Structure & Management Flashcards by Jessie Bigler

Themainpurposeofacancerregistryisto:

provideinformationtopreventandcontrolcancerandimprovecare

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Requiresthatacancerregistrybeamandatorycomponentoftheiraccreditedprogram

Commission on Cancer (CoC)

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Collectsdatafromselectedstatesandgeographicalareas

SEER - surveillance, epidemiology, and end results program

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Chargedwithestablishingcentralcancerregistriesinstateswheretheydidnotpreviouslyexist

NPCR - National Program of Cancer Registries

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Membershiporganizationrepresentingcancerregistryprofessionals

NCRA - National Cancer Registrars Association

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OverseestheUniformDataStandardsCommitteethatpromotesstandardizeddatatransmission

NAACCR - North American Association of Central Cancer Registries

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TheNCISEERProgramreceivespopulation-basedcancerdatafrom:

selectedgeographicalareas

*TheNCISEERProgramisanationalpopulation-basedcancerregistrythatmonitorsarepresentativesamplingofcertaingeographic
areasorabout26%oftheUSpopulation.SomeentirestatesreportcancerdatatoSEER,whilesomestatesonlyhavecertain
metropolitanareas,suchasDetroitandAtlantathatreportdatatoSEER.

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Participation in a specialty cancer registry is:

Voluntary.

Participationinaspecialtycancerregistyrisvoluntary.WhileCoCaccreditedcancerprogramsmustreporttheirdatatotheNCDB,
decidingtobeaCoCaccreditedcancerprogramisvoluntary.Therefore,datathatisreceivedbytheNCDBcomesfromthese
programsthathavevoluntarilysoughtCoCaccreditation.

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TheAmericanCancerSocietyestimatesthatoneofevery_____deathsinAmericaisfromcancer.

Four

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Hospitalcancerregistrarsobtaininformationaboutacaseforthecancerregistryabstractfrom:

thehospital’smedicalrecord
thefreestandingradiationcenteracrosstown
staffandnon-staffphysicianoffices

*Registrarsbridgetheinformationgapandcollectalloftheinformationfrommultiplesourcestocapturecompletecancerinformation
onalloftheirpatients

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Eachstandardsettingorganizationrepresentsvaryingregistryinterests.TheCoCrepresents:

Hospital Registries

*TheAmericanCollegeofSurgeonsCommissiononCancerisconcernedwithhospitalbasedregistries.Hospitalregistriessendtheir
datatotheCoC’sNationalCancerDataBase.

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Whichorganizationactsastheclearinghouseforchangestodatastandardsandstandardizestherequirementsforallstandard
settingorganizations?

NAACCR

*ProposedchangestodatastandardsaresenttotheNAACCRUniformDataStandardsCommittee.Thiscommitteeiscomposedof membersfromallofthestandardsettingorganizations.

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ThePolicyandProcedureManual:

promotesconsistency

servesasatrainingtool
containsthereportablelist

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Somevariablesthatmayeffectregistrystaffinginclude:

ACoS/CoCaccreditationstatus
completenessofthemedicalrecords
amountofdatatobecollected

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TheAmericanCancerSocietyestimatesthatabout_____________________newcasesofcancerwillbediagnosedin2014.

1.66million

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A Time-andMotionStudycanhelpdetermine:

staffingneedsandproductivityrequirements

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Themaincomponentsofaregistrybudgetare:

Capitalexpenses
Salariesandbenefits
Supplies

Fixedcosts

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Cancerregistrarswhoarecertifiedarerequiredtoacquire_______continuingeducation(CE)hoursevery_____year(s).

20, 2

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TheNationalCancerActof1971,oftenreferredtoasthe”WaronCancer,”establishedthe:

NationalCancerInstitute’sSurveillance,EpidemiologyandEndResultsProgram

NCI SEER

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Themonitoringcomponentforthehealthfacility’scancerprogramisthe:

cancerregistry

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Thecancerregistrars’certificationcredentialiscalledthe:

CertifiedTumorRegistrar

CTR

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Does a Central Cancer Registry use datatosupporttherequirementsoftheCommissiononCancer?

