COMPONENT 4 (NPCR): ANNUAL PROGRESS REPORT – YEAR TWO: June 30, 2013 – June 29, 2014 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible I. Five-year Goal: Improve CCR administration and management structure and processes A. Complete development Finalize plan Plan is completed and Meeting 9-30-13 Bates, Snipes, of Strategic Management Set priorities disseminated notes Fuchslin, Hintz, Plan Meet with Kwong, Starr regions Interim Progress Report July-December 2013: Significant accomplishments to date: Independent CCR operational plans were developed and finalized for both the California Department of Public Health (CDPH)/Chronic Disease Surveillance and Research Branch (CDSRB) and the University of California, Davis (UCD) contractor to ensure all essential statewide registry activities were covered and responsible parties identified. Plans were reviewed by regions after CDSRB and UCD came to agreement, comments addressed, and plans disseminated in October – November 2013. Prioritization of operational and production activities accomplished through CCR Directors (CDSRB, regional and UCD managers) monthly meetings with CDSRB managers. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Business and operational plans disseminated and regularly reviewed by CDSRB with all contractors. CDSRB convenes CCR Directors calls monthly, Strategic Alignment Team calls quarterly, operations and production calls monthly to prioritize activities, and automation meetings monthly. CDSRB Chief meets with UCD Program Director monthly. Major problems encountered: None Strategies for problem solving: N/A DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 1 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Workplan revisions needed: None B. Review and update CCR operations manuals, policies, procedures, management reports Establish priorities for review process and timelines List of items for prioritized Operations Timeline and Bates, Fuchslin, review identified and standards project plan Hintz, Kwong, Timeline/project plan for manuals established by Starr, UCD Subcompletion of review and 1-1-14 award updates established Interim Progress Report July-December 2013: Significant accomplishments to date: Data standard cancer reporting volumes I-III for diagnosis year 2014 were on schedule for completion. A structure was created for reporting (monthly, quarterly, semi-annually) on the list of items. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Updates to data standards reporting Volumes I-III for diagnosis year 2014 were completed. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None II. Five-Year Goal: Increase and improve electronic cancer case reporting from all sources A. Maintain and improve Monitor/ensure 100% of files sent are EPath Import electronic reporting from reports are uploaded into DMS Fail Report current sources sent/received Software updates applied Problem DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Epath transmissions monitored Fuchslin, Starr, UCD Sub-award Page 2 Objective Activities Measures of effectiveness Data Update lab software Perform HL7 EPath Parser support annually (as funded) Problems/issues identified and prioritized for resolution Management Report Time-frame for assessing progress weekly Software updates monitored quarterly Monthly Problem management report Staff Responsible Interim Progress Report July-December 2013: Significant accomplishments to date: A project was started to create a single, standardized, statewide Physician Address Database. This will replace and/or complement the current model of each of the eight Regional Registries maintaining their own respective Physician Address Databases. Once operational and populated in the first quarter of 2014, the new statewide Physician Address Database will provide many positive benefits including greater efficiencies and timeliness with our Follow-Back and Casefinding work activities. Another future opportunity will be for the CCR‟s data management system to use email to communicate directly with Physicians regarding Follow-Back, case completeness, timelines, and quality. The electronic pathology (EPath) Task Team met monthly and resolved Epath related issues in a timely manner. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The project (Reporting Source Management) to create a single, standardized, statewide Physician Address Database was delayed due to the complexities of importing data from the eight existing Regional Registry solutions into a new and standardized configuration of reporting relationships. The current project timeline is to populate the Reporting Source Management database in November 2014. The project team comprised of members from all eight Regional DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 3 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Registries meets bi-monthly to ensure success of this critical project. The electronic pathology (EPath) Task Team met monthly and resolved Epath related issues in a timely manner. Major problems encountered: Each of the eight Regional Registries had completely different methods and technical solutions for the process of contacting reporting sources of data. Some of the regions did not have a documented process. The project was delayed by six months due to the issues described above, and those related to it. Strategies for problem solving: Extended the project timeline, and allocated resources necessary to complete the project by end of year 2014. Workplan revisions needed: None B. Increase number of Identify and Number of new labs added EPath Project Progress Fuchslin, Starr, pathology labs prioritize labs to and successfully Report assessed UCD Sub-award transmitting electronic target transmitting quarterly reports Interim Progress Report July-December 2013: Significant accomplishments to date: CCR added one new EPath feed during the reporting period. It was an AIM installation at Integrated Oncology. We have another AIM installation scheduled for the Salinas Valley Medical Group in the Spring of 2014. The real significant breakthroughs in electronic pathology reporting were in two related projects to create electronic pathology reports that could be uploaded into the CCR‟s data management system (Eureka). 