maryland cancer registry december 2015 e-update w€¦ · 6 page 6 maryland cancer registry...

A publicaon by Westat under contract with the DHMH Contract #DHMH-OPASS 07-9486

W hat’s New?

DECEMBER 2015 Maryland Cancer Registry

E-Update

Inside this issue:

What’s New 1-4

Quality Control 5-8

Quarterly tips 9

Meet the Staff 10

Announcement 11

By Kimberly Stern, MHA, CTR Program Manager, Maryland Cancer Registry Tel#(410) 767-5521; Email: [email protected]

“We spend January 1st walking through our lives, room by room, drawing up a list of work to be done, cracks to be patched. Maybe this year, to balance the list, we ought to walk through the rooms of our lives...not looking for flaws, but for potential.” ― Ellen Goodman

It is that me of year where we once again look back at what we have accomplished in the

past year, and look ahead at what is to come in the new one. The Maryland Cancer Regis-

try (MCR) has had another great year thanks to the hard work of State reporng facilies

and CTRs. We have submied the largest number of cases we have ever submied and

are fairly certain we will receive “Gold” cerficaon for our data. I would like to take this

me to thank MCR staff located at both the Maryland Department of Health and Mental

Hygiene and Westat for all the work they do on preparing and subming MCR data. It

takes everyone working together throughout the year to accomplish this major task.

I’m looking forward to all that is upcoming in 2016: the change to ICD-10-CM should not be

too difficult since we use ICD-O-3; we will be required to convert our programs to NAACCR

version 16; and finally, we will begin coding staging in AJCC and SEER again. This coding

will take pracce and review for those who have previously coded it, and training for those

who are new to it. As they say, the only thing constant is change and we as registrars have

seen changes every year. The great news is, these changes mean beer data for research‐

ers to ulmately find a cure or control the incidence of cancer. Thank you for all you do

and have a wonderful New Year!

“There are greater things to be achieved in every New Year, and each and every one must prepare themselves to be great, not by words of the mouth, but by a lot of sacrifices.” ― Michael Bassey Johnson

mailto:[email protected]

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MARYLAND CANCER REGISTRY E-UPDATE

C ont. What’s New

By Serban Negoita, MD, DrPH, CTR MCR Program Director, Director of Operations Tel#(240) 314-2309; Email: [email protected]

Update on November 2015 Call for Data Submission

In November 2015, MCR successfully completed the preparaon and submission of Maryland cancer datasets to two naonal

organizaons: the CDC’s Naonal Program of Cancer Registries (NPCR) and the Naonal Associaon of Central Cancer Regis‐

tries (NAACCR). The Maryland submission dataset consists of 547,017 tumors diagnosed between years 1996 and 2014. In an

effort to improve the meliness of state and naonal cancer data stascs, the MCR decreased the lag me between diagno‐

sis and NPCR/NAACCR reporng from 13 months to 11 months, and accordingly, over 17,000 tumors diagnosed in year 2014

have been transmied to the CDC in November 2015. It is expected that 11-month reporng will become the new naonal

standard and MCR has become an early adopter.

The MCR dataset comprised over 100 data elements required by NPCR and NAACCR in order to publish state cancer data in

the annual United States Cancer Stascs Report, and accept the data to the Cancer In North America (CINA) database. The

Maryland dataset was edited and eventually passed a record-seng 285 single- and mulple-field edits, in addion to 24 inter

-record edits. These includes all Core edits required by NPCR, the advanced edits suggested by NAACCR and several addional

edits required specifically for inclusion in the CINA database.

This successful data submission was built from the hard work and dedicaon of cancer reporters in Maryland, who submied

over 60,000 cancer abstracts to the MCR, the highest number of abstracts received since 2006. In addion to case-finding, ab-

stracng, coding, and eding work, MCR reporters have been exceponally responsive to the Quality Assurance (QA) pro‐

grams of the central registry, such as the Death Clearance Follow-back and the Disease Index Comparison programs. Parcipa‐

on in the QA programs requires significant effort from MCR reporters, and MCR staff would like to use this opportunity to

acknowledge, once again, the fundamental role cancer reporters play in the success of the state cancer registry in Maryland.


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C ont. What’s New

In the spring of 2015, MCR iniated a new QA acvity that resulted in the producon of an Annual Facility Report (AFR) for

each reporng hospital, both COC-approved and non COC-approved. The AFR focused on three indicator categories: (1) Sub-

mission Monitoring Stascs, (2) Disease Index Comparison, and (3) the Timeliness of Submissions. A detailed PowerPoint

presentaon explaining the methodology used to generate the report was distributed with the 2015 AFR in July 2015.

