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CDC-NPCR Pilot Projects Using SNOMED CT Encoded CAP Cancer Checklists. APIII Annual Conference Vancouver, British Columbia Ken Gerlach, MPH, CTR August 18, 2006. Role of Federal Government in Health Data Standards. The needed intervention is not for the government to set the standards, but

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cdc npcr pilot projects using snomed ct encoded cap cancer checklists

CDC-NPCR Pilot Projects Using SNOMED CT Encoded CAP Cancer Checklists

APIII Annual Conference

Vancouver, British Columbia

Ken Gerlach, MPH, CTR

August 18, 2006

role of federal government in health data standards
Role of Federal Government inHealth Data Standards

The needed intervention is not for the

government to set the standards, but

rather for them to convene the key

players and to mediate.

Donald W. Simborg

J Am Med Informatics Assoc

1996;3(4):250

federally funded cancer registries 2006

KY

LA

CA

Federally Funded Cancer Registries, 2006

Seattle/

Puget Sound

Detroit

CT

IA

San Francisco/

Oakland

NJ

UT

San Jose/

Monterey

Los

Angeles

NM

Atlanta

ALASKA

HAWAII

*

`

NPCR

REPUBLIC

OF PALAU

PUERTO

RICO

SEER

*National Program of Cancer Registries (CDC)

†Surveillance, Epidemiology, and End Results Program (NCI)

VIRGIN ISLANDS

NPCR/SEER

united states cancer statistics 2003 incidence and mortality
United States Cancer Statistics: 2003 Incidence and Mortality
  • Covers 96% of US population for incidence, 100% for mortality
  • State, regional, and national data
  • Rates for whites, blacks, Asians/Pacific Islanders, Native Americans, and Hispanics
  • http://www.cdc.gov/cancer/npcr/uscs
geographic coverage of uscs 2003

VIRGIN

ISLANDS

Geographic Coverage of USCS, 2003

Seattle/Puget Sound

WA

ME

MT

ND

MN

OR

VT

NH

WI

ID

MI

SD

NY

MA

WY

Detroit

CT

RI

PN

IA

San

Francisco/Oakland

NE

NJ

NV

OH

IN

IL

UT

DE

MD

San Jose/

Monterey

CO

WV

VA

DC

KS

MO

CA

KY

Los

Angeles

NC

TN

OK

AZ

SC

AR

NM

Atlanta

MS

AL

GA

LA

TX

AK

REPUBLIC

of Palau

FL

HAWAII

Registry contributed incidence data;

all states contributed mortality data

PUERTO

RICO

importance of pathology data for cancer surveillance
Importance of Pathology Data for Cancer Surveillance
  • > 92% cancer histologically-confirmed in pathology laboratories
    • Histology and Cytology
  • Key for complete and timely data
  • Rapid Case-Ascertainment
    • For cancers of special interest
    • Case-control studies
    • Clinical Trials
proposed cancer registry data flow

Hospital B

HL7 File:

Cancer

Abstract

HL7 File:

De-identified Cancer

Abstract

HL7 File:

Clinical

HOSPITAL

REGISTRY

CENTRAL

REGISTRY

NATIONAL

PROGRAMS

Summarize

Consolidate

HL7 File:

Patient Demographics

Hospital C

Private

Physician

Reference

Path Lab

Proposed Cancer Registry Data Flow

Hospital A

north american association of central cancer registries naaccr
North American Association of Central Cancer Registries (NAACCR)
  • Umbrella organization
    • Population-based cancer registries
    • Governmental agencies
    • Professional associations
    • Private groups
  • Purpose: To improve quality and use of cancer data

www.naaccr.org

cancer protocols project workflow
Cancer Protocols Project Workflow

Laboratory System

Hospital Cancer Registry

Central Cancer Registry

Receive Specimen from Surgeon

Receive Report

______________________

Exit/Send acknowledgement

Receive Report

______________________

Exit/Send acknowledgement

Prepare and Analyze

Specimen

Cancer?