1. Path reports from 40 hospital-based path labs in Region 9 (Los Angeles County) started to be electronically loaded into CCR‟s statewide data management system during this reporting period. Region 9 staff scans paper path reports at the 40 sites using Optical Character Recognition (OCR) software. Once scanned and read, the path reports are electronically loaded into Eureka where they are stored, viewable, linked to a patient/tumor, and/or used for Casefinding. 78,000 paper path reports were scanned, read, and electronically uploaded into Eureka during this reporting period. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 4 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress 2. A project was started to integrate Region 1/8‟s (San Francisco Bay Area) laptop software solution for capturing pathology report data at the path lab into CCR‟s data management system. Currently, the path report data entered into the laptop solution by Region 1/8 staff is stored locally at Region 1/8 and not part of the CCR‟s data management system. This project, when completed in early May 2014, will allow for the path report data captured by Region 1/8 staff at twenty (20) path labs to be electronically uploaded into the CCR‟s CaseFinding System. The path report data will be viewable to all CCR staff, and linked to the appropriate patient/tumor. When implemented, tens of thousands of path reports annually from 20 path labs will be electronically uploaded into Eureka using this method. Major problems encountered: Lack of funding to implement epath solutions such as eMaRc and AIM at path labs, and inability to recruit acceptable candidates for the Health Program Specialist (HPS) II e-reporting position that meet both the state Human Resource and CCR criteria for this job title with regards to skills, knowledge, and experience. Strategies for problem solving: The CCR started the process to seek and procure Centers for Medicare and Medicaid Services (CMS) funding to support a statewide implementation of the College of American Pathologist‟s (CAP) electronic Cancer Checklist (eCC) at pathology laboratories. CCR will actively recruit new candidates for the HPS II position that will meet both state and CCR requirements for this position. CCR will reallocate and reprioritize internal resources to support epath reporting. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: 1. The project to integrate Region 1/8‟s (San Francisco Bay Area) laptop software solution for capturing pathology report data at the path lab into CCR‟s data management system was completed as part of the Eureka software releases in April and June. This new capability allows for the path report data captured by Region 1/8 staff using their laptop solution at twenty (20) path labs to be electronically uploaded into the CCR‟s CaseFinding System. 2. St. Joe‟s six hospital path labs have been set up to use CAP‟s eCC reporting and send data to CCR. 3. Recruited Oakland Children‟s Hospital path lab for CAP eCC reporting to be set-up in early 2015. 4. Recruited El Centro Hospital path lab for CAP eCC reporting to be set-up in early 2015. Major problems encountered: Lack of funding to implement e-path solutions such as eMaRc, AIM, and CAP‟s eCC at path labs. The CCR had to abandon efforts to seek and procure Centers for Medicare and Medicaid Services (CMS) funding to support a DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 5 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress statewide implementation of the College of American Pathologist‟s (CAP) electronic Cancer Checklist (eCC) at pathology laboratories, when it was discovered that CMS would only fund based on the percentage of Medicaid patients in the CCR‟s database, not the percentage based on the combined total of both Medicaid and Medicare patients in the database. Strategies for problem solving: Seek restoral of CCR‟s IT position from CDPH ITSD organization to pursue and implement electronic reporting so that CCR can continue to pursue opportunities. Workplan revisions needed: None C. Increase number of other electronic reporting sources Establish project Facilities identified Project plan Progress Fuchslin, Starr, plan to increase Project plan completed assessed UCD Sub-award reporting from quarterly molecular/geneti cs labs & nonhospital facilities Interim Progress Report July-December 2013: Significant accomplishments to date: The CCR continues to recruit labs for molecular/genetic reporting, but none have yet to commit to an epath installation. Major problems encountered: Lack of funding and/or resources to implement epath solutions such as eMaRc and AIM at path labs. Inability to recruit acceptable candidates for the HPS II e-Reporting position that meet both the state Human Resource and CCR criteria for this job title with regards to skills, knowledge, and experience. Strategies for problem