Transcript Stage 2 Meaningful Use

TEXAS CANCER
REGISTRY UPDATE
Non-Hospital Reporting and
Comparative Effectiveness Research
September 20, 2013
Melanie Williams, Ph.D.
Texas Cancer Registry
Texas Department of State Health Services
OVERVIEW
 National Program of Cancer Registries Update
 Increasing Non Hospital Reporting and Stage 2 Meaningful Use
 Challenges and Opportunities
 Planning Processes
 Recent Texas Cancer Registry Activities
 Comparative Effectiveness Research Project
 Successes and Lessons Learned
 Questions
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
 The big news, Collaborative Stage (CS) is not sustainable
 Acknowledged as an innovative idea and the efforts of those who tried to save it
 Too complex to create, manage, and maintain
 Significant burden on registries to collect, edit, and consolidate
 Cost over $2 million in 2009 alone for CSv2
 Does not include the costs of central and hospital-based registries for software changes,
database conversions, training, reference materials, and staff time
 Multiple efforts to simplify CS have failed
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
 Administratively it was not sustainable
 The system became so complex, only a few individuals understood it fully
 Lack of agreement or ability to make changes readily
 CSv3 was estimated to cost over $1.2 million, and there was a significant shortfall of
needed funds
 CDC received funding reductions in 2013, and will likely receive additional ones in
2014 and 2015
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
 CS for state registries ending in 2016, and there will be a multi-year
transition
 Consistent with other national standard setters (National Cancer Institute, Commission on
Cancer, American Joint Committee on Cancer
 Directly coded AJCC

Clinical and pathological

Stage group

TNM

With necessary biomarkers and prognostic factors
 Directly coded Seer Summary Stage
 Goal is to collect as much AJCC staging as possible, but recognize that
some state registries may not be able to do it
 Texas will likely collect both
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
 Why attempt collecting AJCC at the state level?
 Used by physicians
 Desirable for many types of research

e.g., evaluating quality of care
 Clinical and Pathological Stage provide two different aspects of patient staging
 Clinical – drives initial treatment
 Pathological – more precise prognosis estimates; defines subsequent therapy
 Sustainable

There will always be resources for AJCC staging

Infrastructure is in place to update AJCC regularly

Physicians volunteer readily to participate, knowledge is wide-spread across individuals and
specialties

No central cancer registry data base conversions for changes or new versions of stage
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
 Why keep Seer Summary Stage at the state level?
 Still desirable for many uses, including research
 When collecting Seer Summary Stage will also need to collect auxiliary data
 Tumor size
 Number of lymph nodes examined
 Number of lymph nodes positive
 Relevant prognostic factors or biomarkers (e.g., HER2)
 Also sustainable
 Provides continuity across Nation and across time
NATIONAL PROGRAM OF CENTRAL
CANCER REGISTRIES UPDATE
2014 diagnoses
Directly coded TNMc,p
required as
available
CS used for staging
2015 diagnoses
2016 diagnoses
Directly coded TNMc,p
required “as available”
Directly coded TNMc,p
required
Directly coded Summary
Stage required
Directly coded Summary
Stage required
CS used for staging (will
end as soon as possible)
OTHER NATIONAL AND TEXAS CANCER REGISTRY
PRIORITIES
 Increasing non-hospital reporting
 Supporting Stage 2 Meaningful Use
 Sustaining some additional data collection in support of comparative
effectiveness research, e.g., “the forever seven”
 Increasing data acquisition through data linkage or other sustainable methods,
such as direct reporting through EHRs and claims data
 Further building state electronic reporting capacity and health information
exchange
INCREASING NON HOSPITAL REPORTING AND
STAGE 2 MEANINGFUL USE
Objective: Improve completeness, data quality, of certain under-reported cancer
sites and types of treatment
Goal/Method: Primarily through direct electronic health record reporting from
ambulatory/non-hospital sources
Who Reports:
 Emphasis on certain physician specialties, cancer treatment centers, freestanding radiation, and ambulatory surgery centers
 Where there are medical and radiation oncologists, hematologists,
urologists, dermatologists, and gastroenterologists
 Currently, self-identified by contacting the TCR
 Working on other data-driven identification methods, such as analyses
of claims data, Stage 1 meaningful use attestations
THE INCREASING ROLE OF NON-HOSPITAL REPORTING
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0
Number of Cases
Diagnosis year 2011 not yet complete.
INCREASING NON HOSPITAL REPORTING AND STAGE
2 MEANINGFUL USE
 Opportunities
 All new activity and many new relationships
 A whole lot more data
 Improve completeness for cases diagnosed and treated primarily in an outpatient
setting, missed treatment
 Supporting physicians qualifying for financial incentives to report electronically in a
standard format
 Hopeful that HL7 CDA documents will be more complete than pathology reports
 Reducing work load for active case-collection, need for follow-back, and improving
quality assurance activities
 Revolution, transformation, major paradigm shift, and more!?
INCREASING NON HOSPITAL REPORTING AND
STAGE 2 MEANINGFUL USE
 Challenges
 All new activity and many new relationships
 A whole lot more data
 Complexity and newness of HL7 CDA
 Competing priorities
 Lack of funding
PRE-PLANNING PROCESSES
 Conducted environmental scan including:
 Texas Immunizations and Electronic Laboratory Reporting who were involved in Stage 1
Meaningful Use, and
 9 state cancer registries engaged in electronic pathology reporting, had similar size and
infrastructure, and/or who had mature Health Information Exchange systems
 Reviewed “Lessons Learned Stage 1 Meaningful Use (MU)” presentations and
materials provided by NPCR and the Office of the National Coordinator for
HIT (ONC) Public Health Coordinator
 Consulted Advisory Committee to the Texas Cancer Registry and Texas Medical
Association Cancer Committee
 Studied HIT and MU, State HIT, HIE, and Medicaid plans, what groups and
individuals were responsible for what HIT activities
WORK GROUPS
 Co-chairing NAACCR Physician Reporting Workgroup
 Participating in Stage 2 Meaningful Use Public Health Reporting
Requirements Task Force
 Participated in CDC Stage 3 Meaningful Use Workgroup
 Attends state DSHS HIT Executive Steering Committee meetings
 Attends state Medicaid HIT Advisory Committee meetings
IMPORTANT PARTNERSHIPS
 Identified key partnerships, made introductions, and wherever possible,
secured agreement to support and promote Stage 2 MU Cancer
Reporting
 Department public health agency HIT Coordinator
 State Medicaid Health IT Group responsible for the Electronic Health Records
Incentive Program
 State Health IT Coordinator
 Texas Medical Association
 EHR Vendors
 Regional Extension Centers
 3 Health Information Exchanges
BUSINESS PROCESS MAPPING
 Completed proposed business process mapping
 Registration
 On-boarding
 Testing/validation
 Acknowledgement of ongoing submission
 Benefits of business process mapping include:
 Providing a visual step-by-step diagram of business process and workflow
 Indicating who is responsible for each step
 Assisting in determining to what standard a process should be completed
 Indicating how to measure success/results of processes
 Making it easier to identify gaps and if needed, trouble shooting workflow
 Standardizing processes, and allowing staff to have a broader understanding of work
STAGE 2 MU PROPOSED BUSINESS
PROCESS MAP
Registration
NEW REGISTRATION PROCESS
Many different types of entities
are reporting on behalf of
physicians.
REGISTRATION: STEP 1
Items 1-3 will assist in planning and
prioritizing on how to best manage
the order for testing/validation.
Only certified EHR technology meets MU
requirements, but the TCR offers other
alternatives for non-MU cancer reporting.
ANALYZING PHYSICIAN DATA
VISUALIZING DATA FOR PLANNING
NEW WEB PAGES
NEW WEB PAGES
NEW TRAINING
 For cancer registries and Stage 2 MU, see the ONC’s Interoperability and
Public Health Reporting Training
NEW TRAINING
NEXT STEPS
 Developing 3 month project plan for remaining tasks that must be completed before
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going live January 1, 2014
Complete physician reporting Access database/MU tracking tool
Complete Detailed MU Cancer Capability Map
Draft more detailed data flows
Develop audit/additional quality assurance strategies and processes
Complete eMaRC software testing
Consider further and test if possible, downstream impact of EHR reporting
Develop more specific training for registry staff and those reporting for physicians
Market and further promote physician cancer reporting
Develop online dashboard for performance measures

Exploring web-based product (e.g., Tableau)
2011 COMPARATIVE EFFECTIVE
RESEARCH (CER) PROJECT COMPLETION
 Texas was selected as one of ten specialized registries to increase and
improve data collection
 This project was funded as part of the American Recovery and
Reinvestment Act (ARRA) CER activities through the Centers for Disease
Control
 CER Registries collected additional detailed required data items on breast,
colorectal, and chronic myeloid leukemia cases diagnosed in 2011
 Additional goal to increase electronic health record reporting, and data
linkages
2011 COMPARATIVE EFFECTIVE
RESEARCH (CER) PROJECT
Additional data field information included:
 Additional Staging
 Treatment – focusing specifically on colorectal, breast, Chronic Myeloid
Leukemia
 Biomarkers for some sites
 Comorbidities for all sites
 Smoking history for all sites
 Height and weight for all sites
 Occupation for all sites
2011 COMPARATIVE EFFECTIVE
RESEARCH (CER) PROJECT
Reporters were given the following options to provide the additional required
data information:
 Provide text documentation on abstracts/Excel spreadsheet for TCR
staff to code
 Facility visits for TCR staff to abstract and code
 Remote into their system to collect information and code
2011 COMPARATIVE EFFECTIVE
RESEARCH (CER) PROJECT
A total of 132 facilities opted to do one of the following:
33
- Provide text documentation on abstracts and TCR code
9 - Provide information on Excel spreadsheet for TCR to code
79
- Facility visits
11
- Remote into their system to collect information and code
2011 COMPARATIVE EFFECTIVE
RESEARCH (CER) PROJECT
 TCR staff were assigned the first round of CER facilities to
complete the coding for facilities who opted to provide text
or an Excel spreadsheet with the additional treatment
information.
 Following months site visits were scheduled
 First CER submission was due June 2013.
 Continued data collection on cases after June 2013, additional
submissions in August and November 2013
 We ran out of time
CER PROJECT SUCCESSES AND LESSONS
LEARNED
 Overall, we are proud of the efforts of our reporting community
and TCR staff
 Texas collected the most CER data of all 10 states
 The effort for additional data collection using traditional means is
not sustainable, and can in fact be negative on overall operations
 We are committed to sustaining our training efforts across the
state, and are successful with “no registrar left behind”
 Exploration of additional electronic reporting methods and data
collection are of value and sustainable
QUESTIONS
Contact Information:
Melanie Williams, Ph.D.
Branch Manager, Texas Cancer Registry
Texas Department of State Health Services
512-305-8092
[email protected]