of the cancer registry continues to expand, Robinson suggests that registry professionals will need to have a solid understanding of biology, anatomy, physiology, and treatment guidelines on a scale that was not required in the past.

“Education is key. I feel very strongly about needing to send registrars to clinical conferences,” she says, pointing out that clinical knowledge is something that has been historically lacking in a registrar’s background. “I have several higher [clinical] level professionals working for us in the registry. They really fit well in this system because they are extremely knowledgeable about how all the data fits together and what researchers might be interested in studying.”

Alongside an expanded knowledge base, Hebert suggests that registries conduct regular internal education. “I encourage managers to do QA [quality assurance] on staff and have staff do QA on each other,” she says, adding that one way to see whether everyone is on the same page is to have each staff member abstract the same chart. “Even as managers, there is always room for learning and improvement.”

The last two years were big years for changes in the cancer registry, but professionals fully expect that “change” will become the norm going forward.

“As they add data elements to the cancer registrar’s plate, it just proves that we are the best source for that information,” Cleveland says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.