cdc-npcr pilot projects using snomed ct encoded cap cancer checklists
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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 - PowerPoint PPT PresentationTRANSCRIPT
CDC-NPCR Pilot Projects Using SNOMED CT Encoded CAP
Cancer ChecklistsAPIII Annual Conference
Vancouver, British Columbia
Ken Gerlach, MPH, CTR
August 18, 2006
Role of Federal Government in
Health Data StandardsThe 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
NPCR
SEER
NPCR/SEER
REPUBLICOF PALAU
HAWAII
PUERTORICO
VIRGIN ISLANDS
ALASKA
Atlanta
Detroit
San Francisco/Oakland
LosAngeles
San Jose/Monterey
Seattle/Puget Sound
CT
NM
UT
IANJ
CA
LA
KY
*National Program of Cancer Registries (CDC)†Surveillance, Epidemiology, and End Results Program (NCI)
*`†
United States Cancer Statistics: United States Cancer Statistics:
2003 Incidence and Mortality2003 Incidence and Mortality Covers 96% of US Covers 96% of US
population for population for incidence, 100% for incidence, 100% for mortality mortality
State, regional, and State, regional, and national datanational data
Rates for whites, Rates for whites, blacks, Asians/Pacific blacks, Asians/Pacific Islanders, Native Islanders, Native Americans, and Americans, and HispanicsHispanics
http://www.cdc.gov/http://www.cdc.gov/cancer/npcr/uscscancer/npcr/uscs
Geographic Coverage of USCS, 2003
PUERTORICO
AK
HAWAII
CA
ID
WA
MT
WY
UT
CO
AZNM
TX
OK
KS
NE
SD
ND MN
WI
IA
ILOHIN
KY
WVVA
NC
GA
FL
ALMS
MO
AR
LA
NV
MI
PNNJ
NY MA
VT
NH
ME
TN
SC
MDDE
CT RI
DC
Registry contributed incidence data; all states contributed mortality data
OR
Atlanta
Detroit
SanFrancisco/Oakland
LosAngeles
Seattle/Puget Sound
San Jose/Monterey
REPUBLICof Palau
VIRGINISLANDS
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
Path Report
Op Report
History & Physical
Admissions
Dx Imaging
Other Records
HOSPITALREGISTRY
Summarize
NATIONALPROGRAMS
HL7 File:De-
identified Cancer
Abstract
CENTRALREGISTRY
HL7 File:Cancer
Abstract
Consolidate
Hospital B
Hospital C
PrivatePhysician
ReferencePath Lab
Hospital A
HL7 File:Clinical
HL7 File:Patient
Demographics
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
Laboratory System
Hospital Cancer Registry
Hospital Cancer Registry
Central Cancer Registry
Central Cancer Registry
Receive Specimen from
Surgeon
Prepare and Analyze
Specimen
Input Data into CAP Checklist
Transmit Checklist To
physician
Receive Report______________________
Exit/Send acknowledgement
Format Checklist: PHIN Standards
Receive Report______________________
Exit/Send acknowledgement
Cancer?
YesYes
A CDC-led effort to improvepublic health communicationsby using and promoting
healthdata and technology
standardsthat electronically enable: - detection and monitoring - data analysis - knowledge management - alerting - response
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
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
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
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
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
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
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?