solving: The CCR started the process to seek and procure CMS funding to support a statewide implementation of CAP‟s eCC at pathology laboratories. CCR will request funds from NPCR to support PHIN MS/eMaRc installations at selected path labs. CCR will actively recruit new candidates for the HPS II position that will meet both state HR and CCR requirements for this position. CCR will reallocate and reprioritize internal resources to support epath reporting. Workplan revisions needed: None DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 6 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Annual Progress Report January-June 2014: Significant accomplishments to date: In collaboration with the College of American Pathologist, the CCR started a project so seek funding from external funders (such as the California HealthCare Foundation, the Moore Foundation, and others) to fund a project to collect molecular and genetic information using CAP‟s electronic Cancer Checklist at one or more sites. Major problems encountered: Lack of a complete and consistent data standard for the collection of molecular/genetic information as a structured data source document. Strategies for problem solving: Seek funding to create an Integrating the Healthcare Enterprise (IHE) data standard for molecular/genetic data. Workplan revisions needed: None D. Increase utilization of synoptic reporting of pathology data utilizing the College of American Pathology (CAP) Electronic Cancer Checklist (eCC) Collaborate with Successful receipt of data Number of Progress Bates, Fuchslin, CAP to facilities assessed Starr, UCD Subincorporate CCR using the quarterly award, Regional reporting needs eCC and Registries Subinto their longtransmitting awards term planning to CCR for deployment of the eCC in California Interim Progress Report July-December 2013: Significant accomplishments to date: Successfully completed a pilot project for implementation of the College of American Pathologists‟ (CAP) electronic Cancer Checklists (eCC) in California pathology labs and sent electronic pathology reports as structured data to CCR. The success of the pilot project led to CDPH being interested in pursuing additional funding for full implementation of CAP eCC in additional pathology labs. A proposal is being developed to request additional CMS funding for this implementation. CCR staff in collaboration with CAP staff made multiple presentations as part of an effort to recruit potential path labs and health DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 7 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress management organizations into implementing CAP‟s eCC solution. In an effort to seek external funding, CCR/CAP staff made two presentations to the California HealthCare Foundation (CHCF). CHCF asked CCR/CAP staff to make additional presentations in early 2014 to the CHCF project approval team. CCR staff continued to pursue CMS funding by completing work activities related to seeking approval and multi-year funding for this project. CCR/CAP tentatively reached agreement with El Camino Hospital to move to a full eCC production implementation sometime in 2014, dependent on a CERNER software upgrade that includes the eCC module. Major problems encountered: While CAP‟s eCC is getting a very positive response from pathologists and their respective organizations when presented, it‟s clear that health institutions are feeling overwhelmed with all the IT changes taking place and planned for the future. Getting into the queue for an IT software change at these organizations is challenging. Strategies for problem solving: Providing the funds needed to complete the work activities related to implementing eCC at a path lab is compelling, so our efforts to secure funding from CMS, CHCF, and others like them appear to be a sound strategy moving forward. To remove the objection of being burdened by IT changes, our plan is to shift the focus and burden from the path lab reporting organization to the path lab software vendors (such as Cerner). Our current plan is to work with path lab software vendors to implement eCC as part of their software offerings, thereby making an eCC implementation part of a routine path lab software upgrade. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: 1. St. Joe‟s six hospital path labs set-up to use CAP‟s eCC and send data to CCR. 2. Recruited Oakland Children‟s Hospital path lab for CAP eCC reporting to be set-up in early 2015. 3. Recruited El Centro Hospital path lab for CAP eCC reporting to be set-up in early 2015. Major problems encountered: Coordinating the six St. Joe‟s path lab sites proved to be very challenging, as defining and matching up CCR demographic data requirements to the site laboratory system ability to discover and export this data into a standardized HL7 message has proved to be a significant process. This was further complicated at St. Joe‟s by their interface between the mTuitive middleware and Meditech LIS, in addition to accurately mapping their dataflow within their system network. Basically, DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 8 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress St-Joe‟s six path lab sites had little in common, and it was the burden of this project to create a solution that would work for a very complex enterprise system architecture design. Strategies for problem solving: Rigorous Project Management was utilized to ensure success. Workplan revisions needed: None E. Implement physician office electronic reporting of cancer cases under