In response, several hospital registry coordinators expressed interest in providing MCR with feedback about the report meth-

odology, so MCR plans to organize a WebEx meeng (online call) on January 29, 2016, 1 PM EST. Representaves from both

the DHMH MCR program and Westat MCR QADM project will be present on the call to address suggesons regarding report

methodology, explain how Disease Index Comparison can be used to improve the Annual Facility Report results, and discuss

ad-hoc suggesons received from meeng parcipants. You are encouraged to provide your suggesons and comments in

advance using the MCR Tech Line ([email protected]).

Main reporters and supervisors from hospital facilies registered with the MCR will receive the inial invitaon for the WebEx

meeng in early January 2016, followed by a reminder and meeng materials in the days preceding the meeng. Please con-

tact your MCR Hospital Field Representave if you do not receive an invitaon by January 18 or you need addional

details.

Responding to the call of naonal organizaons to increase the meliness and relevance of cancer stascs, MCR has moved

to an 11-month data submission model, with tumors diagnosed in the index year being consolidated and submied for cancer

stascs by November of the subsequent year. In addion, MCR plans to act on suggesons from reporters to eliminate du‐

plicate or triplicate requests for follow-back because of overlapping QA iniaves such as audits, disease index comparison

and the death clearance follow-back process. These imperaves require a readjustment of acvies in the annual cycle,

which starts in December of a given year and ends in November of the following year.

The Disease Index Comparison, now conducted on an annual basis, should eliminate the need for case-finding audits (except

certain pathology reports or radiaon therapy log audits). It should also decrease the need for follow-back of many of the

Annual Facility Reports Methodology and

Disease Index Comparison Reconciliation WebEx Meeting

Plans for MCR QA Activities - Year 2016


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C ont. Plans for MCR QA Activities - Year 2016

death clearance cases, provided that pernent informaon is included in the reconciliaon reply. To gain the

expected added efficiency benefits, the Disease Index Comparison (including the reconciliaon acvity) must be conducted

early in the annual cycle and accordingly, for the December 2015—November 2016 cycle, MCR iniated the call for cases in

early December 2015. It is expected that disease indices will be returned to MCR by reporng facilies in early January 2016

and will be analyzed by the MCR QADM project staff in January—February 2016. Disease Index Comparison results will be-

come available to hospitals in March 2016, and to the extent reconciliaon results are received from hospital reporters by

April 2016, reporters can be assured that further review is not needed for matched cases or even non-matched cases that

were sasfactorily reconciled before audits or death clearance follow-back. In most instances, the MCR QA-related acvies

of hospital registries can be completed by May 2016, and the AFR 2016 will be released in June 2016.

In addion to changing the ming of data submission and Disease Index Comparison, MCR plans to implement a new QA step

that requires no addional work or response from reporters. MCR’s will extend the regular edits report generated at the me

new files are uploaded to the Web Plus to include a lisng of Medical Record Number, Accession Number and Sequence Num‐

ber (but not SSN or any confidenal informaon) for all abstracts. The extended report will conveniently provide reporters

with a documented receipt of all cases submied to the MCR.

MCR understands the constraints and challenges imposed on hospital registries by the increased demands on meliness and

by mulple QA acvies. As a result, DHMH and Westat staff hopes that hospital registry workload can be minimized by effi‐

cient programing of central registry QA acvies coupled with accurate tracking of informaon exchanges between hospital-

based and central registries.

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Q uality Control

FACILITY COMPLETENESS % ACCURACY %

A 99.6 99.9

B 98.6 99.1

C 100.0 98.4

D 97.0 99.1

E 56.2 96.2

F 99.3 99.7

G 98.7 98.8

H 92.2 99.1

2015 Audit Results

0.010.020.030.040.050.060.070.080.090.0

100.0

A B C D E F G H

Perc

ent %

Hospitals

Case Completeness and Data Quality Audit Results For Cases Diagnosed in 2013

COMPLETENESS %

ACCURACY %

By Vanessa Mclean, BS, Lead CTR Maryland Cancer Registry Tel#(301) 251-4217; Email: [email protected]


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C ont. 2015 Audit Results

Thank you to all parcipang facilies for another successful audit year! We would like to congratulate the University of Mary-

land Balmore Washington Medical Center for a perfect case completeness rang of 100%, and Anne Arundel Medical Cen-

ter for a near perfect compliance rang in both completeness and accuracy of data with a score of 99.6% and 99.9% respec‐

vely. The lowest ranked facility had a case completeness of 56.2% however, their data quality rate was very well at 96.2%. Of

the facilies audited, five (5) were recognized for their exceponal data with a score of at least a 98% in both completeness

and accuracy, an increase in facility numbers last years audits. As always, there is sll room for improvement so below is a list

of recommendaons:

◊ Facilies should review their facility disease index periodically to monitor case completeness. For example, a quarterly or

monthly review of your index would improve completeness substanally.

◊ Developing quality monitoring reports to assess accuracy of specific data is highly recommended, so for example, re-

abstracng acvies may be useful in assessing quality of data.

Thank you again to all audited facilies for their great efforts and hospitality. We look forward to having another exceponal auding year in 2016.

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Maryland law requires that physicians who have diagnosed and/or treated cancer (or a central nervous system tumor) for a non-

hospitalized paent must report to MCR if the paent was not otherwise reported by a hospital, freestanding laboratory, free-

standing ambulatory care facility, or therapeuc radiological center. Currently, there exist different methods these physicians can

report abstracts on cases: (1) submit paper/hard copies, if they ancipate less than 100 cases per year; (2) enter data directly into

Web Plus; or (3) submit electronic reports through electronic health records (EHR) soware within the context of Meaningful Use

(MU). The method that a physician chooses for reporng can be based on factors that include volume, workload, and the resource

capabilies of the physician and/or pracce, however, if they use EHR soware system, they may have the capability to parci-

pate in electronic cancer reporng through MU.

The Medicare and Medicaid EHR Incenve Programs were created under the American Reinvestment and Recovery Act to provide

financial incenves to providers and hospitals that adopt and demonstrate MU of EHRs. There are three main components of MU:

• The use of a cerfied EHR in a meaningful manner, such as e-prescribing

• The use of cerfied EHR technology for electronic exchange of health informaon to improve quality of health care

• The use of cerfied EHR technology to document clinical quality data and other measures

MU is divided into three stages, in which cancer reporng falls into Stage 2. As cancer treatments evolve away from hospital

sengs and towards ambulatory healthcare sengs, there is increased interest in capturing data from ambulatory healthcare

providers. These providers are also increasingly using EHRs, providing an opportunity for the use of these systems for electronic

cancer reporng in a way that is more automated and more conducive to the operaons of certain providers. MU requires that

you have cerfied EHR technology and the capability to create electronic reports using Centers for Disease Control and Prevenon

Health Level Seven (HL7) Clinical Document Architecture (CDA) standards. If you are a Provider that is unsure whether your EHR

has the capability to create electronic reports based on these standards, please talk to your EHR soware vendor.

The MCR is currently conducng MU validaon tesng; if you are interested in subming cases electronically, you may register

for MU by following this link:

hps://mmcp.dhmh.maryland.gov/ehr/SitePages/PublicHealthObjecves_Main.aspx

C ont. Quality control

Meaningful Use Update for Physician Offices: Get Onboard!

By Carmela Groves, RN, MS (QA Technical Specialist, Operations Support, Tel#(301) 251-2216 and Diane Ng, MPH (MCR Research Assistant, Tel# (301) 279-4518

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As part of the onboarding process, MCR will work with approved Providers with cerfied EHRs on validaon tesng of electronic

files, and establish a roune electronic reporng mechanism with Providers who have completed successful validaon tesng. At

the moment, MCR is only accepng electronic cancer reports if it is conducted for MU; electronic reporng independent of MU is

not an opon at this me.

For more detailed informaon related to MU, see the state and federal websites listed below:

hps://meaningfuluse.crisphealth.org/

hps://mmcp.dhmh.maryland.gov/ehr/SitePages/Home.aspx

hp://www.cms.gov/Regulaons-and-Guidance/Legislaon/EHRIncenvePrograms/index.html?redirect=/EHRIncenveprograms

hp://www.cdc.gov/ehrmeaningfuluse/index.html

C ont. Meaningful Use

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In 2014 and 2015 SEER added new reportable histology terms to their Program and Coding Manual which had not been included

in any ICD-O-3 errata or implementaon guide, and therefore, were not addressed throughout the cancer surveillance communi‐

ty. CDC has reviewed the terms (reportable according to SEER) and made the following decisions:

1. Non-invasive mucinous cysc neoplasm of the pancreas with high-grade dysplasia replaces mucinous cystadenocarcinoma,

non-invasive (8470/2) and is REPORTABLE.

2. Solid pseudopapillary neoplasm of pancreas (8452/3) is synonymous with solid pseudopapillary carcinoma (C25._) and is

REPORTABLE.

3. Based on expert pathologist consultaon, metastases have been reported in some CPEN cases, therefore, with all other

pancreac endocrine tumors now considered malignant, CPEN will also be considered malignant, unl proven otherwise.

Most CPEN cases are non-funconing and are REPORTABLE using histology code 8150/3, unless the tumor is specified as

a neuroendocrine tumor, grade 1 (assign code 8240/3) or neuroendocrine tumor, grade 2 (assign code 8249/3)

4. Laryngeal intraepithelial neoplasia, grade III (LINIII) (8077/2), C320-C329) is REPORTABLE.

5. Squamous intraepithelial neoplasia, grade III (SINIII) (8077/2), except Cervix and Skin, is REPORTABLE.

6. Mature teratoma of the testes in adults is malignant and REPORTABLE as 9080/3, but connues to be non-reportable in

prepubescent children (9080/0). The following provides addional guidance:

Adult is defined as post puberty

Pubescence can take place over a number of years

Do not rely solely on age to indicate pre or post puberty status. Review all informaon (physical history, etc.) for

documentaon of pubertal status. When tescular teratomas occur in adult males, pubescent status is likely to

be stated in the medical record because it is an important factor of the diagnosis.

Do not report if unknown whether paent is pre or post pubescence. When tescular teratoma occurs in a male

and there is no menon of pubescence, it is likely that the paent is a child, or pre-pubescent, and the tumor is

benign.

While there has not been an official errata to address these histology terms, CDC recommends adding them to your ICD-O-3 Manuals.

Q uarterly Tips

ICD-O-3 IMPLEMENTATION AND REPORTABILITY

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MARYLAND CANCER REGISTRY

As current President of the Tumor Registrars Associaon of Maryland (TRAM), it is

my hope to encourage more CTR’s to join our state associaon, not only to enhance

membership, but to gain access to quality speakers, elevate the educaon programs

we can offer, and reach out to those less experienced. It is a me of change for all of

us and those with less than 5 years’ experience in our profession will need to learn

how to stage cases using TNM and Summary Stage. We must meet the needs of all

our members, and in parcular, reach out to those new to the field. As I indicated on

our TRAM website:

I have been employed in the cancer registry profession since 1987 when I started as a

‘follow-up’ clerk making $7.50 an hour, which back then was prey good for a clerk!

That just shows how much mes have changed. I gained my cerficaon in 1988 and

realized the other day that I have been doing this for 27 years! It was interesng when

I moved from North Carolina to Maryland in 1999, there were people in TRAM whom I knew from NC; I was shocked to see Cleve-

land Sigh and Sheryl Daugherty in the audience and see Annee Dixon at our meengs some me later. We have a very talented

and diverse organizaon which I hope will connue to grow and evolve into your primary resource for educaon and support.

Where will the next 27 years take us? We must connue to prepare for future data collecon and standards, work together to try

to meet your educaonal needs to prepare you for a bright and prosperous future.

M eet the staff— Mary Mesnard, BS, RHIA, CTR

By Mary Mesnard, BS, RHIA, CTR , Westat, Senior Study Director Tel#: 301-212-3705 Email: [email protected]


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A nnouncement

Helpful Resources

Maryland Cancer Registry –HOME phpa.dhmh.maryland.gov/cancer/SitePages/mcr_home.aspx

Point of Contact:

Kimberly Stern, MHA, CTR Program Manager Maryland Cancer Registry 201 W. Preston St. Rm 400 Baltimore, MD 21201 Email: Kimberly.Stern @maryland.gov Phone: (410) 767-5521 Fax: (410) 333-5218 Tumor Registrars Associa-tion of Maryland www.tramd.org

Follow on Facebook:

NAACCR

CDC

NCRA

National Cancer Institute

National Cancer Institute, Shady Grove Campus

National Cancer Institute – News and Public Affairs

On Twitter:

@CDC Cancer

@NCRAnews

@NAACCR

@theNCI

@NCIBulletin

Send us your Feedback:

[email protected] or [email protected]

Maryland Cancer Registry. 1500 Research Blvd., Rockville, MD 20850. Tel# 301-315-4292

2016 NAACCR WEBINAR SCHEDULE

1/7/16 – Room 200

Collecting Cancer Data: Bone and Soft Tissue

2/4/16 – Room 200 Collecting Cancer Data: Breast

3/3/16 – Room 200 Abstracting and Coding Boot Camp

4/7/16 – Room 200 Collecting Cancer Data: Ovary

5/5/16 – Room 200 Collecting Cancer Data: Kidney

6/2/16 – Room 200 Collecting Cancer Data: Prostate

7/7/16 – Room 200 Patient Outcomes

8/4/16 – Room 200 Collecting Cancer Data: Bladder

9/1/16 – Room 200 Coding Pitfalls

Note: All webinars are held at: 201 W. Preston Street, Balmore, MD 21201 Interested? Please contact Carolyn Davis at Carolyn.davis@maryland. gov

www.tramd.org



mailto:Carolyn.davis@maryland.

maryland cancer registry december 2015 e-update w€¦ · 6 page 6 maryland cancer registry...

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