Vol. 18 •Issue 15 • Page 14
Making the Data Meaningful
Cancer registrars can make their data meaningful to hospitals and be viewed as a revenue-generating entity.
Fairview Hospital, an affiliate of the Cleveland Clinic, recently witnessed the true potential certified tumor registrars (CTRs) bring to the cancer care team.
About 6 months ago, the cancer committee was discussing future studies it wanted for its cancer program’s Commission on Cancer accreditation, program planning and beyond, but they kept coming back to the same problem: how were they going to collect all of this data?
It would certainly take manpower; people to pull charts and collect the data, to compile, analyze and turn the numbers into stories about the cancer program. Susan Dunson, MSN, RN, OCN, administrator of oncology services, recalled it well. “The oncology program said ÔYou want all this data for your studies, and we want to get it for you, but we don’t have the manpower to provide it,'” she relayed.
That’s when the CTRs stepped into the spotlight. They explained to the committee that much of the data was already in the registry, and if it wasn’t, they’d set up a concurrent abstracting process to capture the necessary data, recalled Brenda Mileto of CHAMPS, a cancer registry staffing, management and consulting company.
“We will do it,” the CTRs said, and with that began a series of meaningful contributions to the cancer program.
Just last year Fairview launched a new cancer wellness program that offers exercise, dietician counseling, yoga and an advance practice nurse as a counselor for patients with breast cancer. Dunson explained it was the data from the registry that actually helped make a case for starting this wellness program, as CTRs reported breast cancer as the top cancer site at Fairview.
The CTRs at Fairview are now an integral part of the cancer team, Mileto noted—the administration and quality committee show a high level of respect for the data they bring out of the registry and consider CTRs the data experts.
“I have always had a great relationship with my cancer registrars, but now I am in awe of what they can do for me,” Dunson said. “I certainly think of them first when I need something!”
Show Your Worth
By producing data that continuously contributes to the hospital’s quality improvement initiatives, the cancer registrars at Fairview were able to elevate their cancer registry from a department that was viewed as having no visible returns to one that’s seen as a strategic partner to hospital administration.
You can have a similar success story, but it is up to you to provide meaningful data to the hospital and ultimately contribute to improved cancer care.
Laurie Hebert, RHIA, CCS, CCS-P, CTR, director of cancer registry services, CARE Communications, and Xiaocheng Wu, MD, MPH, assistant director of the Louisiana Tumor Registry, provided examples of what data a cancer registrar could pull that would be meaningful to hospital administration and the medical staff.
This is not a full list—there are limitless amounts of data a cancer registrar can pull to help provide an overview of cancer patient care, but it’s a start. “There is no way to say, ÔThis is exactly how you do it,'” Hebert said. “That takes learning and being a properly trained and experienced registrar.”
Here is their list:
Top cancer sites and the percentages of patients at each. Your hospital will want to know what sites bring in the highest volume of cancer patients. This can aid in the allocation of financial resources for future planning, and assist in improving patient care. An example: If the last 5 years of data reveal you treat a significant amount of pediatric cancer patients, one may consider developing a pediatric cancer center.
Treatment modalities by stage. Select one type of cancer and pull the treatment modalities and survival rates by stage, and compare them to national standards from the National Cancer Data Base, which is a national benchmark on the standard of care based on the type of cancer and its stage. This is a way to assess how the type of cancer patient care your program provides measures up—or doesn’t measure up—to nationally collected data, Hebert explained. This type of comparative data analysis may yield improvements in patient care or indicate that the care provided is consistent with what occurs nationally.
Financial class at each stage for a specific site. If a high percentage of colorectal cancer patients are coming in with stage IV disease, look at their financial class. “I’d look at, are a majority of our colorectal cancer patients uninsured?” Hebert said. “Think about it, it makes sense—if you’re uninsured you may wait until the last minute to go to the doctor due to the lack of financial resources.” These clues can help your administration and cancer committee target programs accordingly: one may decide to institute free colorectal cancer screenings to hopefully catch the cancer at an earlier stage of disease.
Class zeros. By pulling a list of class zeros—or patients diagnosed at your facility that go elsewhere for treatment—it can show where your facility is losing revenue and could lead to your administration deciding to purchase new diagnostic/treatment equipment or offer new cancer services to stop the leakage.
Tumor marker levels. Hebert participated in a study on PSA levels of prostate cancer patients, which focused on determining what PSA level would warrant a prostate biopsy. The study ultimately led to physicians deciding to start prostate biopsies at a lower PSA level than the national standard, so they could start catching prostate cancer earlier and at a stage that is much more treatable.
Estimated market share by ZIP code. This can help your hospital identify a certain cluster of cancer in one area, and possibly better identify the causes for increased incidence. “Say as the registrar is abstracting, she is seeing more bladder cancer cases in a certain ZIP code—and it’s just a hunch,” Hebert said. “She can run a report on that specific site in that ZIP code and compare it to the overall bladder cancers in the registry. She can then present it to the cancer committee and—this is totally hypothetical—it turns out there is a huge chemical plant in that ZIP code that could possibly be a contributing factor, as many diagnosed patients work at that chemical plant. All of this data is available and accessible from the cancer registry, provided it was initially collected.”