NO.

*HospitalregistriesusetheircancerregistrydatatosupporttherequirementsoftheCommissiononCancer.

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Thefirststepindeterminingstaffing,officespaceandequipmentneedsisto:

Establish the caseload.

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Nationalreportingrulesandrequirementsensurethatthedatacollected,regardlessofwhereitiscollected,is:

Standardized
*Thestandardsettingagenciesprovidesreportingrequirementstocancerregistries.Theserequirementsensure
thatwhatonecancerregistrarinonefacilitycollectsiscollectedthesamewayasanothercancerregistrarinanotherfacility-
whetheritbeinthesamecity,stateorontheothersideofthecountry.Thisiscriticalinbeingabletocombinedata
intolargerdatabasesandtobeabletocomparedatacollectedfrommanysources.Itiswhatmakesthedatameaningfultotheusers
ofthedata.

Under the HIPAA rules, can one hospital cancer registry provide follow-up and treatment information to a different hospital cancer registry?

Yes, as long as both hospitals have had a relationship with the patient

Under the HIPAA rules, can the hospital registry report cases of cancer to the central cancer registry?

Yes, a business agreement of patient authorization is not required.

Individually identifiable information includes all of the following:

The ability to deduct the patient's identity patient's address patient's treatment *Individually identifiable health information refers to information related to the patient.

The cancer registry should do which steps when evaluating confidentiality & security procedures: A Identify the risks of disclosure of confidential information B Create and implement a plan to reduce the risk of releasing confidential information C Train all department staff on the privacy and security of confidential information DMonitor the implementation and correct any breaches of policy and procedure

All of the above

Why does The HIPAA Privacy Rule requires a Business Agreement for business: Between a hospital and the American College of Surgeons Between a hospital and registrars under contract from a vendor

a business agreement is necessary for ACoS/CoC Accredited Cancer Programs to provide information for accreditation purposes. The Privacy Rule requires business agreements with entities that carry out health care functions on behalf of covered entities (vendors for contract services) while state and regional cancer registries are acting on behalf of the state, not the covered entity.

T or F Everyone who works in department, including unpaid volunteers,contract employees, and casual laborers,must be trained on HIPAA

True

T or F The HIPAA Privacy Rule allows sharing information between facilities if both had a relationship with the patient; state law allows for state registry staff to audit cancer information by viewing patient records.

True

Registrars have a professional | code of ethics published by which organization?

NCRA National Cancer Registrars Association

When were covered entities, other than small health plans, required to fully comply with the HIPAA rules?

4/14/2003

Confidentiality policies and procedures should protect the privacy of:

Patients Physicians Healthcare facilities

The HIPAA Privacy Rule gives an individual a right to an accounting of disclosures of their health information except:

Disclosures necessary to carry out treatment Disclosures necessary to file for billing reimbursement

The cancer registry's confidentiality policies and procedures for the release of cancer registry data should ... - Be approved by the institution and the cancer committee. -Clearly define circumstances under which the registry can release information. -Include employee confidentiality pledges. -All of the above

All of the Above

A return address using the words Cancer Registry, or other similar terms should not be used on envelopes containing materials or requests for information that are sent to patients primarily because:

It violates the patients privacy

T or F Hospital cancer registry employees with computer access to the facility's electronic medical record are allowed to look up information on their own noncancer related hospital admissions without having to go through the formal release of information process.

False *Cancer registrars have a lot of information at their fingertips, even more so if the facility has an electronic medical record. The cancer registry should only be accessing information that is necessary to complete assigned job duties.

Administrative laws or rules define which of the following for reporting cancer information to State cancer registries? - Who is required by law to report cancer cases -How to report cancer cases - Which cases must be reported - Penalties for non compliance -All of the above Why?

All of the Above Because: Statutory law is the legislation that requires state cancer reporting while the administrative law should clearly delineate who, what, when and how of cancer reporting. The administrative law provides the information to comply with the statute for reporting.

