Cancer Registars: Is Concurrent Abstracting that Scary?

by Holly J. Kulhawick, CTR

ThinkstockPhotos-180686516Concurrent abstracting is the process of completing the cancer registry abstract in stages after each treatment occurs, rather than all at one time, four to six months after diagnosis. Some registries have always abstracted concurrently, but others are finding—or at least feeling as if—they are being forced into concurrent abstracting by the new Commission on Cancer (CoC) requirement to submit to the Rapid Quality Reporting System (RQRS). RQRS is a reporting and quality improvement tool that provides real-time clinical assessment of hospital-level adherence to quality of cancer care measures. On January 1, 2017, participation in RQRS will become mandatory for all CoC-accredited cancer programs.

Facing Down the Fear

Recent discussions on the National Cancer Registrars Association’s Facebook page indicate a high level of anxiety among those converting to concurrent abstracting. As with all fears, this one is best dealt with by facing it down and examining it under a bright light. Is concurrent abstracting really that difficult? No. Does it take more time? Sometimes. Cancer programs implementing concurrent abstracting for RQRS, can use resources on the RQRS website to help with updates and data quality assurance. CoC-accredited facilities can log on to CoC DataLinks to access their RQRS data. The password-protected site provides monthly alerts on the patients submitted to RQRS as well as updates on the treatment administered, offered, or recommended.

As CTRs embark on concurrent abstracting, they need to release the mantra that it has no advantages. Instead, recognize that this is the best way to provide quality, up-to-date cancer data, and accept the challenge. A major concern when converting to concurrent abstracting is who completes the updates. Certified Tumor Registrars (CTRs) are fiercely territorial regarding their work. This is not a helpful position to take when conducting concurrent abstracting. It is important to allow different members of the team to take turns updating the cases. In doing so, registrars may find that two sets of eyes are better than one at spotting errors or capturing all the nuances of a case. This can also prove to be an advantage in improving data quality and fostering teamwork.

Another concern is the need to return repeatedly to cases to provide treatment updates. To many CTRs, this seems like a doubling of the work. It does increase the time in certain abstracts, but the improvement in quality can be an offsetting factor. Think about it. How many times is an abstract seen only once? Not many, since in many large cancer registries the tasks are assigned to different staff members. One person may load the case and another may add surgeries and biopsies. Some registries use an automated system to load radiation or chemotherapy data with a staff person conducting follow-up months later. This same type of work plan can be used for concurrent abstracting. Allowing several staff to construct and review the abstract can also assist with quality assurance (QA). If only one person is assigned to conduct QA, they may be less attentive. If they know others will be reviewing the abstract, they may be more conscientious.

Data Clinicians Want and Need

Physicians have long complained about the latency of cancer registry data. Concurrent abstracting and RQRS help to address their concerns. Cancer registrars must respond. The cancer registry data does take too long to collect and to be put to use. Today, everyone wants instant results and oncology is no different. Any patient’s case can spiral out of control over a matter of days. Clinicians want to be able to monitor and respond as close to real time as possible. If it takes cancer registrars four to six months to even start a case, they are not providing clinicians with the data that they want and need—data that helps ensure high-quality cancer treatment and care.

Programmatic Benefits

The cancer registry department also benefits from concurrent abstracting. In addition to physicians valuing real-time data, your facility’s Finance and Administrative departments will too. They can analyze the data to help improve operations and services. As a result, these departments see the cancer registry fulfilling a vital need for the organization. This can often lead to more timely responses to requests for budget items, IT support, and additional staff. The cancer registry database can also be used to prepare tumor conference presentation forms. In many facilities, the completion of these forms is very involved, requiring registry staff to create the equivalent of an abbreviated abstract. This is a drain on staff time, since most tumor conferences occur monthly. With concurrent abstracting, the timely data can be merged to populate the forms, reducing the time to just minutes per form. Clinical staff appreciate the results and the doctors no longer need to haul office medical records to tumor conferences.

A near-to-real-time cancer registry database can also help in preparing Survivorship Care Plans (CoC Standard 3.3). To assist with these plans, cancer registry departments may want to consider educating nurse navigators on the database and providing them access so that they can update chemotherapy and/or offsite treatments. Sharing the database will not only help with these important plans, but will also foster a sense that the registry belongs to the team, not just CTRs.

Moving to concurrent abstracting may seem daunting—and, yes, even scary—but it’s an important step that can support and advance the work of the entire cancer care team.

