April 12, 2010

Plug Into the Future
By Selena Chavis
For The Record
Vol. 22 No. 7 P. 20

Advances and new insights into cancer treatment are helping to create a need for an overhaul of cancer registry procedures. Industry professionals weigh in on how to get up to speed.

Progress is good but sometimes catching up with progress can be overwhelming. That’s the current state of affairs for cancer registries across the country in light of sweeping reform that is either under way or planned for the next year.

Industry advancements and a lack of standards among regulatory bodies have necessitated changes to the way information is collected and exchanged. According to industry professionals, many of the changes occurred in 2009, but there is still much to be done in 2010.

“Science has progressed,” notes Karen Phillips, product manager for IMPAQ Medical Systems, a subsidiary of cancer treatment solutions company Elekta. “We’ve identified many more diagnostic factors that affect treatment and outcomes.”

Phillips adds that the industry as a whole has agreed to the adoption of minor changes annually and major changes every three years to avoid the need to implement major reform on an annual basis. Based on that calendar, 2010 marks the year where the rubber meets the road as many professionals expect the oncoming modifications to be daunting.

Laurie Hebert, RHIA, CCS, CCS-P, CTR, director of cancer registry services for HIM consulting and staffing group Care Communications, says it will take a concerted effort by healthcare organizations and cancer registry personnel to put new procedures into play. However, the end result will be higher quality information. “It revolves around improving patient care, improving outcomes, and addressing discrepancies in data collection efforts,” she says.

The author of a recent white paper on the topic, “Leading Through Massive Change in the Cancer Registry,” Hebert points out that the National Cancer Registrars Association’s 2009 conference offered much discussion regarding what registrars and registries can expect in the near future. In addition to regulatory changes to standards, processes for education are changing, as are data collection procedures. While some changes were implemented in 2009, the final alterations and clarifications will continue to emerge throughout this year.

For many vendors and registries, the frustrating part of the process is not knowing exactly what’s coming. “We don’t have all the staging,” explains Carol Mulheim, cancer registrar at Mercy Cancer Center in Canton, Ohio, who adds that while it appears the Collaborative Staging Manual, published jointly by the American Joint Committee on Cancer (AJCC) and Health and Human Services, has been completed, it has not yet been posted online. “Everything is not there yet. … It’s difficult to predict the exposure to what’s coming up and what we have to do with it,” she says.

Software updates cannot be completed until all the changes have been spelled out, putting vendors in a hurry-up-and-wait mode. “From our vendor perspective, these changes touch nearly every aspect of software,” Phillips points out. “It’s like rebuilding the whole program.”

Preparing for Changes
According to Hebert, because the criteria have not been completely finalized, many of the specifics regarding changes are still unknown. “With the magnitude of the changes, we know there will be at least some impact on productivity,” she says. “This is a really hot topic.”

In the white paper, Hebert spells out the wide reach of the modifications that were known as of mid-March. Also, the recently published seventh edition of the AJCC Cancer Staging Manual contains significant changes. Organized by disease site into 57 comprehensive chapters, the new edition features major revisions to many chapters, including breast, colon, prostate, and kidney. New primary site chapters have been established for extrahepatic bile ducts, distal bile duct, cutaneous squamous cell carcinoma, Merkel cell carcinoma, and the adrenal gland. There is also an expanded section on ophthalmologic malignancies.

Meanwhile, The American College of Surgeons Commission on Cancer (ACoS CoC) Cancer Program Standards Manual was revised in 2009, and the Facility Oncology Registry Data Standards manual contains changes and clarifications effective in 2009 and 2010.

The much-anticipated Collaborative Staging Manual will undergo significant revisions in 2010, and there will be hematopoietic rule changes to the Multiple Primary and Histology Coding Rules manual, published by the National Cancer Institute’s Surveillance, Epidemiology, and End Results (NCI/SEER) program. Finally, the North American Association of Central Cancer Registries (NAACCR) is planning changes to its standards, which include significant record layout modifications, according to Hebert.

“The changes are really dramatic,” says Phillips, suggesting that the new formats are 400% longer than what the industry is currently employing. “There is a standard format for exchanging data between registries and that has completely changed.”

Phillips cites breast cancer as an example, pointing out that there are 24 site-specific factors required.

Hebert suggests healthcare organizations operating cancer registries consider what it will take to get staff up to speed on the new processes, adding that the best sources of information and training tips are regulatory bodies such as ACoS CoC, the NAACCR, and the NCI/SEER program. Also, training will likely be offered by state association registries through meetings, Webinars, and other formats.

“There needs to be a lot of reaching out. People need to get educated,” she notes. “Hospital administration needs to be aware this is happening and allow registrars the time and resources to become educated.”

Phillips encourages registries to take advantage of the educational opportunities being provided, some of which are free. “The standard setters are offering reference materials and training, Webinars, and speaker availability for local, regional, and state meetings,” she says. “Hospital registrars need to collaborate and learn as much as they can in advance. There will be a need for additional training this year, and there may be costs associated with that training.”

Registries will also need to consider whether to continue collecting data that may have been removed from the requirements by the standard setters. Offering the history of tobacco use as an example, Phillips notes that some states require collection of that data, but it is no longer included as part of the national regulatory requirements.

“They need to decide if they will continue to collect that and how it will fit into the format,” she says.

Hebert suggests that once deadlines are confirmed, cancer registrars should put a timeline in place and determine priorities for moving forward. Approvals should be secured ahead of time from organizational management with regard to the timeline, and professionals should remain regimented and focused throughout the transition. Education should also be extended to peers and leadership teams about the timing and extent of the changes.

Impact on Productivity
Industry professionals agree it is too early to gauge the impact that changes made in 2009 have had on productivity, but most believe that there has been and will continue to be some kind of workflow disruption.

“There’s definitely going to be a learning curve,” Phillips emphasizes. “We can just expect it to take longer to do the abstract due to the extra data requirements.”

Hebert echoes those sentiments, adding that while the full impact may be unclear, hospitals and health networks should expect the time investment to be significant and potentially costly. “One question is whether the lack of productivity, at least initially, will necessitate the need for more staff. We don’t know that yet, but it’s a potential need that will play out,” she says. “Everyone is concerned about productivity in addition to all of the other aspects of cancer registry management.”

Operating a one-person registry at Mercy Cancer Center that may abstract between 700 and 750 cases annually, Mulheim agrees there will be some impact on productivity but adds that it is currently not an overriding concern for her. “It’s not going to be so daunting. … We’ve been exposed to new collaborative staging before,” she notes. “It’s going to require just looking at each site. Everything will fall into place. … It’s just going to take longer.”

However, Mulheim notes a greater burden will fall on large healthcare networks. Pointing to one of Ohio’s larger university teaching hospitals, she explains that the difference in workflow equates to several thousand additional cases per year, requiring numerous registrars and specializations.

Since the full standards had not been released as of mid-March, vendors say it’s difficult to begin educating clients on new practices. Also, many registries have not begun abstracting 2010 cases since deadlines do not occur for six months after cases are seen.
“For me, I’m still doing 2009 cases,” Mulheim says. “I won’t start looking at those [new] manuals until I start doing 2010 cases.”

Vendors note that the six-month window is also buying them some time since software changes cannot be made until the new standards are finalized. But Phillips adds that there are some healthcare organizations that try to complete their case load within a month.
“What we’re doing is allowing them to abstract things that haven’t changed using the old 2009 software,” she explains. “2010 cases will need to be partially abstracted using the 2009 software complemented by a paper worksheet until the updates can be released.”

Industry Reaction
While industry professionals agree that the changes are needed and warranted, Phillips reiterates that many are challenged by the delay.

“We’re in March and don’t have the full standards yet. That’s been the most frustrating part,” she says, adding that there has been a good effort on the part of the standard setters to communicate progress. “The primary delay is that the changes in staging are so profound.”

Frustrations aside, Mulheim says it’s time. “They review staging manuals … and when they revise, it’s a better way to stage them,” she explains. “Every time they refine the process, it becomes a little more defined. It’s making it better.”

Phillips agrees, adding that standardization will continue to lead the charge for better, more detailed information. “We don’t know what causes all cancers or how to treat them all,” she says. “The whole idea behind standardization is to figure out what treatments work best.”

— 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.

Six Activities to Get Prepared
Author of the white paper “Leading Through Massive Change in the Cancer Registry,” Laurie Hebert, RHIA, CCS, CCS-P, CTR, director of cancer registry services for HIM consulting and staffing group Care Communications, offers the following six steps to prepare for the changes.

1. Read: Registrars can expect a lot of communication from such sources as the American College of Surgeons Commission on Cancer (www.facs.org/cancerprogram), state associations and registries, the National Cancer Registrars Association (www.ncra-usa.org), the North American Association of Central Cancer Registries (www.naaccr.org), and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program (www.seer.cancer.gov).

2. Plan: Registrars should create an implementation plan and timeline once all communications and deadlines have been finalized.

3. Prioritize: Registrars should determine what must happen and when and how current work will be accomplished while preparing for upcoming changes. With many moving parts, this effort’s success will depend heavily on registrars being clear about priorities and securing buy-in on those priorities from their organization’s executive team.

4. Manage time: Time management skills will be essential as hospitals and health networks transition to updated standards. To effectively manage time during these transitions, registrars must not only effectively set priorities but stay disciplined and focused on the plan to ensure ongoing progress and avoid unnecessary setbacks.

5. Educate: Registrars should educate themselves, peers, and their organization’s leadership teams early and often about the scope, nature, and timing of the pending changes. They should also request the resources necessary to prepare for the pending transition as part of annual budgeting processes and offer to provide more information or a formal presentation if the need for these additional resources prompts more questions from the leadership team.

6. Update: Registrars must be sure to update all internal policies, procedure manuals, and systems that will be affected by the many upcoming changes.

— SC