Transcript Slide 1

CDC-NPCR Pilot Projects Using
SNOMED CT Encoded CAP
Cancer Checklists
APIII Annual Conference
Vancouver, British Columbia
Ken Gerlach, MPH, CTR
August 18, 2006
Role of Federal Government in
Health Data Standards
The needed intervention is not for the
government to set the standards, but
rather for them to convene the key
players and to mediate.
Donald W. Simborg
J Am Med Informatics
Assoc
1996;3(4):250
Federally Funded Cancer Registries,
2006
Seattle/
Puget
Sound
Detroit
CT
IA
San Francisco/
Oakland
NJ
UT
San Jose/
Monterey
CA
KY
Los
Angeles
NM
Atlanta
LA
ALASKA
HAWAII
REPUBLIC
OF PALAU
*National
Program of Cancer Registries (CDC)
Epidemiology, and End Results Program (NCI)
†Surveillance,
NPCR *
`
SEER †
NPCR/SEER
PUERTO
RICO
VIRGIN
ISLANDS
United States Cancer Statistics:
2003 Incidence and Mortality




Covers 96% of US
population for incidence,
100% for mortality
State, regional, and
national data
Rates for whites, blacks,
Asians/Pacific Islanders,
Native Americans, and
Hispanics
http://www.cdc.gov/canc
er/npcr/uscs
Geographic Coverage of USCS, 2003
Seattle/
Puget WA
Sound
MT
ME
ND
MN
OR
VT
NH
WI
ID
MI
SD
WY
San
Francisco/
Oakland
San Jose/
Monterey
NY
CT
Detroit
PN
IA
NE
NV
NJ
IL
UT
OH
IN
DE
MD
CO
WV
KS
MO
CA
Los
Angeles
MA
VA
DC
KY
NC
TN
OK
AZ
SC
AR
NM
MS
AL
LA
Atlanta
GA
TX
AK
REPUBLIC
of Palau
FL
VIRGIN
ISLANDS
HAWAII
Registry contributed
incidence data;
all states contributed
mortality data
PUERTO
RICO
RI
Importance of Pathology Data
for Cancer Surveillance

> 92% cancer histologically-confirmed in
pathology laboratories



Histology and Cytology
Key for complete and timely data
Rapid Case-Ascertainment
For cancers of special interest
 Case-control studies
 Clinical Trials

Proposed Cancer Registry Data Flow
Hospital B
Hospital A
Path Report
Op Report
HL7 File:
Clinical
History &
Physical
Admissions
Dx Imaging
Other
Records
HL7 File:
Patient
Demographic
s
HL7 File:
HL7 File:
Cancer
Abstract
Deidentified
Cancer
Abstract
HOSPITAL
REGISTRY
CENTRAL
REGISTRY
Summarize
Consolidate
Reference
Path Lab
NATIONAL
PROGRAMS
Private
Physician
Hospital C
North American Association of
Central Cancer Registries (NAACCR)

Umbrella organization


Population-based cancer
registries

Governmental agencies

Professional associations

Private groups
Purpose: To improve
quality and use of cancer
data
Cancer Protocols Project Workflow
Laboratory System
Hospital Cancer Registry
Central Cancer Registry
Receive Report
Receive Report
Receive Specimen from
Surgeon
Prepare and Analyze
Specimen
______________________
Exit/Send acknowledgement
Cancer?
Yes
Input Data into CAP Checklist
Format Checklist: PHIN Standards
Transmit
Checklist
To physician
______________________
Exit/Send acknowledgement
A CDC-led effort to improve
public health communications
by using and promoting health
data and technology standards
that electronically enable:
- detection and monitoring
- data analysis
- knowledge management
- alerting
- response
Reporting Pathology
Protocols (RPP)


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Demonstration projects funded by CDC NPCR
Implement SNOMED CT Encoded CAP Cancer
Checklists
In 2001

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California and Ohio
Cancers of the colon and rectum
In 2004


California, Maine, and Pennsylvania
Cancers of the breast, prostate, and melanoma of the
skin
RPP2 Laboratory Participants

Funded in 2004

California


City of Hope Hospital National Medical Center,
California
Maine
Maine Medical Center and
 Dahl Chase Labs


Pennsylvania

University of Pittsburg Medical Center
CoC Cancer Program Standard 4.6


The CoC requires that 90 percent of
pathology reports that include a cancer
diagnosis will contain the scientifically
validated data elements outlined on the
surgical case summary checklist of the
College of American Pathologists (CAP)
publication, Reporting on Cancer
Specimens.
Protocols not Checklists
RPP1 Project - Process


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
Identify question concepts on Checklist
without a LOINC code
Presentation to LOINC for codes
Clarify Content and Suggest Revisions to
the Checklist with CAP Cancer Committee
Development and Consensus on
Implementation Tables
Development of Evaluation Measures
RPP1 Vocabulary

Logical Observations and Identifiers
Names and Codes (LOINC)
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Question – Metadata - Header - Data Item
Name
Systematic Nomenclature of Medicine,
Clinical Terms
(SNOMED CT)
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Answer – Data - Checkable line item - Data
Item Codes
RPP2 Vocabulary

Systematic Nomenclature of Medicine,
Clinical Terms
(SNOMED CT)

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Question – Metadata - Header - Data Item
Name
Systematic Nomenclature of Medicine,
Clinical Terms
(SNOMED CT)

Answer – Data - Checkable line item - Data
Item Codes
SNOMED CT Encoded CAP
Checklist
TUMOR SITE [R-0025A, 371480007] Tumor site (observable entity)
___ Cecum [T-59100, 32713005] Cecum structure (body
structure)
___ Right (ascending) colon [T-59400, 51342009] Right colon
structure (body structure)
___ Hepatic flexure [T-59438, 48338005] Structure of right colic
flexure (body structure)
___ Transverse colon [T-59440, 485005] Transverse colon
structure (body structure)
___ Splenic flexure [T-59442, 72592005] Structure of left colic
flexure (body structure)
___ Left (descending) colon [T-59450, 55572008] Left colon
structure (body structure)
___ Sigmoid colon [T-59470, 60184004] Sigmoid colon structure
(body structure)
___ Rectum [T-59600, 34402009] Rectum structure (body
structure)
___ Not specified [T-59000, 14742008] Large intestinal structure
(body structure)
Why HL7 Version 2.3.1?


In 2001 – For First Project – Reasonable,
National Standard
For Second Project, proposed HL7 Version
2.5 – Vendor pushback


Vendors using Version 2.3.1 and Version 2
AP Laboratory community appears to be
using this Version

Challenge – Transition to More Robust
Formats
RPP Messaging Tables

HL7 Version 2.3.1
Field Guide Table
 OBX Table (CAP Checklist Concepts)
 Maps of CAP Checklists Concepts to NAACCR
Data Items
 Map from Collaborative Stage to CAP Checklist
Concepts