Stage data distribution by year. Showing a hospital they have, say, 30 percent breast cancer diagnosed at localized stage in 2000 and it increased to 50 percent diagnosed at early stage by 2008, “That is what a hospital administration wants to know; whether they have had improvements,” Dr. Wu said.
Cancer patient survival rates by year of diagnosis. Your hospital administration would definitely want to see if their patients’ survival improved over time, Dr. Wu said.
Making Yourself Meaningful
While your job as a cancer registrar is to present the data, the decisions are ultimately up to the CEOs, cancer committees and quality management teams; however, you are contributing a very important piece of the puzzle by taking the numbers and turning them into clues or coherent stories about the cancer program or patients.
Dunson, who said at first she was unaware of the comprehensive data contained in the registry, now can’t imagine what she’d do without it. “As a clinician you can’t see the whole picture unless somebody puts it in data fields for you—so that’s what the registrars do. They give us that big picture outlook,” she said. “I think the cancer registry speaks to the quality of the cancer program.”
And aside from the hospital, cancer program and cancer patients benefiting from your meaningful data, there’s one last person who will benefit from your hard work: You. That’s because by making your data meaningful, it, in turn will make you more meaningful to the hospital, said Natalie J. Copeland, RHIA, CTR, owner of M-ROCS. And that equates to registrars being seen as more important and more valuable.
“When administration begins to view us as more important because we’re affecting the revenue, that can help us to support our request for higher salaries,” said Copeland. “We’re moving into a different area. Hopefully 5 years from now, people will know who we are and what we do.” n
Ainsley Maloney is an assistant editor with ADVANCE.
Time to Shine
Pay-for-Performance (P4P) is coming in October, and considering that approximately 20 of the 134 measures are cancer-related—and most is data the cancer registrar already collects—P4P can be an excellent opportunity for cancer registrars to shine, said Natalie J. Copeland, RHIA, CTR, owner of M-ROCS.
“These are measures we already capture, or ones we can capture by building user-defined fields to collect them,” Copeland said. “It’s important for us to get involved in this so we can move from being a department that’s seen more as a cost center to one that is seen as affecting the revenue of the hospital.”
The problem is that it’s already July, Copeland said, and if you haven’t been approached by your administration to contribute, it’s likely they aren’t aware of your ability to affect the issue. “The administration is probably talking to three or four other different departments to get everybody to start collecting information—we’ve got to show them we can streamline it and have all of the data come from one place,” Copeland said.
To help cancer registrars step up and contribute to P4P, Copeland and Susan Bolick-Aldrich, director of the South Carolina Central Cancer Registry, are hoping to start a task force to assist cancer registrars through that transition from data collectors to data analysts.
Some of the goals of the task force will be to help cancer registrars move toward concurrent abstracting to collect more timely data and to raise hospital administrators’ awareness of the resource in the registry, so they can work together toward a common goal.
There is no time to fall behind, Copeland said, because eventually P4P is going to have quality measures developed strictly for cancer patients. “That is coming,” Copeland said. “So we really need to be the ones already collecting that cancer information on those current 20 cancer measures, so that when we get to that point, we are the place administration comes to for the collection and analysis of those measures.”
Looking Deeper into the Data
The reason cancer registrars are skilled data analysts isn’t because they know what keys to punch to pull up the data—it’s because they know how to analyze, interpret and piece together clues to give the data meaning.
Which is why, when you assess the proportion of your hospital cancer patients receiving guideline concordant care, or treatment consistent with what the National Comprehensive Cancer Network (NCCN) and/or the National Institutes of Health (NIH) recommend, there are a few tricks you need to look out for or the data will be skewed, said Xiaocheng Wu, MD, MPH, assistant director of the Louisiana Tumor Registry.
Here are some factors you must consider before deciding whether a patient received guideline concordant care:
1) Co-morbidity. Out of the proportion of patients who don’t receive guideline concordant care, look at those with severe co-morbid conditions and that might be the key factor as to why, Dr. Wu said. “For example, a person who is 75 years old and is sick with diabetes or heart problems may not receive chemotherapy because he or she is not a good candidate for that particular therapy.”
2) Receptor Status. When you assess the proportion of early stage breast cancer patients receiving hormonal therapy in your hospital, you have to know the estrogen / progesterone receptor status, Dr. Wu said, because hormonal therapy is recommended only to patients with receptor positive tumors and especially tumor size greater than 10 mm.
3) Incomplete data. Because some patients undergo surgery at hospitals, but then go to a physician’s office for post-hormonal therapy, many smaller registries don’t have the manpower to follow-up with every patient and collect full treatment data. This won’t produce accurate percentages of standard care. For this Dr. Wu recommends conducting special patterns of care studies: one year select one cancer site and follow up with each patient’s entire treatment from diagnosis to post-surgery.