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May 25, 2009

Advanced Placement — The Effects of New CTR Education Requirements
By Alice Shepherd
For The Record
Vol. 21 No. 11 P. 10

In 2006, the Council on Certification of the National Cancer Registrars Association (NCRA) announced changes in the education requirements that make cancer registrars eligible to sit for the certified tumor registrar (CTR) credentialing examination. To give applicants the opportunity to fulfill the prerequisites, the NCRA began a phase-in of changes in 2008, which continue this year and will be completed by 2010. At the center of the changes is the requirement of an associate’s degree in an allied health field (as defined by the NCRA) in addition to the work experience that has traditionally been required for credentialing. What will this mean for CTRs and the healthcare organizations that employ them?

What Prompted the Change?
The changes resulted from recommendations that came out of a 2005 study commissioned by the NCRA and conducted by the University of California, San Francisco titled “Frontline Workers in Cancer Data Management: Workforce Analysis Study of the Cancer Registry Field.” Researchers polled registry professionals across the country in hopes of developing an understanding of the current cancer registry workforce, focusing on demographic profiles; factors impacting supply and demand; workforce size, projections, and vacancy rates; education and pathways to enter the field; and career satisfaction and retention.

The survey revealed that cancer registrars were generally satisfied with their jobs yet frustrated by a lack of support and recognition, inadequate compensation, and difficulty keeping up with changing standards. Registrars also complained that there were few practical advantages to earning certification because some employers did not value it. The bottom line was that they wanted greater visibility, awareness, recognition, and promotion opportunities.

The research also showed that the lack of a college degree was a problem; registrars needed more education in the areas of anatomy, physiology, and medical terminology. If a college degree were to be required, 55% of the survey respondents felt that an associate’s degree would best prepare students for work in a cancer registry.

“NCRA’s workforce study compared the cancer registry discipline to similar fields in healthcare and made recommendations on how the profile of the CTRs could be raised,” says Michael Hechter, the NCRA’s director of membership and certification. “The council concluded that an associate’s degree requirement was necessary to elevate and promote the profession, plus show CTRs as dependable professionals who have the spectrum of knowledge and competence needed to advance cancer research.”

New Requirements
The NCRA’s Council on Certification administers the semiannual CTR examination in which candidates must meet eligibility requirements through a combination of experience in the registry field and educational background. However, until 2008, Eligibility Route 1 had no higher education requirements. Under this route, candidates for the CTR credentialing exam needed only two years of work experience in a cancer registry and a minimum education of a high school or a general equivalency diploma. That pathway was chosen by most exam candidates, which meant they did not need to prove a formal background in medical terminology or human anatomy and physiology.

In 2008, a requirement of two semesters of coursework in human anatomy and/or physiology was added to the Eligibility Route 1 requirements. In 2009, additional course work was added. For the remainder of this year, Eligibility Route 1 now requires a minimum of two years of full-time (24 months or 3,900 hours) or equivalent experience in the cancer registry field and the equivalent of one year (12 credit hours) of college education that includes two semesters or three quarters of human anatomy and/or physiology, one semester of medical science/biology, plus a college-level course in medical terminology.

Also in 2009, Eligibility Route 2 was amended to require the successful completion of 160 hours of work practicum in a CTR-staffed cancer registry and successful completion of an NCRA-accredited cancer information management associate’s degree, or successful completion of an NCRA-accredited formal education program and successful completion of a minimum of an associate’s degree or equivalent (four semesters/six quarters). The other Eligibility Routes—through which many RHIAs and RHITs achieve exam eligibility—previously required an associate’s or higher degree and remain unchanged.

In 2010, Eligibility Route 1 will be eliminated, meaning that all candidates for the CTR exam must apply through another route and have a minimum of an associate’s degree. Currently, working registrars who have already passed the exam and been certified by the NCRA will not be affected.

“In 2007, the last year before any changes were to take effect, NCRA saw a big increase in exam candidates—623 compared with a past average of over 500 candidates per year,” says Hechter. “In 2008, when the first changes were implemented, the number of candidates dipped to 345. We estimate that in 2009 and 2010, the numbers will be back closer to the average as applicants catch up to the changes in eligibility routes.”

Adding the associate’s degree requirement is also expected to increase exam pass rates, which had been declining from a nearly 90% pass rate in 1983 to less than 60% in 2004, according to the NCRA’s workforce study. “By specifying more demanding eligibility requirements and coursework, the council wants to help prepare the candidates better,” says Hechter. “Last year, we already saw a small increase in the pass rates, which was encouraging.”

Education for the Real World
The CTR exam consists of 250 multiple-choice questions. “Fifty of these are open book and get to the heart of cancer registry work—the coding and abstracting of the data that is so critical to cancer research,” says Hechter. “The Council on Certification regularly reviews exam questions to ensure they are appropriate for the current practice of cancer registrars.”

In addition to the council’s work, the NCRA’s Formal Education Program Review Committee regularly analyzes changes in eligibility requirements for the CTR exam to provide NCRA-accredited education programs with timely information about the exam. “Since the associate’s degree requirement was introduced, most programs have maintained their certificate or degree programs as originally designed,” says Hechter. “However, some programs specifically designed to prepare students for cancer registry work have recently become accredited.”

North Carolina’s Davidson County Community College took a proactive approach after learning of the new NCRA requirement four years ago. It created a cancer information management program specifically for students planning to seek employment as CTRs. Developed in consultation with the NCRA and the North Carolina Community College system, the program leads to an associate’s degree in applied science in cancer information management and includes crucial courses in medical terminology, anatomy, physiology, and pathophysiology.

“We’re graduating our third class this spring,” says Jeannine Woody, RN, MSN, dean of health, wellness, and public safety at Davidson. “The full program takes two years, but students who already hold an associate’s degree in health information technology can complete the additional requirements in nine months.”

All of Davidson cancer information management courses are online, and most of the other courses required for the degree are offered in the evening, online, or in a hybrid form that combines Internet and classroom. “We want to make cancer information management education available across the nation,” says Woody. “We’ve been contacted by students from Florida, Maryland, and Hawaii.”

Will the CTR Shortage Get Worse?
“Two percent of cancer programs were denied approval by the American College of Surgeons Commission on Cancer (ACoS CoC) after being surveyed in 2006,” says Laurie Hebert, RHIA, CCS, CCS-P, CTR, director of cancer registry services at Care Communications. “This can spell trouble financially and from a compliance perspective for hospital administrators, and the task of maintaining compliance is only going to get more difficult as changes in the educational requirements for CTRs further limit the already thin supply of these critically important professionals going forward. The pending changes will essentially make it more difficult for interested professionals to qualify to sit for the exam. This will likely result in a reduced supply of CTRs.”

However, Hebert agrees that adding the associate’s degree requirement was a step in the right direction. “Until recently, hospitals could simply assign someone working in the HIM department or other staff position to work as a cancer registrar, even when that person had no prior registry experience, and many registrars got started that way, via on-the-job training,” she says. “Two years later, they took the exam with no formal education in anatomy, physiology, or medical terminology. An associate’s degree will ensure that registrars have the educational background they need to be successful.”

Hebert also believes that more demanding educational requirements should promote the professionalism of CTRs and raise the discipline as a whole to a higher level that garners more respect and commands higher salaries. “The CTR credential has not always been highly valued by administrations,” she says, “so why should a cancer registrar bother with the exam if certification did not bring higher pay or professional recognition?”

“When I first heard about the requirement for an associate’s degree, I thought it was a good idea,” says Lisa Robinson, RHIA, CTR, regional manager of clinical data registries for Aurora Healthcare, a system of 13 acute care hospitals and 12 cancer clinics in Wisconsin. “People coming into the profession with an associate’s degree would already have a solid foundation in medical terminology, pathophysiology, and statistical analysis. But the more I thought about it, I began to wonder if we’re not shooting ourselves in the foot by decreasing the already low supply of eligible CTRs.”

After discussing the issue with some of her experienced registrars, Robinson suggests that a certificate program could possibly be an appropriate alternative instead of a two-year degree. “Sometimes, even though people have an associate’s or bachelor’s degree, they later realize that cancer registry is not a good fit for them,” she notes. “A certificate program would take less time while giving them a taste of the profession sufficient to decide if they are really suited for it. They could then work in a registry for two years before taking the exam.”

On the other hand, Robinson has observed that some of her best employees are those who have had a formal education. In fact, at Aurora, an associate’s degree or higher has been a requirement for cancer registrars for the past eight years. When the requirement was implemented, registrars who did not hold degrees were grandfathered in.

The majority of Robinson’s CTRs are RHITs or RHIAs, and there is even a registered nurse and an employee with a master’s of public health. “Some came to us because I gave talks about our profession at colleges,” she says. “Since they already had the HIM education, they were easy to train and excelled as registrars. The bottom line is that a good educational foundation makes CTRs more successful.”

ACoS CoC standards state that each accredited cancer program must have at least one CTR on staff or have a CTR supervising staff members who lack the CTR credential. “There is a solution for organizations that want to maintain their CoC accreditation but lose their CTRs or do not have a cancer registrar who is eligible to sit for the exam,” says Hebert. “They can bring in independent contractors to supervise noncredentialed registrars in the interim. Independent contractors can also assist with on-the-job training of new CTRs as a supplement to their academic training when internal CTRs are too busy or uncomfortable as trainers.”

Hechter believes the associate’s degree requirement will actually make it easier for healthcare entities to attract and retain qualified registrars. “CTRs will get more respect in organizations, including HR [human resources] departments, which will hopefully translate into higher salaries,” he says. “CTRs see themselves as equal players in the fight against cancer and certainly should be rewarded accordingly. As newly credentialed CTRs enter the workforce, it may encourage organizations to invest in additional professional development for their current CTRs, so they can continue to learn, grow, and become more highly respected.”

Even without support from their employers, younger, previously certified CTRs may choose to add an associate’s degree to their portfolio to stay competitive, suggests Hebert, particularly since the demand for CTRs is growing.

For several reasons, Aurora has had little turnover among registrars despite the CTR shortage. One is that it pays them competitively in the same professional-technical pay range as coders. “We don’t want to lose a registrar to being a coder or a coder to being a registrar,” says Robinson. “Another reason for long-term retention is that our organization places great value on the data produced by cancer registrars. Further, because CTRs rotate through all job duties, including supporting the multidisciplinary cancer conferences, the job remains interesting and challenging.”

The responsibility to achieve and maintain compliance by employing CTRs credentialed under the new requirements falls on the shoulders of cancer committees and hospital administrators at ACoS CoC-accredited organizations. As an ACoS CoC-accredited program, Aurora needs credentialed CTRs. “Although we don’t pay the exam fees, the majority of our registrars choose to get certified anyway because they get more recognition and are better able to keep up with the ongoing developments in the profession,” Robinson says.

What’s Next?
As the work of cancer registrars grows even more sophisticated and demanding in support of research, education, and treatment, will an associate’s degree be enough? “We’ll have to wait and see if the education provided through an associate’s degree is sufficient,” says Hebert. “CTRs are truly becoming data managers and need technical savvy to keep up with the advances in the technologies that are the tools of their trade. If a bachelor’s degree turns out to be needed in the future, it will be as a result of the need for greater management and technological skills.”


— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.

For more information about the new CTR education requirements, visit the NCRA at www.ncra-usa.org or the NCRA’s exam Web site at www.ctrexam.org.