Guest blogger Holly J. Kulhawick, CTR, is Supervisor, Cancer Registry, at ACCC Cancer Program Member Renown Health in Reno, Nevada.

Patient-Centered Approaches to Improving Population Health


by Susan van der Sommen, MHA, CMPE, FACHE

Crowd of multidisciplinary people-for webAn increasingly prevalent term in our health-related vocabulary is “population health.”  Every journal or health-related article uses the term as if it is widely understood. So what is it, really? How will we measure it and, more importantly, improve it?

The oft-quoted article by Kindig and Stoddart (2003), “What is Population Health?”  defines population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Whereas others have also sought to define the term, in my readings and research, I have yet to come across a more comprehensive—yet startlingly straightforward—explanation.  In his paper, Population Health in the Affordable Care Act Era, Michael Stoto, PhD, notes that despite differing definitions, the term “population health” is seen by many as an opportunity to connect healthcare delivery systems with community-based organizations, public health departments, and other entities to reach community members that may not access the traditional healthcare system effectively and/or receive the care they need.

Leaders at the Duke Cancer Institute  in Durham, North Carolina, have adopted a new approach to research and patient-centered care; that is, collaborating with local community members and groups to improve education, outreach, and access for their most disparate – and often underserved – populations. Their patient-centered approach, designed to assess and respond to community needs, increase participation in clinical trials (particularly for minority populations), and mitigate care gaps, is being implemented as part of a five-step strategic plan. At the core of the plan is the development of a Community Advisory Council, inclusive of community partners and patients, and the broad dissemination of findings in their robust community needs assessment. Resulting from these two initiatives was a prioritization of program and research activities with further development of programs and partnerships focused on the highest priorities defined by the council’s work. Of course, measurement and evaluation is at the core of all population health initiatives – and is the fifth component of Duke Cancer Institute’s strategic plan. Learn more.

The Duke Cancer Institute is seeking to meet the health needs of their population in a manner that is pertinent to all cancer centers and healthcare organizations. Defining a population’s needs through community partnerships and patient involvement is the key to being able to measure and ultimately improve health outcomes.

In a more widespread population health initiative,  ACCC has recently launched its Optimal Care Coordination Model for Lung Cancer Patients on Medicaid project with support from the Bristol-Myers Squibb Foundation. Research shows that minority and socio-economically disadvantaged individuals have higher incidence of cancer, are diagnosed at a later stage, and have a higher mortality rate. To address this unmet need, ACCC is currently partnering with five ACCC-member programs located in different geographic regions throughout the U.S. These programs are serving as Development Sites, helping ACCC document the current state of care coordination for Medicaid patients with lung cancer. This will help inform draft principles for development of a model for a more comprehensive, evidence-based approach to care coordination, access, and health equity for Medicaid patients with lung cancer. Read more about this exciting initiative in the September/October issue of Oncology Issues.

Make plans to attend the 2016 National Oncology Conference  in St. Louis, Missouri from October 19-21 to learn best practices from your colleagues at cancer programs across the country.

Susan  van der Sommen, is Executive Director, DSRIP, Bassett Healthcare Network, and Chair of the ACCC Editorial Committee.

Tele-Health Technology Connects Patients with Nutrition Services

by Nicole Esco, MPA, RD, LDN

Innovator Seal16singularAfter receiving a cancer diagnosis, patients suddenly face a schedule full of appointments. Not only can this be overwhelming, the schedule can also leave patients feeling that there is little room for additional, potentially beneficial appointments such as a consultation with an oncology dietitian. Even when patients want to schedule a visit with the dietitian, transportation is often a barrier and a source of additional stress for patients unable to drive or with limited support at home. Those living in rural communities may have to travel a significant distance just to receive their treatments, and as care providers we want to limit the burden on our patients.

At Baton Rouge General Medical Center Pennington Cancer Center in Baton Rouge, Louisiana, all patients receiving radiation therapy have access to the services of a registered dietitian for individual nutrition consultations, follow-up care, and referrals to community resources. Some patients will encounter challenges with eating during treatment, and the dietitian can ensure that these patients have the tools to manage any side effects that may interfere with eating well, adequate hydration, and maintaining a healthy weight.

Registered dietitians apply evidenced-based nutritional intervention to improve patient outcomes. For example, patients at high nutritional risk (those with cancers of the head and neck, stomach, pancreas, and lung, and patients receiving tube feeding/IV nutrition) need weekly follow-up since they are at greater risk for eating difficulties, dehydration, and/or maintaining a healthy weight due to treatment side effects.  But the fact is that scheduling a separate appointment with the dietitian in addition to their daily treatment schedule and other medical appointments is challenging for these patients. At Pennington Cancer Center our focus is on providing patients with comprehensive care with as little disruption to their schedules as possible.

Delivering Care Close to Home

In 2014, Pennington Cancer Center expanded its radiation oncology services, adding a third center located in Zachary, Louisiana, 16 miles north of our Baton Rouge clinics. This new clinic serves the surrounding rural communities in Louisiana and Southern Mississippi –areas where patients previously had to travel significant distances to receive radiation treatment.

Pennington Cancer Center is committed to ensuring that nutrition services are available to all patients undergoing radiation treatments. Our challenge: finding a way to make these services convenient for patients and efficient for staff scheduling.  As a result, we explored various telemedicine solutions. One challenge was finding a telemedicine option that was both HIPAA-compliant and easy for staff to use. We wanted a program that provided secure data transmission, safeguarding patient information. Our IT team was integral in helping us to implement an effective telemedicine program and ensure the security of video conferencing.

Today, we offer patients virtual nutrition counseling sessions conveniently scheduled when they are already at the radiation center for their daily treatment appointment.  Scheduling these sessions in conjunction with their treatment schedule eliminates the need for additional appointments or having to arrange transportation to other clinics for an in-person visit. These virtual sessions provide patients with the same nutrition information and resources that they would receive if they were meeting with the dietitian face-to-face.

During these virtual sessions, the dietitian’s role is to engage the patient and help build rapport. Video conferencing is a new concept for a lot of our patients, and some are more comfortable initially than others. On the other hand, some patients are very comfortable and open up immediately. Watch our short video to learn more.

Pennington Cancer Center’s initiative Tele-Health Technology Connects Patients with Nutrition Services is being recognized with a 2016 ACCC Innovator Award. Join us at the ACCC 33rd National Oncology Conference in October and learn more about how we implemented this patient-centered service.

Guest blogger ACCC member Nicole Esco, MPA, RD, LDN, is the registered dietitian in the Radiation Oncology Center, Pennington Cancer Center Baton Rouge, LA.



CMS Eases MACRA Quality Payment Program Timeline

By Leah Ralph, Director of Health Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoIn response to considerable pressure from industry stakeholders, medical groups and policymakers, the Centers for Medicare & Medicaid Services (CMS) announced last week that it would provide increased flexibility for practices to report out and comply with new data and performance requirements under the Quality Payment Program (QPP), created by the Medicare Access and CHIP Reauthorization Act (MACRA) passed last year.

In a blog post titled “Plans for the Quality Payment Program in 2017: Pick Your Pace,” Acting CMS Administrator Andy Slavitt lays out four pathways to compliance with the new Quality Payment Program (in order of easiest to the hardest):

  • Report some data.  Providers can avoid a negative penalty by submitting some data as required by the Quality Payment Program, including data from after January 1, 2017. CMS states this option is “designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019.” This option allows you to avoid a negative payment adjustment in 2019.
  • Participate for only part of the calendar year. Providers may submit data as required by the Quality Payment Program for a reduced number of days (not the whole year), and the performance period could begin after January 2017. Under this option, you could still qualify for a small positive payment adjustment in 2019.
  • If you’re ready to go in 2017, participate for the full calendar year. For practices that are ready to go and choose this option, their performance period will begin January 1, 2017, and they will submit data under the Quality Payment Program for a full year. These practices will qualify for a modest positive payment adjustment in 2019. CMS expects many practices will be able to do this.
  • Participate through an Advanced Alternative Payment Model (APM).** While the three previous options would fall under the Merit-Based Incentive Payment System (MIPS) track, the fourth option allows providers who are receiving a certain percentage of Medicare payments or seeing a certain number of Medicare patients through a qualifying APM (the provider is taking two-sided or “more than nominal” risk) to participate through the Advanced APM track. These providers would qualify for a 5% incentive payment in 2019 in addition to any savings produced through the APM and would not be subject to MIPS requirements. (**Remember CMS lays out a very high bar to qualify for the APM track in the proposed rule: 90% of physicians are expected to choose MIPS).

Until 2019, physicians will see an annual 0.5% increase in payments, at which point payments will then be determined by performance in the Quality Payment Program either through MIPS or an advanced APM.

CMS has said the decision to provide leniency was in recognition of the “wide diversity of physician practices.” The agency has also said it is considering alternative start dates, shorter performance periods, increased flexibility for small or rural practices, and finding other ways for physicians to get more experience with the program requirements before being penalized.

CMS originally proposed that providers begin to report on measures outlined under the Quality Payment Program in January 2017 but that payments would not reflect that performance period until 2019. However with the new guidance from CMS, the easiest option essentially does not require real provider participation in 2017, but allows providers to test whether their systems are ready to fully participate in the future. While the details of the measures will remain unclear until a final rule is released, the Quality Payment Program will require practices to submit information on quality measures, how they use technology, and what improvement activities they are undertaking.

Through our comments to the agency in  June, ACCC advocated for increased flexibility and more time for physicians to prepare for undertaking the new requirements under the Quality Payment Program. We also asked the agency to restructure the APM requirements so that they are more achievable.

We commend CMS for releasing flexibility prior to a final rule on MACRA, which we expect to see later this fall, and ask for continued accommodations for practices that face myriad new requirements in the coming months and years.

CMS Coding Flexibility Ends October 1

Form-with-stethoscopeBy Cindy Parman, CPC, CPC-H, RCC

When the implementation of the ICD-10-CM coding classification became effective on Oct. 1, 2015, the Centers for Medicare & Medicaid Services (CMS) promised not to consider the reporting of an unspecified diagnosis code an audit error. This grace period was a limited benefit at best, since providers don’t want to be audited at all and when audited, diagnosis coding is often the least of their worries. As a result, CMS appeared to be benevolent and all providers (falsely) believed that diagnosis codes were not as important as procedure codes. Effective Oct. 1, 2016, this flexibility period will end, although the close of this grace period actually changes nothing.

However, on Oct. 1, 2016, updates to the ICD-10-CM Official Guidelines for Coding and Reporting go into effect, which will add more than 1,900 new diagnosis codes to the classification. Given the need for specific diagnosis codes, hospitals, physician practices and freestanding cancer centers should consider the following:

  • Clinical documentation should be as specific as possible to ensure that all patient medical conditions are fully described. Many facilities implemented clinical documentation improvement programs prior to the implementation of ICD-10 and it may be necessary to revisit this training.
  • All providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible. ICD-10-CM has more detailed and specific codes than in the prior classification, which improves the accuracy of patient classification.
  • Although unspecified codes will continue to be accepted when there is a lack of clinical information, they should be avoided when possible. Medical coders should query the physician when nonspecific information is included in the medical record to ensure that the patient’s conditions and illnesses are fully classified.
  • Diagnosis codes frequently report the medical necessity for the service performed and should be as accurate and complete as possible. Providers should concentrate documentation efforts on the diagnoses treated most often and denials should be carefully reviewed to ensure coverage requirements are met.
  • As physician reimbursement shifts from fee-for-service to a quality and/or value-based payment system, reporting all primary medical conditions, comorbidities, and complications will ensure accurate reimbursement.

Since most, if not all, of the major insurers did not adopt any type of diagnosis coding flexibility over the past year, providers should already be fully documenting the patient’s medical condition and reporting all diagnosis codes at the highest degree of specificity. The updated CMS ICD-10-CM FAQs page is located here .

Guest blogger Cindy Parman, CPC, CPC-H, RCC, is a principal at Coding Strategies, Inc., Powder Springs, Ga.  She authors the “Compliance” column for Oncology Issues, the journal of the Association of Community Cancer Centers.

What’s the Skinny On Skin?

Salon Professionals Performing Skin Cancer Outreach

By Robin Travers, MD

With Labor Day Weekend summer officially winds down. Despite the approach of crisp fall days and cooling of temperatures, it is still vital to take proper sun safety precautions all year round. Skin cancer is by far the most common type of cancer around the world, and most (but not all) skin cancers are related to exposure to ultraviolet (UV) light from the sun. Guest blogger dermatologist Robin Travers, MD, shares a unique community outreach program that other cancer programs can adapt to their community’s skin cancer prevention needs.

A Unique Opportunity

Estheticians and other salon professionals are in a unique position to take note of unusual growths on their client’s skin and initiate an important conversation that may ultimately save a patient’s life! These warning signs sit right on the skin’s surface, and using a few simple rules, a beauty professional is in a terrific position to be able to recognize them and save a life.

Estheticians, hair stylists, nail technicians, and massage therapists can play an important role in recognizing all three types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma. Which is why the Melanoma Foundation of New England’s Skinny on Skin program is a critical education tool for beauty industry professionals.

The Skinny on Skin program is offered as an on-site educational session to groups of salon professionals who take advantage of the MFNE’s commitment to free professional skin cancer education. New England-based hair stylists are invited to register for local Skinny on Skin training events online. In addition, Skinny on Skin has developed a web-based training platform, allowing salon professionals across the United States to take advantage of this proven educational program without geographic, time, or financial barriers.

If caught in its early stages, melanoma is highly curable and salon professionals can play an important role in making this a reality.  The comfortable, friendly relationship a salon professional frequently has with a client offers the perfect setting for an alert esthetician or massage therapist to encourage the client to seek further medical attention for a potentially deadly skin cancer.

In fact, a 2011 study published in JAMA Dermatology,1 showed that, even though very few hair professionals had received any formal skin cancer education, many stylists already informally examine the skin of the head and neck and offer skin care advice as part of their profession. This study showed that salon professionals could be armed with confidence from a skin cancer educational session.


Knowing a few simple warning signs of melanoma allows salon professionals to be instrumental in finding early skin cancers and helping clients get help early. The Skinny on Skin program asks salon professionals to look for these “ABCDEs” of melanoma.

  1. Asymmetry. Benign, normal moles should be symmetric. If you mentally draw a line through the middle of a mole, the two sides should match. If they do not, this asymmetry may be an early warning sign for melanoma.
  2. Border irregularity. Benign moles have a smooth, even border.
  3. Color. There is no single color that is worrisome. The key is that a mole should be evenly colored throughout.
  4. Diameter. Benign moles are usually less than 6 mm in size. Moles that are larger moles than a pencil eraser size are thought to be more worrisome for melanoma.
  5. Evolution. Benign moles tend to look the same over time. If a mole starts to evolve or change in size, shape, symptoms, color, or elevation, this may be an early sign of melanoma.

Far more people visit their estheticians, hair stylists, and other salon professionals on a regular basis than their dermatologist. Salon professionals see their clients every few months and build a trusting relationship over time.  This puts them in a unique position to save their client’s life by spotting any unusual spots on their skin that may be early skin cancers and directing them to the appropriate professional for treatment. As part of their community outreach and prevention efforts, cancer programs may want to consider reaching out to salon professionals in their community with education similar to what the Melanoma Foundation of New England has done with its Skinny on the Skin program. Learn more at:


  1. Bailey EE, Marghoob AA, Orengo IF, Testa MA, White VR, Geller AC. Skin cancer knowledge, attitudes, and behaviors in the salon: a survey of working hair professionals in Houston, TexasArch Dermatol. 2011;147(10):1159-1165.

Dr. Robin Travers is a dermatologist at SkinCare Physicians in the Boston, Mass., area. She writes a monthly column in JAMA Dermatology summarizing the most relevant and exciting recent dermatology research. Dr. Travers serves on the Medical Advisory Board of the MFNE and coaches MFNE’s Marathon Team for the Boston Marathon every year.

A longer version of this blog was published in the July/August 2016 Oncology Issues.

Will Spending More on Healthcare Result in Better Cancer Outcomes?

by Chad Schaeffer, MS, FACHE

Healthcare costsA recent study published in the Journal of the National Comprehensive Cancer Network finds that spending more on healthcare does not always correlate to better outcomes.  The authors of the article, “Wealth, Health Expenditure, and Cancer: A National Perspective,” studied different areas of the U.S. and looked at the wealth, spending, and cancer outcomes for breast cancer, colorectal cancer, and all cancers.1

The researchers, led by Dr. Jad Chahoud, point out that in 2013 the U.S. spent $2.9 trillion on healthcare—more than any other country—yet ranked 27 in life expectancy compared with the 34 countries that comprise the Organization for Economic Co-operation and Development (OECD).  Their conclusion is that the U.S. healthcare system is flawed by an unequal resource allocation and socioeconomic disparities. This has long been the case when the U.S. is compared to many European countries, which have universal healthcare or a single-payer system and access to healthcare is often more consistently available to all citizens.

However, things get very interesting when the researchers compare different regions within the U.S. and find differences in cancer outcomes. When looking at colorectal cancer and all cancers, the common theme is that wealthier states, such as New York, Illinois, and California, tended to have better outcomes compared to the least wealthy states, such as Mississippi, West Virginia, and Alabama. The wealthier states spent more per capita, but not necessarily for healthcare. For instance, West Virginia spent more on healthcare per capita ($7,667.14) than Illinois ($6,756.36), but the outcomes for colorectal and all cancers are better in Illinois.




Mortality/Incidence Ratio (colorectal cancer) Mortality/Incidence Ratio
(all cancers)
Illinois 0.3652 0.3823
West Virginia 0.3936 0.4306

Yet for breast cancer, the researchers discovered that paying more did correlate with better outcomes.  They surmise that this could be the result of effective breast cancer screenings and an overall high level of breast cancer awareness.


As I read the article and the findings from the study, two or three points come to mind. The first point is that since the extra spending on healthcare was effective for breast cancer, and—if the authors are correct that screening was a major factor—this could be good news for colorectal cancer if we can continue to improve screening rates. The second point is that with the new emphasis from Medicare and other payers on paying for quality, perhaps there will be an improved value in our healthcare system, leading to better outcomes. The last thought is that with the Affordable Care Act in place for several years and more Americans now having health insurance, and with a greater emphasis on screenings, would this potentially change the outcomes?  It is too early to say for certain, but if screenings rates improve, this will likely make a difference in overall outcomes.  We will have to wait and see.

Chahoud J, Rieber AG, Semaan A. Wealth, health expenditure, and cancer: A national perspective. J Natl Compr Cancer Netw. 2016;14:972-978.

ACCCBuzz contributing blogger Chad Schaeffer, MS, FACHE, is Executive Director of the Edwards Comprehensive Cancer Center at Cabell Huntington Hospital. He serves on the ACCC Editorial Committee.

Three Ways to Support Your Cancer Registrars

By Linda Corrigan, MHE, RHIT, CTR

Check boxCommission on Cancer (CoC) Cancer Program Standards 2016 are designed to ensure a comprehensive approach to the care and treatment of patients. Cancer programs seeking CoC accreditation must demonstrate that they’ve met or exceeded these standards—many of which require data tracking. Your cancer registrar can assist your clinicians in designing the best “tracking tool” for your program. For many programs, the best tool will be your cancer registry software. Cancer registrars well-versed in high quality data collection are key to the success of a cancer program. In turn, there are three critical ways your program can support its cancer registrars:

  • Make sure your cancer registrars are up-to-date by supporting training and continuing education opportunities. Change is a constant in the world of oncology. Treatments are advancing, CoC standards are added and/or revised, and state cancer registry data-collection guidelines are updated annually. A prime example of this constant change is the American Joint Committee on Cancer’s (AJCC) soon-to-be-released Cancer Staging Manual. The new 8th edition, scheduled for publication in October 2016, will revise how cancer is staged.
  • Encourage your cancer registrars to get involved in state and national organizations and provide funds for them to attend meetings and conferences. The key to helping your cancer registrar stay current is networking and continuing education. Some registrars have as many as three separate organizations and/or federal agencies that “set” the standards for exactly how and what data are collected from a facility’s cancer program. Cancer registrars who attend national conferences and state meetings or who are encouraged to volunteer for national and state-level organizations develop a network of colleagues from across the country that can be tapped as a resource when your program has questions.
  • Staff your cancer registry appropriately. The best way to support and retain your cancer registrar and to ensure high-quality data collection is to make sure you have the staffing bandwidth for the number of cancer cases your facility manages each year. Review NCRA’s Workload and Staffing Study: Guidelines for Hospital Cancer Registry Programs to help assess your staffing needs.

The National Cancer Registrars Association (NCRA) and the Association of Community Cancer Centers (ACCC) are two national associations that can help cancer programs support their cancer registrars. NCRA’s Annual Educational Conference provides a thorough and cost-effective way for cancer registrars to stay informed and to network. Attendees learn about updates to treatments and staging, CoC standards, clinical trials, and national trends. The 2017 conference, scheduled for April 5-8, in Washington, D.C., will focus on the AJCC’s 8th edition of the Cancer Staging Manual. Look for conference updates on the NCRA website here.  NCRA’s Center for Cancer Registry Education is a learning management system designed to provide easy access to high-quality educational programming. The website offers a variety of online products to help registrars tailor training and manage the continuing education credits needed to maintain their Certified Tumor Registrar (CTR) credential.

ACCC is also a great resource for cancer registrars. ACCCExchange, the association’s online member discussion forum, connects registrars with peer-to-peer solutions, strategies, and resources for how to best meet CoC standards. ACCC’s journal Oncology Issues provides in-depth articles on programmatic innovations implemented by ACCC member programs, coding updates, and advocacy issues—and can be a valuable resource for registrars to better understand advancements in cancer treatment and care. Coming in October, the ACCC 33rd National Oncology Conference in St. Louis will focus on practical “how to’s” for cancer programs and practices, with peer-to-peer learning on process improvement strategies, putting data to work to improve care, and more. Learn more here.

Contributing blogger ACCC member Linda Corrigan, MHE, RHIT, CTR, is president, National Cancer Registrars Association.

Building a Palliative Care Program from the Inside Out

By Michelle Abramowski, MSN, CRNP, and Patsy Astarita, LCSW-C, OSW-C

Palliative care has become an essential part of oncology care, particularly in patients with stage IV cancers, multiple co-morbidities, or advancing cancer despite treatment. The literature supports the value of collaborative oncology and palliative care services.1,2 While many cancer programs have developed outpatient palliative care clinics to meet this need, others may be challenged to offer these services on an outpatients basis.

At the Kaufman Cancer Center  we used existing resources to create a multidisciplinary outpatient palliative care program that addresses the care management and goals of our patients with advanced cancer. In October, this initiative will be recognized with a 2016 ACCC Innovator Award at the ACCC 33rd National Oncology Conference in St. Louis.

In a conference session on Friday, October 21, we will be sharing the “how to’s” of building a palliative care program by starting where you. Here’s a sneak peek at how we did it.

First Things First

Our first step was to identify existing challenges and strengths.


  • Inadequate communication between treatment teams
  • Lack of education related to palliative care
  • No budget
  • Documentation challenges and data management
  • Existing hospital palliative team focused on ICU
  • Patient navigation emphasis on newly diagnosed patients instead of palliative care
  • Reactive versus proactive use of resources.


  • Existing leaders and clinicians with a passion for palliative care
  • Creating a culture of sensitivity change
  • Existing inpatient palliative care program focused on improving quality outcomes and providing cost-effective care
  • Transitioning from fee-for-service to value-based care payer model.

Building Begins

In the summer of 2014, we formed a workgroup that included key members of our clinical team. We reviewed literature, evaluated existing models, identified national metrics, and selected specific outcome measures to track our progress.

In October 2014, we launched a weekly palliative care conference. This multidisciplinary conference includes oncologists, nurse practitioners, nurses, social workers, dietitians, and pharmacists. Every clinical area of the cancer treatment team is included and represented. Our team developed a decision-making tool to help identify patients in need of palliative care. The initial focus was patients with evidence of non-curative disease and/or an ECOG performance status of 2 or greater. Additionally, we incorporated use of Glare’s validated 5-item palliative care questionnaire.3

We identified key clinical team members willing to become palliative care experts within their discipline through personal education and the development of palliative care skills. This group of specialists meets bi-monthly to gain and share knowledge, develop new palliative care skills, and to monitor overall progress of our on-going effort.

Where We Are Now & What Lies Ahead

 As we near the two-year mark on this effort, we are seeing:

  • Fewer Emergency Department visits
  • Reduced ICU admissions
  • Earlier admission to hospice
  • Reduction in end-of-life chemotherapy
  • Earlier and more frequent “goals of care” meetings
  • Improved communication between patient, families, and treatment team.

And we’ve identified the following goals to continue moving our palliative care services forward:

  • Ongoing education and development of our palliative experts
  • Incorporation into multidisciplinary clinics
  • Updating patient educational materials
  • Improving community partnership
  • Continuing to track outcomes and identify new measures of success
  • Increasing visibility and awareness of our palliative care resources.

Four Lessons Learned

Our experiences building our palliative care services have taught us:

  • How to use valuable existing resources
  • Early palliative care intervention improves outcomes
  • Invite everyone to participate—multidisciplinary expertise is vital
  • Secure support from leadership early in the process.

How About You?

Our patient-centered model of palliative care is a continuous process that focuses on our patients’ values, beliefs, and wishes for end-of-life care. Discover what talent already exists in your cancer program that can help reduce patient suffering, improve quality of care, and make best use of your resources. Can you create a program from the inside out?



1Temel J, Greer J, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med. 2010;363:733-742.
2May P, et al.  Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33, 1-8.
3Glare, et al. Palliative care in the outpatient oncology setting: evaluation of a practical set of referral criteria. J Oncol Pract. 2011;366-370.

Michelle Abramowski, MSN, CRNP, is nurse practitioner, and Patsy Astarita, LCSW-C, OSW-C, is manager, Supportive Care & Community Services, UMD Upper Chesapeake Health, Kaufman Cancer Center.


Palliative Care: Patient-Centered Support

By Sandy Balentine, MSN, RN, OCN, MBA

HC provider cupping patients hand (for web)The understanding that palliative care is not hospice care has been, and continues to be, a challenge for both patients and providers to grasp. Palliative care is “. . . specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.”1  Palliative care is appropriate at any age and at any stage of a serious illness. It is offered alongside—not instead of—curative  care.

Hospice is a philosophy of care for people who are near end of life and are no longer seeking curative treatment.

Palliative Care—Part of Team-Based Care

The role of palliative care is to treat pain and other symptoms, and help patients realistically review the goals of their care. Clinicians trained in the subspecialty of palliative care work together with the patient’s disease-directed care team, helping to better meet the patient’s needs with a team-based approach. The team includes nurse practitioners, physicians, social workers, dietitians, chaplains, pharmacists, registered nurses, and others. The team helps patients gain control of their illness by exploring their goals of care, better understand their treatment options, and avoid unwanted care.  A partnership develops that includes the palliative care team, the patient, and the patient’s family. Patients are relieved to have help with understanding what to expect and how to handle it, and difficult decisions can be made with more information and insight.  Palliative care can help patients and their families cope with the challenges of living with a serious illness. Family members receive support, and as a result feel they can, in turn, better support their loved one.

A Focus on Quality of Life

A pivotal study of patients with metastatic NSCLC by Jennifer Temel and colleagues demonstrated that early palliative care showed significant improvements in quality of life and mood, as patients received less aggressive treatment at end of life but experienced longer survival.

The Institute of Medicine’s (IOM’s) 2013 report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, cites the need for improved access to palliative care for patients with cancer, noting that:

“Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence.”

At Valley Hospital, we recognized the difference that palliative care can make in the quality of life for our cancer patients.  We started with an inpatient palliative care program and today also offer palliative care in the outpatient setting or for homebound patients at home in the privacy of their residence. This service is an extra layer of support for an improved quality of life for our patients.

Growing Services to Meet Patients’ Needs

By the end of 2014, our inpatient palliative care service was extraordinarily busy, and the team knew that this service needed to be available to patients before they were admitted to the hospital in a crisis situation. With improved symptom management, hopefully some of these patients could avoid being admitted to the hospital. So we began the process of developing a palliative care service for our outpatients. Our first step was to put together a multidisciplinary weekly meeting that included a psychiatrist, pain management physician, palliative care nurse practitioner, chaplain, pharmacist, social workers, registered nurses and others. This team would review cases and give input and recommendations, combining the joint knowledge of the group. Patients were identified through the physician practice providers, Infusion Center or Radiation Oncology staff, or by self-referral.

As we began to develop the outpatient program, it quickly became obvious that there was a population whose needs we were not meeting. These patients were homebound or had an extremely difficult time getting in to the office.  Still, these patients needed the support that palliative care could provide. To meet this need, our home care agency has now started to integrate palliative care support to our homebound/home care patients as well.

Improving Access for All

Although great strides have been made in palliative care in the last few years, access to these services remains uneven. Palliative care is not available in many smaller hospitals or in rural areas. According to a 2015 report from the Center to Advance Palliative Care (CAPC), Alabama is one of the states with the lowest access, with less than one third of hospitals offering palliative care.  Reasons for this low coverage include a lack of knowledge about palliative care among healthcare providers, socioeconomic factors, geographic factors, transportation issues, and other factors. CAPC is a national organization dedicated to increasing access to quality palliative care for people facing serious illness. CAPC has helped the advancement of palliative care services by providing tools, training, and technical assistance to clinicians as a catalyst to change the conversation around palliative care.  CAPC’s vision is simple: to have palliative care available everywhere.

To ensure that health professionals understand the quality of life issues that exist for their patients, students in medicine, nursing, social work, psychology, and pastoral care, all need to have a robust educational program to help them understand what palliative care encompasses and how it can help patients. This training needs to include early lessons on discussing end-of-life decisions, how to handle anger and sadness from families, and how to respond personally to the loss of a patient. Only then will we be able to approach CAPC’s vision of palliative care available to every patient.

Stay tuned for an upcoming blog from 2016 ACCC Innovator Award winner University of Maryland Upper Chesapeake Health, Kaufman Cancer Center on how to build a palliative care program “From the Inside Out.”


1Center to Advance Palliative Care.  About Palliative Care. Available at

ACCCBuzz contributing blogger Sandy Balentine, MSN, RN, OCN, MBA, is the Director of Clinical Oncology at ACCC Member Program, The Valley Hospital.