A community group wants to investigate a very rare type of cancer. The cancer registry provides a report with the survival rates grouped by the type of surgery and the primary surgeon. Is this violating confidentiality? Why?

Yes Confidentiality procedures should also protect healthcare providers in addition to the patient.

When the data is combined, which two agencies are able to provide data covering 100% of the U.S. population?

NPCR and SEER Approximately 96% of all cases of cancer diagnosed each year are reported to NPCR. This is due to the fact that the focus is covering the population. SEER and NPCR work in cooperation with each other. When the NPCR data is combined with the SEER data, 100% of population is included. National Program of Cancer Registries Surv, Epidemiology, and End Results

The process of converting the medical record information into standardized codes within a uniform data set is called:

Abstracting

The geographic areas selected for inclusion in the SEER Program was based on their:

Epidemiologically significant population subgroups. These geographic areas were selected for inclusion in theSEER Program based on their ability to operate and maintain a high quality population-based cancer reporting system. The population covered by SEER is comparable to the general US population with regard to measures of poverty and education. The SEER population tends to be somewhat more urban and has a higher proportion of foreignborn persons than the general US population.

The central cancer registry strives for the primary source of cancer cases to be from:

Reporting of cases by the facility that diagnosed and/or treat the patient. Other methods identify missing cases and help to improve casefinding processes so that the identification of cases is taking place where it should be - at the facility that diagnosed or treated the patient.

The primary foundation of data collection for cancer registration in the US is?

ACS - American Cancer Society **The primary foundation for cancer data is hospital registry.

Most central cancer registries require that _____________ be abstracted and reported.

Both analytic and non-analytic cases *Remember that the central registry is trying to identify all cases of cancer within a defined population. While it is important, for case ascertainment purposes there is less focus on why the patient was seen at the reporting facility and more on ensuring that all patients with a diagnosis of cancer are included.

Which cancer registries can calculate incidence and mortality rates?

State population-based cancer registry *Rates are calculated using the number of new cancer cases divided by the population at risk. The state registry has all of the known cancer cases within the state's boundaries. ***Only population-based registries can calculate rates.

``` Comparing the original source document to the coded data submitted to the central cancer registry to identify errors is a quality control activity called: ```

Re-abstracting Audit

Describe the National Cancer Data Base?

It is a Multi-hospital central cancer registry.

In a population-based central cancer registry, | what occurs in the patient merge process?

A list of patients that share some of the same patient identifiers is generated A list of possible patient matches is generated

What are the reporting requirementsfor the state central cancer registry?

State reporting requirements are defined by legislation and should include which cases to report (the reportable list), starting with January 1 of a given year (the reference date) and any ambiguous terminology that constitutes a diagnosis of cancer. Of course, other issues are addressed as well.

Case consolidation is a major responsibility of:

Central Registries

The committee responsible for providing a formal mechanism for reviewing and recommending proposed changes in data codes and/or the addition of new items to ensure that data remain comparable among central registries is the:

Uniform Data Standards Committee

The two main funding sources in | the United States for population-based cancer registries are:

NCI and CDC *The NCI funds the SEER Cancer Registries and the CDC funds the NPCR Cancer Registries. The NCDB is not a population-based central cancer registry and is funded by the ACoS and the American Cancer Society.

In addition to receiving cases of cancer from hospital registries and physician offices, the central cancer registry also identifies eligible cases through

Exchanging data with other state central cancer registries Matching death certificates with the central cancer registry database Matching pathology and cytology reports with reports from pathology laboratories

In a population-based central cancer registry, what occurs in the cancer case reconciliation process?

Multiple cancer records for the same patient that have been reported by several facilities are reviewed. These are merged (or reconciled) into one cancer record with the best information from all facilities.

``` State central cancer registries require the patient's street address, county and zip code primarily for which of the following? ```

The patient's address (street, county, zip) is used to geocode records to infer a geographic location that is used to aid in the investigation of suspected cancer clusters.

The January 1 reference date for | the start date of data collection by the registry is used by:

Both Hospital and Central Registries