Yes

Input Data into CAP Checklist

Format Checklist: PHIN Standards

Transmit Checklist

To physician

slide10
A CDC-led effort to improve

public health communications

by using and promoting health

data and technology standards

that electronically enable:

- detection and monitoring

- data analysis

- knowledge management

- alerting

- response

reporting pathology protocols rpp
Reporting Pathology Protocols (RPP)
  • Demonstration projects funded by CDC NPCR
  • Implement SNOMED CT Encoded CAP Cancer Checklists
  • In 2001
    • California and Ohio
    • Cancers of the colon and rectum
  • In 2004
    • California, Maine, and Pennsylvania
    • Cancers of the breast, prostate, and melanoma of the skin
rpp2 laboratory participants
RPP2 Laboratory Participants
  • Funded in 2004
    • California
      • City of Hope Hospital National Medical Center, California
    • Maine
      • Maine Medical Center and
      • Dahl Chase Labs
    • Pennsylvania
      • University of Pittsburg Medical Center
coc cancer program standard 4 6
CoC Cancer Program - Standard 4.6
  • The CoC requires that 90 percent of pathology reports that include a cancer diagnosis will contain the scientifically validated data elements outlined on the surgical case summary checklist of the College of American Pathologists (CAP) publication, Reporting on Cancer Specimens.
  • Protocols not Checklists
rpp1 project process
RPP1 Project - Process
  • Identify question concepts on Checklist without a LOINC code
  • Presentation to LOINC for codes
  • Clarify Content and Suggest Revisions to the Checklist with CAP Cancer Committee
  • Development and Consensus on Implementation Tables
  • Development of Evaluation Measures
rpp1 vocabulary
RPP1 Vocabulary
  • Logical Observations and Identifiers Names and Codes (LOINC)
    • Question – Metadata - Header - Data Item Name
  • Systematic Nomenclature of Medicine, Clinical Terms (SNOMED CT)
    • Answer – Data - Checkable line item - Data Item Codes
rpp2 vocabulary
RPP2 Vocabulary
  • Systematic Nomenclature of Medicine, Clinical Terms (SNOMED CT)
    • Question – Metadata - Header - Data Item Name
  • Systematic Nomenclature of Medicine, Clinical Terms (SNOMED CT)
    • Answer – Data - Checkable line item - Data Item Codes
snomed ct encoded cap checklist
SNOMED CT Encoded CAP Checklist

TUMOR SITE [R-0025A, 371480007] Tumor site (observable entity)