Field Guide Table
MSH
MSH-1
Data Type
ST
Message Header Segment
Field Separator - the pipe, |, separates one
field from another
MSH-2
ST
Encoding characters - separators within the
fields
^ component separator
~ repetition separator
\ escape character
& subcomponent separator
MSH-3
HD
Sending Application
NAACCR
Opt/Req
NAACCR Data
Item
RPP Opt /Req
R
R
R
R
O
R
Namespace ID for the sending application
R
ST
Coded value for the name of the sending
application
R
ID
Universal ID Type of for the seinding
application ID
R
MSH-3.1
IS
MSG-3.2
MSH-3.3
MSH-4
HD
Sending Facility (facility that is sending this
message)
R
MSH-4.1
IS
text name of the sending laboratory
R
MSH-4.2
ST
Clinical Laboratory Improvement Act
Identifier of the laboratory
R
MSH-4.3
ID
universal ID type
R
7020, 7030,
7040, 7050,
7060
R
R
R
R
OBX Table
Proposed Item
Name for
RPP2
CAP Checklist
Item Name
Field
comm
ent
Data
type
SNOMED CT
ConceptID
SNOMED
CT Alpha
code
Concept Description
NAACCR Data
Item Number
Greatest
dimension
Specimen Size
NM
384627007
R-00417
Specimen size, largest dimension
(observable entity)
Additional
dimensions
Specimen Size
SN
384626003
R-00416
Specimen size, additional
dimension (observable entity)
Additional
dimensions
Specimen Size
SN
384626003
R-00416
Specimen size, additional
dimension (observable entity)
SPECIMEN
SIZE cannot be
determined
Specimen Size
ST
399606003
M-091CA
not coded
SPECIMEN
SIZE
Specimen Size
ST
371475003
[R-00255
Specimen size (observable entity)
LATERALITY
LATERALITY
CE
384727002
F-048D0
Specimen laterality (observable
entity)
410
TUMOR SITE
TUMOR SITE
CE
371480007
R-0025A
Tumor site (observable entity)
400
Mapping Table
CAP Checklist
Question
Checklist Identifier
Patient Name
SNOMED
Code
NAACCR Data Item Name[Number]
NAACCR Data
Item Code
R-10139,
406058005
CAP Checklist
Answer
SNOMED
Code
Melanoma of the
Skin
P1-40305,
35646002
Excision, ellipse
G-81FE,
396353007
R-0025D,
371484003
Name--Last[2230], Name--First[2240],
Name--Middle[2250], Name-Prefix[2260], Name--Suffix[2270], Name-Alias[2280], Name-Spouse/Parent[2290]
Surgical pathology
number
R-002A2,
371482004
MACROSCOPIC
F-048D6,
395526000
SPECIMEN TYPE
R-00254,
371439000
Path Report Number [7090]
RX Hosp-Surg Prim Site [670]
20
Specimen Type: Business Rule
•IF “excision, wide” OR “re-excision, wide” is checked, AND IF
lateral margin is uninvolved by invasive melanoma AND lateral
margin is uninvolved by in situ melanoma AND deep margin is
uninvolved by invasive melanoma
AND
• IF distance of lateral surgical margin is > 20 mm AND
distance of deep surgical margin is > 20 mm THEN code 47 for
RX hosp-Surg Prim Site.
OR
• IF distance of lateral surgical margin is > 10 mm AND < 21
mm AND distance of deep surgical margin is >10 mm and < 21
mm THEN code 46 for RX hosp-Surg Prim Site.
• OTHERWISE code 20 for RX hosp-Surg Prim Site.
Collaborative Stage - CAP Checklist
Collaborative Staging Value
CAP Protocol Item (CAP Checklist Answer)
SNOMED Code
Location on RPP2
Mapping Worksheet
CS Tumor Size
Tumor size, invasive component, greatest dimension
[R-00418, 3843001]
Row 29
Codes 989–998
No equivalent
No equivalent
No equivalent
Code 999
Cannot be determined
[F-005C1, 399686001]
Row 31
Code 00
Any combination of histologic type and behavior code 2 EXCEPT
Paget disease without invasive invasive carcinoma ; No listed histology with
behavior code 3.
Code 05
No equivalent
No equivalent
No equivalent
Code 07
Paget disease without invasive carcinoma
[M85403, 2985005]
Row 35
Codes 10 – 30
No equivalent
No equivalent
No equivalent
Code 40
PT4a: Extension to chestwall, not including pectoralis muscle
[R-003C6, 373186004]
Row 98
Code 51 & 52
No equivalent PT4b: Edema (including peau d’orange) or ulceration of the
skin or breast or satellite skin nodules confined to the same breast (see CS code
description - requires statement of percent of breast involved)
No equivalent
[R-003C9, 37319002]
No equivalent
Row 99
Codes 61 – 62
No equivalent (CS codes 40 & 51 and 40 & 52)
No equivalent
No equivalent
Code 71 & 73
No equivalent (requires a statement regarding percent of skin involved)
No equivalent
No equivalent
Code 95
PT0: no evidence of primary tumor
[G-F182, 3988006]
Row 86
Code 99
PTX: cannot be assessed
[G-F187, 43189003]
Row 85
Codes 000–988
CS Extension
Rows 32-34 and/or
Rows 41-53
Messaging Issues
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Versioning
Nested questions
Multiple primaries – message structure
How handle text
Types of Versioning
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SNOMED CT – updated every January and
July
CAP Cancer Checklists – may be updated
every January and July
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
Date of Checklist – for major changes
SNOMED CT Encoded CAP Cancer
Checklists – may be updated every
January and July