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
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
MSH Data Type
Message Header SegmentNAACCR Opt/Req
NAACCR Data Item RPP Opt /Req
MSH-1 ST
Field Separator - the pipe, |, separates one field from another
R
R
MSH-2 ST
Encoding characters - separators within the fields ^ component separator ~ repetition separator \ escape character & subcomponent separator R
R
MSH-3 HD Sending Application O R
MSH-3.1 ISNamespace ID for the sending application
R
MSG-3.2 STCoded value for the name of the sending application
R
MSH-3.3 IDUniversal ID Type of for the seinding application ID
R
MSH-4HD
Sending Facility (facility that is sending this message)
R
7020, 7030, 7040, 7050, 7060 R
MSH-4.1 IS text name of the sending laboratory R R
MSH-4.2 STClinical Laboratory Improvement Act Identifier of the laboratory R
R
MSH-4.3 IDuniversal ID type
R R
Field Guide Table
Proposed Item Name for
RPP2CAP Checklist
Item Name
Field comm
entData type
SNOMED CT ConceptID
SNOMED CT Alpha
code Concept DescriptionNAACCR Data Item Number
Greatest dimension
Specimen Size NM 384627007 R-00417Specimen size, largest dimension
(observable entity)
Additional dimensions
Specimen Size SN 384626003 R-00416Specimen size, additional
dimension (observable entity)
Additional dimensions
Specimen Size SN 384626003 R-00416Specimen size, additional
dimension (observable entity)
SPECIMEN SIZE cannot be
determinedSpecimen Size ST 399606003 M-091CA not coded
SPECIMEN SIZE
Specimen Size ST 371475003 [R-00255 Specimen size (observable entity)
LATERALITY LATERALITY CE 384727002 F-048D0Specimen laterality (observable
entity)410
TUMOR SITE TUMOR SITE CE 371480007 R-0025A Tumor site (observable entity) 400
OBX Table
CAP Checklist Question
SNOMED Code NAACCR Data Item Name[Number]
NAACCR Data Item Code
CAP Checklist Answer
SNOMED Code
Checklist IdentifierR-10139, 406058005
Melanoma of the Skin
P1-40305, 35646002
Patient Name R-0025D, 371484003
Name--Last[2230], Name--First[2240], Name--Middle[2250], Name--Prefix[2260], Name--Suffix[2270], Name--Alias[2280], Name--Spouse/Parent[2290]
Surgical pathology number
R-002A2, 371482004 Path Report Number [7090]
MACROSCOPICF-048D6, 395526000
SPECIMEN TYPER-00254, 371439000 RX Hosp-Surg Prim Site [670] 20 Excision, ellipse
G-81FE, 396353007
Mapping Table
•IF “excision, wide” OR “re-excision, wide” is checked, AND IF lateral margin is uninvolved by invasive melanoma AND lateral margin is uninvolved by in situ melanoma AND deep margin is uninvolved by invasive melanoma AND• IF distance of lateral surgical margin is > 20 mm AND distance of deep surgical margin is > 20 mm THEN code 47 for RX hosp-Surg Prim Site.OR• IF distance of lateral surgical margin is > 10 mm AND < 21 mm AND distance of deep surgical margin is >10 mm and < 21 mm THEN code 46 for RX hosp-Surg Prim Site. • OTHERWISE code 20 for RX hosp-Surg Prim Site.
Specimen Type: Business Rule
Collaborative Staging Value CAP Protocol Item (CAP Checklist Answer) SNOMED Code Location on RPP2 Mapping Worksheet
CS Tumor SizeCodes 000–988
Tumor size, invasive component, greatest dimension [R-00418, 3843001] Row 29
Codes 989–998 No equivalent No equivalent No equivalent
Code 999 Cannot be determined [F-005C1, 399686001] Row 31
CS ExtensionCode 00
Any combination of histologic type and behavior code 2 EXCEPTPaget disease without invasive invasive carcinoma ; No listed histology with behavior code 3.
Rows 32-34 and/or Rows 41-53
Code 05 No equivalent No equivalent No equivalent
Code 07 Paget disease without invasive carcinoma [M85403, 2985005] Row 35
Codes 10 – 30 No equivalent No equivalent No equivalent
Code 40 PT4a: Extension to chestwall, not including pectoralis muscle [R-003C6, 373186004] Row 98
Code 51 & 52 No equivalent PT4b: Edema (including peau d’orange) or ulceration of the skin or breast or satellite skin nodules confined to the same breast (see CS code description - requires statement of percent of breast involved)
No equivalent[R-003C9, 37319002]
No equivalentRow 99
Codes 61 – 62 No equivalent (CS codes 40 & 51 and 40 & 52) No equivalent No equivalent
Code 71 & 73 No equivalent (requires a statement regarding percent of skin involved) No equivalent No equivalent
Code 95 PT0: no evidence of primary tumor [G-F182, 3988006] Row 86
Code 99 PTX: cannot be assessed [G-F187, 43189003] Row 85
Collaborative Stage - CAP Checklist
Messaging Issues
Versioning Nested questions Multiple primaries – message
structure How handle text
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
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
_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 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
MSH/PID/PV1ORC - 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 – " " " "
Multiple Primary - Structure
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 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
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
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 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?
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
Published on the NPCR web site www.cdc.gov/cancer/npcr/
Contacts Ken Gerlach 770-488-3008
Missy Jamison 770-488-7154 [email protected]
Sharon Winters 412-647-6390 [email protected]
Anil Parwani 412-623-1326 [email protected]
Thank you
Ken Gerlach
770-488-3008
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