___ Cecum [T-59100, 32713005] Cecum structure (body structure)

___ Right (ascending) colon [T-59400, 51342009] Right colon structure (body structure)

___ Hepatic flexure [T-59438, 48338005] Structure of right colic flexure (body structure)

___ Transverse colon [T-59440, 485005] Transverse colon structure (body structure)

___ Splenic flexure [T-59442, 72592005] Structure of left colic flexure (body structure)

___ Left (descending) colon [T-59450, 55572008] Left colon structure (body structure)

___ Sigmoid colon [T-59470, 60184004] Sigmoid colon structure (body structure)

___ Rectum [T-59600, 34402009] Rectum structure (body structure)

___ Not specified [T-59000, 14742008] Large intestinal structure (body structure)

why hl7 version 2 3 1
Why HL7 Version 2.3.1?
  • In 2001 – For First Project – Reasonable, National Standard
  • For Second Project, proposed HL7 Version 2.5 – Vendor pushback
    • Vendors using Version 2.3.1 and Version 2
  • AP Laboratory community appears to be using this Version
    • Challenge – Transition to More Robust Formats
rpp messaging tables
RPP Messaging Tables
  • HL7 Version 2.3.1
    • Field Guide Table
    • OBX Table (CAP Checklist Concepts)
    • Maps of CAP Checklists Concepts to NAACCR Data Items
    • Map from Collaborative Stage to CAP Checklist Concepts
messaging issues
Messaging Issues
  • Versioning
  • Nested questions
  • Multiple primaries – message structure
  • How handle text
types of versioning
Types of Versioning
  • SNOMED CT – updated every January and July
  • CAP Cancer Checklists – may be updated every January and July
    • Date of Checklist – for major changes
  • SNOMED CT Encoded CAP Cancer Checklists – may be updated every January and July
    • No mechanism
melanoma issue nested concepts
Melanoma Issue: Nested Concepts
  • SPECIMEN TYPE [R-00254, 371439000] Specimen type (observable entity)
  • ___ Excision, ellipse [G-81FD, 396353007] Specimen from skin obtained by elliptical excision (specimen)
  • ___ Excision, wide [G-81FE, 396354001] Specimen from skin obtained by wide excision (specimen)
  • ___ Excision, other (specify): ____ [G-81FF, 396355000] Specimen from skin obtained by excision (specimen) (specify): ____ not coded
  • ___ Re-excision, ellipse [G-8202, 396357008] Specimen from skin obtained by elliptical re-excision (specimen)
  • ___ Re-excision, wide [G-8203, 396358003] Specimen from skin obtained by wide re-excision (specimen)
  • ___ Re-excision, other (specify): _____ [G-8201, 396356004] Specimen from skin obtained by re-excision (specimen) (specify): ____ not coded
  • ___ Lymphadenectomy, sentinel node(s) [R-003AF, 373193000] Lymph node from sentinel lymph node dissection (specimen)
  • _X_ Lymphadenectomy, regional nodes (specify): _axillary_ [G-8204, 396359006] Lymph node from regional lymph node dissection (specimen) (specify): ____ not coded
  • ___ Other (specify): ____ not coded
  • ___ Not specified [G-8110, 119325001] Skin (tissue) specimen (specimen)
cwe with repeating segments
CWE With Repeating Segments
  • _X_ Lymphadenectomy, regional nodes (specify): _axillary_ [G-8204, 396359006] Lymph node from regional lymph node dissection (specimen) (specify): ____ not coded
  • OBX|1|CWE|371439000^Specimen type (observable entity)^SCT^^^^^SPECIMEN TYPE||396359006^Lymph node from regional lymph node dissection (specimen)^SCT^^^^^^Lymphadenectomy, regional nodes (specify)~^^^^^^^^axillary||||||F
multiple specimen cancers scenarios
Multiple Specimen/Cancers Scenarios
  • One specimen to two or more cancers with the same primary site
  • One specimen to two or more cancers with different primary sites
  • Many specimens to two or more cancers with the same primary site
  • Many specimens to two or more cancers with different primary sites
slide30

Multiple Primary - Structure

MSH/PID/PV1

ORC - Specimen         OBR – Part 1 and Worksheet 1 (type)                OBX – Heading/Question and Value                OBX – " " " "                OBX – " " " "        OBR – Part 1 and Worksheet 2 (type)                OBX – Heading/Question and Value                OBX – " " " "                OBX – " " " "        OBR – Part 3 and Worksheet 3 (type)                OBX – Heading/Question and Value                OBX – " " " "                OBX – " " " "

incorporate text
Incorporate Text
  • For the transmission of text data, RPP2 will rely upon the NAACCR E-Path transmission standards as noted in NAACCR Volume V
recommendations
Recommendations
  • All cancers are not reported via an existing checklist
    • Need strategy for the remainder
  • Multiple histology and primary rules may differ
    • Examine coding rules used by pathologists for consistency with cancer registry rules
  • Checklists need to be assessed for stage information
    • Collaborative stage
recommendations1
Recommendations
  • Cancer registry community needs to evaluate
    • Expand NAACCR E-Path standards to synoptic
    • Establish mapping between checklist data items and NAACCR data items
  • Informatics community needs to assess vocabulary and mapping issues
    • Establish the question and answer vocabulary
recommendations2
Recommendations
  • Examine costs associated with synoptic reporting
    • Cost for pathology lab software (AP LIS)
    • Cost for SNOMED CT Encoded CAP Checklists
  • Pathology lab software vendors
    • Add text fields to synoptic reports
    • Add drop-down menus for histology codes
potential
Potential
  • Reduce coding from narrative text
  • Facilitate the abstracting process
  • Capture intent of pathologists
  • Improve rapid case-ascertainment systems
  • Create more complete case reports
  • Improve completeness of reporting
an idea whose time has come
An idea whose time has come?
  • Work through issues of vocabulary and mapping
  • Work through staging issues
  • Implement checklists more quickly
  • Integrate into cancer registry software
    • Abstract
    • Rapid Case-Ascertainment
rpp report
RPP Report
  • Published on the NPCR web site
    • www.cdc.gov/cancer/npcr/
contacts
Contacts
  • Ken Gerlach 770-488-3008 kgerlach@cdc.gov
  • Missy Jamison 770-488-7154 mjamison@cdc.gov
  • Sharon Winters 412-647-6390 winterssb@upmc.edu
  • Anil Parwani 412-623-1326 parwaniav@upmc.edu
thank you
Ken Gerlach

770-488-3008

kgerlach@cdc.gov

Thank you

The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention