September 10, 2012

Filling the Void — Unraveling the Cancer Registrar Shortage
By Annie Macios
For The Record
Vol. 24 No. 16 P. 14

With the number of cancer programs on the rise, will there be enough qualified professionals to meet the need?

Cancer registry is certainly not a new profession, but it is generally considered to be on the periphery of the HIM scene that is dominated by coders and the various incarnations of medical transcriptionists. Nevertheless, the contributions of cancer registrars are invaluable to the process of gathering vital information that is used in the management of cancer and to improve patient outcomes.

According to the National Cancer Registrars Association (NCRA), the Commission on Cancer (CoC) of the American College of Surgeons (ACoS) required the establishment of cancer registries for hospital-based cancer programs as early as 1956. By October 1992, the National Program of Cancer Registrars legislation was passed to support the implementation and enhancement of cancer registry programs.

The June 2006 NCRA Workforce Study estimated that there were 7,280 registrars in the workforce at that time, with a projected need to add 800 more over the next 15 years. It also noted that additional registrars would be needed to replace those who retire from the field.

Despite the warning that there would be positions to fill, many facilities are lacking these professionals. But why has it been difficult to find qualified cancer registrars, and what can be done to fill the vacancies?

Reasons for the Shortage
Published in May by Care Communications, the white paper “Cancer Registry Workforce Shortage Still Mounting Fast as Demand Accelerates” sounds a call to action to acknowledge the shortage, commit to fixing problems, and train individuals to increase the number of qualified cancer registrars.

“As organizations increasingly acknowledge reporting backlogs and related problems in the cancer registry, administrators are finding it’s not as easy to commit to fixing these problems and train qualified professionals as it used to be,” author Laurie Hebert, RHIA, CCS, CCS-P, CTR, vice president and general manager of cancer registry services at Care Communication, said in the report.

The foremost reason for the shortage is that prerequisites to sit for the certified tumor registrar (CTR) exam have become more rigorous, Hebert says. For example, she notes that an associate’s degree in an allied health field is now a requirement.

According to NCRA statistics, only 316 candidates took the exam in 2011, the lowest number recorded since the organization began keeping track more than 10 years ago. Only 62% passed the test, meaning that a meager 196 CTRs joined the existing talent pool last year. That low number is exacerbated by the fact that an average of 135 CTRs leave the profession annually, according to the NCRA.

Joyce Ritter, RHIA, CTR, manager at the Goldston Cancer Registry in Amarillo, Texas, believes an aging workforce is the main culprit for the overall shortage. “Looking at the cancer registrar field, some are at retirement age, so it is basically a matter of attrition,” she says.

Still, the new requirements aren’t helping matters. Many cancer registrar hopefuls completed the requirements, but others already in the fold chose not to pursue them, citing the investment in time and money as deterrents, and instead decided to retire.

While the higher standards have impacted the size of the workforce, the increase in the number of cancer programs being established has also contributed to the shortage. According to Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, director of professional practice resources at AHIMA, there is a growing need for comprehensive cancer data review, collection, and monitoring as new advancements in healthcare and medicine provide better opportunities for cancer patients. This leap in data-oriented tasks has left the industry shorthanded in certain areas.

“As with any specialty, the need for experienced registrars is of particular interest. As the number of reportable cases of cancer increases, so does the need for data abstraction. However, to make that possible, the data must be abstracted correctly and in a timely fashion. Cancer registry opportunities are available from entry-level positions in hospitals to state departments of health surveillance and expanded to regulatory agencies and other vendors. These situations have created a high need,” Wiedemann says.

Another contributing factor to the shortage is the lack of a specific degree program—be it two or four years—for cancer registrars, Wiedemann says. The specialty is often covered as a part of a larger course during a student’s college education, she says. “As such, many students don’t recognize that this area exists or don’t understand that HIM professionals have the data collection skills and knowledge needed for this area,” she explains.

Solving the Problem
Wiedemann believes the expanded opportunities in cancer registry have created interesting challenges for those assigned the task of filling open positions. The difficulty in finding qualified candidates has led some organizations to outsource the work rather than spend an excessive amount of time identifying and attracting the appropriate hire. As a result, registrars have several options.

“For experienced individuals, I think that there are opportunities to work in contract positions in which they keep their regular job but work limited hours at other facilities or for another company performing abstracting functions,” Wiedemann says.

Fledgling registrars also have options. “For those interested in pursuing a registrar career, their best chance may be with some on-the-job training at their facility or local state department of health,” Wiedemann says. “Certainly new students could focus on this during their clinical experiences and make contacts within this area that can assist them in locating a job after graduation.”

Wiedemann notes that because many organizations make CTR certification a requirement for employment, new graduates and inexperienced abstractors have two options: obtain certification prior to applying for work or ask their prospective employer to make the requirement conditional. For example, agree to become certified within six months of hire.

“Of these options, I think that on-the-job training may be the best route,” Wiedemann says. “The organization has several positions that deal in data abstraction on a regular basis that could, through training, enable a person to gain skills and knowledge in the cancer field that would make them a good registrar. Applicants could be found in the HIM department, the quality department, or the coding department, among others.”

Making the Transition
HIM professionals make excellent prospects to fill cancer registrar positions, Hebert says, adding that more people with HIM skills are considering a move to cancer registry. “This comes as no surprise to those familiar with the complementary nature of HIM and cancer registry skill sets,” she says.

“I think this field [cancer registry] is a well-kept secret,” Ritter says. “I had previously been a director of medical records and was given the opportunity to change to the cancer registry field. Now I feel like part of the cancer team, and it is so rewarding.” The Goldston staff includes several registrars who switched fields. There’s a nurse and a respiratory therapist who made the transition as well as an RHIT who previously worked as a medical transcriptionist.

Wiedemann adds that because cancer registries prioritize accurate and timely data collection, HIM professionals are uniquely qualified to serve in those departments. Their competency in data collection, data monitoring, data analysis, statistical analysis, coding, and other information management functions helps them adapt more smoothly.

“An HIM professional’s knowledge of medical terminology also sets a basic understanding of the terminology used throughout the abstract process, and minimal additional training specific to cancer registry would complete their ability to make the transition,” Wiedemann says. Candidates also need to have an attention to detail, thorough knowledge of disease processes, familiarity with coding and classification systems, an ability to work with clinical care providers, and data abstraction and analysis skills.

According to Hebert, health professionals looking to transition into a cancer registry career should follow these steps:

• Self-educate. Prospective candidates should understand the necessary educational requirements, responsibilities, and duties of cancer registry professionals.

• Meet the requirements. With this understanding in place, commit to meeting the educational requirements.

• Prepare and sit for the CTR exam. Prospective exam applicants should take advantage of all opportunities for review prior to taking the test.

• Never stop learning. Continuing education is critical for long-term success.

Best Bets
Candidates who have a broad knowledge of anatomy and physiology, computer skills, and the ability to multitask and are comfortable interfacing with various departments are a step ahead of the game, Ritter says. Someone who is innovative, able to comprehend cancer manuals, and motivated to keep abreast of the latest developments stands an excellent chance at succeeding in the field, she adds. “There are 26 types of cancer we deal with and no case is the same, so there is so much to learn that it can’t all be done on the job,” Ritter says.

Knowing the way around a computer falls nicely in line with the experiences of HIM employees. “Everything we do is based on the computer,” Ritter says. “Most facilities are using some type of electronic health record, which is key because we use that to build a comprehensive abstract on each patient, and a prospective cancer registrar must have computer knowledge for that. Plus, most registrars look at more than one database to create the abstracts. All our manuals are computerized. If [workers] are not computer savvy, they will need to be.”

Wiedemann agrees that technology will play a major role in the future of cancer registry. “Health IT is extremely important in today’s healthcare environment. Even cancer registry databases are affected by EHRs,” she notes. “The need for quality documentation and information within the EHR is paramount as abstractors move forward with data collection. Lack of documentation affects the quality of the information the cancer registrar is looking at and therefore the quality of abstraction.”

Cancer registrars may be required to view multiple systems to obtain the information they once found in paper records, such as pathology and laboratory modules, and progress and operative notes. These may not be easily located in the EHR or may reside in different systems, making it necessary for registrars to do a little digging. The more information available to abstractors and the more comfortable they are with technology, the better the results will be, Wiedemann says.

Ritter says the cancer registrar position is evolving and becoming a more important cog in cancer programs because hospital administrators use the collected data for planning, education, and improving patient outcomes. “What is attractive about working as a cancer registrar is that you feel [like] part of the cancer team,” she says. “Speaking from experience, sometimes you don’t feel appreciated in other HIM jobs, but as a registrar I feel very appreciated because I am working with doctors and cancer committees and feel like I am making a huge impact on the field. Most of the published data—from outcomes to surveillance—comes from the cancer registry.”

Ritter concludes that cancer registry is a viable option for HIM professionals looking to switch roles. “I think HIM jobs are great. Some think they have to stay in a position like medical records to remain in the field, but it’s good for people to know there is another avenue out there that is exciting and rewarding,” she says. “As a cancer registrar, you develop a passion for this field. The NCRA and the ACoS CoC are collaborating with other stakeholders and have put a big emphasis on the cancer registrar position. It is an exciting field that just keeps evolving.”

— Annie Macios is a freelance writer based in Calgary, Alberta, Canada.