No mechanism
Melanoma Issue: Nested
Concepts
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SPECIMEN TYPE [R-00254, 371439000] Specimen type (observable entity)
___ Excision, ellipse [G-81FD, 396353007] Specimen from skin obtained
by elliptical excision (specimen)
___ Excision, wide [G-81FE, 396354001] Specimen from skin obtained
by wide excision (specimen)
___ Excision, other (specify): ____ [G-81FF, 396355000] Specimen from
skin obtained by excision (specimen) (specify): ____ not coded
___ Re-excision, ellipse [G-8202, 396357008] Specimen from skin
obtained by elliptical re-excision (specimen)
___ Re-excision, wide [G-8203, 396358003] Specimen from skin
obtained by wide re-excision (specimen)
___ Re-excision, other (specify): _____ [G-8201, 396356004] Specimen
from skin obtained by re-excision (specimen) (specify): ____ not coded
___ Lymphadenectomy, sentinel node(s) [R-003AF, 373193000] Lymph
node from sentinel lymph node dissection (specimen)
_X_ Lymphadenectomy, regional nodes (specify): _axillary_ [G-8204,
396359006] Lymph node from regional lymph node dissection
(specimen) (specify): ____ not coded
___ Other (specify): ____ not coded
___ Not specified [G-8110, 119325001] Skin (tissue) specimen
(specimen)
CWE With Repeating Segments

_X_ Lymphadenectomy, regional nodes
(specify): _axillary_ [G-8204, 396359006]
Lymph node from regional lymph node
dissection (specimen) (specify): ____ not
coded

OBX|1|CWE|371439000^Specimen type
(observable entity)^SCT^^^^^SPECIMEN
TYPE||396359006^Lymph node from regional
lymph node dissection
(specimen)^SCT^^^^^^Lymphadenectomy,
regional nodes
(specify)~^^^^^^^^axillary||||||F
Multiple Specimen/Cancers
Scenarios
 One
specimen to two or more cancers
with the same primary site
 One specimen to two or more cancers
with different primary sites
 Many specimens to two or more cancers
with the same primary site
 Many specimens to two or more cancers
with different primary sites
Multiple Primary - Structure
MSH/PID/PV1
ORC - Specimen
OBR – Part 1 and Worksheet 1 (type)
OBX – Heading/Question and Value
OBX –
"
"
"
"
OBX –
"
"
"
"
OBR – Part 1 and Worksheet 2 (type)
OBX – Heading/Question and Value
OBX –
"
"
"
"
OBX –
"
"
"
"
OBR – Part 3 and Worksheet 3 (type)
OBX – Heading/Question and Value
OBX –
"
"
"
"
OBX –
"
"
"
"
Incorporate Text
 For the transmission of text data, RPP2
will rely upon the NAACCR E-Path
transmission standards as noted in
NAACCR Volume V
Recommendations

All cancers are not reported via an existing
checklist


Multiple histology and primary rules may
differ


Need strategy for the remainder
Examine coding rules used by pathologists for
consistency with cancer registry rules
Checklists need to be assessed for stage
information

Collaborative stage
Recommendations

Cancer registry community needs to
evaluate



Expand NAACCR E-Path standards to synoptic
Establish mapping between checklist data items
and NAACCR data items
Informatics community needs to assess
vocabulary and mapping issues

Establish the question and answer vocabulary
Recommendations

Examine costs associated with synoptic
reporting



Cost for pathology lab software (AP LIS)
Cost for SNOMED CT Encoded CAP Checklists
Pathology lab software vendors


Add text fields to synoptic reports
Add drop-down menus for histology codes
Potential






Reduce coding from narrative text
Facilitate the abstracting process
Capture intent of pathologists
Improve rapid case-ascertainment systems
Create more complete case reports
Improve completeness of reporting
An idea whose time has come?




Work through issues of vocabulary and
mapping
Work through staging issues
Implement checklists more quickly
Integrate into cancer registry software
Abstract
 Rapid Case-Ascertainment

RPP Report

Published on the NPCR web site

www.cdc.gov/cancer/npcr/
Contacts




Ken Gerlach
770-488-3008
[email protected]
Missy Jamison
770-488-7154
[email protected]
Sharon Winters 412-647-6390
[email protected]
Anil Parwani
412-623-1326
[email protected]
Thank you

Ken Gerlach

770-488-3008

[email protected]
The findings and conclusions in this presentation are those of the
author(s) and do not necessarily represent the views of the Centers
for Disease Control and Prevention