Meaningful Use initiatives Coordinate with CCR staff participate in Staff Progress Bates, Fuchslin, state MU relevant meetings, performance assessed Starr, UCD Substakeholders workgroups reviews quarterly award Complete Successful submission of Meeting development of test messages from minutes and infrastructure providers project and systems to Move to production reports from receive and task team process MU data # of offices from EHRs submitting Complete testing data and deployment electronically Interim Progress Report July-December 2013: Significant accomplishments to date: CCR staff worked with CDPH Health Information Exchange (HIE) Gateway staff to set-up the data transport mechanism between the CDPH HIE Gateway and CCR to receive data from Eligible Providers (EPs). CCR staff was identified and assigned to support all MU related work activities. During the reporting period, CCR completed all work activities necessary in a timely manner to be able to receive data from EPs in an ongoing production manner. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 9 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Annual Progress Report January-June 2014: Significant accomplishments to date: CCR staff continued to work with CDPH Health Information Exchange (HIE) Gateway staff to set-up the data transport mechanism between the CDPH HIE Gateway and CCR to receive data from Eligible Providers (EPs). CCR staff was identified and assigned to support all MU related work activities. During the reporting period, CCR completed all work activities necessary in a timely manner to be able to receive data from EPs in an ongoing production manner. Major problems encountered: The CDPH HIE Gateway is limited to accepting data from EPs using the Web-Service data transport mechanism exclusively. So far, few vendors have consumed the CDPH Web-Service. A substantial number of California Vendors would prefer to use Direct, Secure FTP, and/or PHIN-MS that are not currently supported by the HIE Gateway. Strategies for problem solving: CCR is seeking to find solutions within CDPH to allow for a wider choice of data transport mechanisms. Workplan revisions needed: None III. Five-year Goal: Improve timeliness, completeness and quality of cancer case reporting A. Increase proportion of Identify List of physician practices Reporting physicians reporting physicians in completed source by cancer cases targeted Specialty offices targeted year of specialties for recruitment diagnosis Implement direct web-based reporting to targeted specialty offices Establish pilot plan to integrate with office EHR DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Review progress quarterly Deployment plan implemented by 6-28-14 Fuchslin, Starr, UCD Sub-award, Regional Registries Subawards Page 10 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible systems Develop metrics for assessing improvement Interim Progress Report July-December 2013: Significant accomplishments to date: The pilot of the web-based Physician Office user interface in Region 9 was successful, and the screen is now ready for broader deployment. CCR successfully created a Physician Admin Screen in Eureka that will be used to create a database of all physician offices in California and will identify their affiliations and specialties. In the next reporting period staff will manually populate the database using the screen to ensure all data collected utilizes the same data fields, which will result in a very complete data base of physician offices in California. The database will then be used for marketing and outreach to physician offices for direct reporting to Eureka. The marketing will be conducted in two phases, Phase I will focus on dermatologists, and Phase II will focus on urologists. CDPH created an HIE Gateway for providers to submit EHR to CDPH for reportable diseases, including cancer, in order to meet the MU Stage 2 reporting requirements that will go into effect in the next reporting period. CDPH also created an HIE webpage to provide information to Eligible Providers, including Physician Offices, related to reporting cancer cases. CCR‟s Eureka system has been programmed and eMaRc installed in order to accept the cancer cases reported through MU Stage 2 via the CDPH HIE Gateway in compliance with the January 1, 2014 date established for cancer reporting. Mr. Starr was hired to fill the HPSII – Project Manager position in August, and the Direct Access project for physician offices is a high priority for this position. Mr. Starr focused on learning about registry operations and knowledge transfer during the majority of this reporting period, but he will be dedicating his full attention to managing projects in the next reporting period. This project includes a strong emphasis on marketing and outreach, and Ms. Burgos, the half time AGPA position, has now been assigned to take the lead on developing marketing materials for Physician Offices. Major problems encountered: CDPH is having difficulties hiring staff with the appropriate knowledge for the HPS II – e- Reporting position given the constraints of the hiring system in CDPH. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 11 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress A lack of appropriate project management continued to be a problem during the first quarter of this reporting period. Staffing remained an issue for UCD. Some vacant positions were filled by the end of this reporting period, and the focus has been on knowledge transfer and acclimating the new staff. Coordination of MU Stage 2 activities has been difficult given CDPH‟s desire to have all MU reportable disease information submitted through the CDPH HIE Gateway vs. directly reporting to CCR. Strategies for problem solving: Program staff are actively recruiting individuals with the skill set required for the HPS II – ereporting position, and educating them on the lengthy process to get on State certification lists for hire. Program hopes to have some qualified individuals eligible on the list in the first quarter of next year. The hiring of Mr. Starr as the dedicated Project Manager will alleviate the issues related to lack of project management. Mr. Starr will also work directly with CDPH Information Technology staff regarding data exchange through the CDPH HIE Gateway to ensure data is efficiently transmitted to CCR. With more positions now filled in the UCD contract, and knowledge transfer occurring for the new staff, the goal of the Physician Admin Screen project was able to be achieved. With Mr. Starr now assigned to manage the Direct Access project, staff being assigned to populate the Physician Office database, Ms. Burgos being assigned to lead the marketing and outreach, and CDPH‟s HIE Gateway for MU Stage 2 Cancer Reporting, we expect the past barriers to increasing physician office reporting to be removed. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The project (Reporting Source Management) to create a single, standardized, statewide Physician Address Database was delayed due to the complexities of importing data from the eight existing Regional Registry solutions into a new and standardized configuration of reporting relationships. The current project timeline is to populate the Reporting Source Management database in November 2014. The project team comprised of members from all eight Regional Registries meets bi-monthly to ensure success of this critical project. The Reporting Source Management capability was expanded DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 12 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress to include physician office electronic health record (EHR) software vendors, so that in the future, the CCR can begin to collaborate with EHR vendors to report cancer. Ms. Burgos and Mr. Starr created marketing materials targeted at dermatology and urology physician offices. CCR purchased booths at two specialist conferences for dermatologists and will showcase the new marketing materials at the conferences later in 2014. CCR staff continued to work with CDPH Health Information Exchange (HIE) Gateway staff to set-up the data transport mechanism between the CDPH HIE Gateway and CCR to receive data from Eligible Providers (EPs). CCR staff was identified and assigned to support all MU related work activities. During the reporting period, CCR completed all work activities necessary in a timely manner to be able to receive data from EPs in an ongoing production manner. Major problems encountered: The CDPH HIE Gateway is limited to accepting data from EPs using the Web-Service data transport mechanism exclusively. So far, few vendors have consumed the CDPH Web-Service. A substantial number of California Vendors would prefer to use Direct, Secure FTP, and/or PHIN-MS that are not currently supported by the HIE Gateway. Strategies for problem solving: CCR is seeking to find solutions within CDPH to allow for a wider choice of data transport mechanisms. Workplan revisions needed: None B. Exchange data with other state central cancer registries and other sources Maintain existing agreements with 23 states, ACTUR, VA Streamline process of data upload by Data exchange completed and agreements updated Data uploaded into DMS DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Data exchange agreements WTQ reports Progress reviewed quarterly Fuchslin, Starr, Bates, Hintz, Shipman, UCD Sub-award Page 13 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible incorporating identified process improvements. Interim Progress Report July-December 2013: Significant accomplishments to date: CCR continues to maintain the 23 existing Data Exchange agreements with other states, and is executing a new agreement with Ohio. During this reporting period, we received data from Arkansas, Colorado, Florida, Idaho, Illinois, Louisiana, Montana, Nevada, New York, North Carolina, Oregon, Texas, and Wisconsin. CCR continues to receive data from ACTUR and VA hospitals through existing Data Use Agreements. During this reporting period we received data from seven of the eight VA hospitals, including Fresno, Long Beach, Palo Alto, Sacramento, San Diego, San Francisco, and West Los Angeles. Maintenance of the Out of State Data Exchange Agreements and the ACTUR and VA Data Use Agreements is being shifted from a contractual responsibility to a State responsibility to ensure continuity in the future when contracts terminate. Data exchange and data upload processes are now being analyzed, and process improvements will be recommended during the next reporting period. Major problems encountered: During the transition of CCR Operations from one contractor to another, it was determined that no in-house knowledge existed within CDPH related to the Data Use and Data Exchange Agreements required for these data exchange activities and the processes required to execute and maintain the agreements. As a result, some agreements expired during the transition. Fortunately, there was no impact to receipt of data due to the expired agreements. Strategies for problem solving: Development and maintenance of CCR Data Use and Data Exchange Agreements will be the responsibility of CDPH, rather than contractors, in order to ensure continuity of knowledge related to these agreements. Primary focus during the next reporting period will be to update all expired agreements. Ms. Shipman was hired as the full time grant manager for this award in August. She will now take an active lead in analyzing processes and developing metrics in collaboration with UCD contract staff and the Regional Registry staff. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 14 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: CCR continues to maintain the 23 existing data exchange agreements. Also, consulting with legal department to use the NAACCR Agreement for Administering the Central Cancer Registry Inter-Registry Resident Data exchange. CCR continues to receive data from ACTUR and VA hospitals through existing Data Use Agreements (DUA). DUA with VA facilities and ACTUR are being updated. Analysis of data exchange and data upload process is not complete. Recommendations should be forthcoming. Major problems encountered: Data Use and Data Exchange Agreements have been transitioned from contractor to CDPH staff. Strategies for problem solving: N/A Workplan revisions needed: None C. Meet all NPCR National/Advanced Data Quality Standards Improve metrics Metrics reviewed CTQ reports Progress Bates, Fuchslin, for measuring New report established NPCR Data reviewed Starr, UCD Subprogress towards Standards are met Evaluation monthly award goals Reports Interim Progress Report July-December 2013: Significant accomplishments to date: Successfully completed NPCR and NAACR data submissions for 2011 data on December 5, 2013 that met the National Data Quality Standard per the NPCR Program Standards. This was the first submission for the UCD Contractor without assistance from the prior contractor. Although an extension was required in order to complete the data submission, it was a great accomplishment for the new contractor. The data submission process continues to be documented, and a procedure manual should be complete by the next reporting period. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 15 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Requirements were gathered for enhanced regional reports for case completeness through collaborative work efforts between UCD contract staff, Regional Registry contract staff, and CDPH. Due to the complexity of the requirements gathered, the programming is scheduled for the first quarter of next year. This work effort will have a positive impact on the 2014 submission. Major problems encountered: CCR requested, and was granted, two extensions for submitting the NPCR and NAACR data submissions. This was the first data submission done entirely by the new contractor for these services, and sufficient time was not allowed for preparing the data, running edits, and addressing data issues prior to data submission. Strategies for problem solving: UCD contractor will ensure that the procedure manual is revised to include additional time to prepare data and run edits prior to data submission deadline. In addition, UCD contractor is cross training other staff so that the knowledge does not exist in only one position. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Successfully completed in January 2014, the 2012 Data Submission (NAACCR Call for Data). The end of year 2104 Data Submission of 2012 cases is on schedule and expected to exceed both case completeness and timeliness quality indicators. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None D. Perform data linkages specified in NPCR Program Standards. Maintain and update data use agreements Perform linkages Linkages performed on schedule Quality standards for follow-up are met DP12-1205 - CA_NPCR_Annual Progress Report Year 2 NPCR DER % of cases with current follow-up Progress reviewed quarterly Kwong, Rico, Shipman, UCD Sub-award Page 16 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible . Streamline linkage process by incorporating identified process improvements. Interim Progress Report July-December 2013: Significant accomplishments to date: CDPH has streamlined the process for CCR to receive Death Clearance files, which resulted in more timely linkage with Death Clearance information. All linkages are functioning properly. The following linkages were completed prior to the December data submission: Death Clearance, DMV, Cal-Voter, Birth Certificates, OSHPD, SSI, and Indian Health Services. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Passive follow-up linkages have continued smoothly. During this reporting period the 2012 Death Statmaster and 2013 Death Certificate Incremental linkages were processed. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 17 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible IV. Five-year Goal: Enhance overall program of quality assurance and education for registrars A. Conduct casefinding Provide Audit schedules and CTQ report Quarterly report Snipes, Regional and re-abstracting audits oversight and protocols established Final report of findings Registries Subfor targeted reporting functional Completeness rates of statewide awards facilities direction to Accuracy rates findings regional Edit errors registries . Minimum one casefinding and/or reabstracting audit completed by each SEER region with a final report to CCR management of statewide findings Interim Progress Report July-December 2013: Significant accomplishments to date: Casefinding and/or re-abstracting audits have been completed by regional registries. Major problems encountered: Due to regional workload constraints, reports were not completed in this reporting period. Report of audit findings from regional registries have not been received by CDPH. Final report will be delayed. Strategies for problem solving: CDPH will communicate with Regional Registries to send findings from audits to CDPH. CDPH will submit audit reports to UCD. Once regional results are provided to UCD, UCD staff will analyze regional results, identify educational opportunities, new and/or revised edit opportunities, and business rule automation opportunities. Contract staff will follow-up with regional registries on any identified action plan outlined by the regional registries. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 18 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Casefinding and reabstracting audits are performed by regional registries. Copies of final reports are to be distributed to CDPH. Major problems encountered: Regional Scope of Work (SOW) did not explicitly indicate to forward copies of audit reports to CDPH. SOWs have been updated to indicate that a copy of audit reports are to be distributed to CDPH. CDPH intends to share results of reports with UCD central registry staff for their analysis and recommendations from a statewide perspective. Strategies for problem solving: Once regional results are provided to UCD, UCD staff will analyze regional results, identify educational opportunities, new and/or revised edit opportunities, and business rule automation opportunities. Contract staff will follow-up with regional registries on any identified action plan outlined by the regional registries Workplan revisions needed: Regional SOW required revision. B. Establish data consolidation procedures Continue to Business rules prioritized Volume III Quarterly status Snipes, UCD write, program and completed standard updates Sub-award and implement manual Class of case consolidation rules; progress in rules terms of preliminary automated consolidation rules. Interim Progress Report July-December 2013: Significant accomplishments to date: Class of Case was identified as a first step in writing consolidation rules. During this period, Class 43 was finalized, tested, and implemented into CCR‟s system. Also, during this period Class 00 was drafted with DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 19 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress analysis in progress. Class 34 and Class 40 have also been drafted with analysis ongoing. Ten edit-to-auto change rules were drafted and have been scheduled to be programmed in early 2014. Discussions occurred regarding the development of consolidation logic for Co-morbidities/Complications and Race. CCR expects to reach a consensus on how to proceed by the end of January 2014. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Class 00 was finalized, tested and implemented into the Eureka system. During this period, analysis was initiated on Class 10-14 as well as Class 34-36. Ten edit to auto-change rules were finalized and implemented. Consolidation logic for Race and Co-morbidities was drafted, reviewed, finalized and implemented. Positive, potential and non-matches for tumor linkage are manually reviewed and linked by regional staff. In order to reduce the regional manual work effort, an automation approach was investigated for the manual process of tumor linkage. During this time period significant progress was made on the development and implementation of tumor linkage automation rules. Exact match rules were implemented by the end of December 2013. Additionally, site specific rules based on SEER‟s Multiple Primaries and Histologies Manual for breast, colon, lung and prostate were developed, tested and implemented during this time period. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None C. Improve feedback to regional registries on data Develop business plan for Plan established Feedback mechanism DP12-1205 - CA_NPCR_Annual Progress Report Year 2 CTQ Report Edit Error Quarterly status updates Snipes, UCD Sub-award Page 20 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible quality/completeness evaluating and established lists providing Audit feedback Reports Interim Progress Report July-December 2013: Significant accomplishments to date: Monthly Production meetings with statewide and regional operations managers were structured to proactively identify and resolve problems/issues in a timely manner. A metrics development plan was created to address gaps in areas were reports/metrics are needed to further improve data quality and case completeness. Part of the plan includes developing a dynamic real-time dashboard on the CCR‟s data management system homepage that will inform the user/region of their current status regarding case completeness and data quality whenever they log into the system. Major problems encountered: Demand for metrics and information is greater than current staffing can supply. Strategies for problem solving: UCD contractor is researching the ability to use UCD student interns to help with metrics development. CCR is investigating the possibility of building more solutions (such as our Data Miner system) that will enable users and management to mine data independently, instead of requesting the reports programmer to build a report. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: A dashboard was developed for the CCR‟s data management home page. Regional feedback received indicated that it may be too distracting and confusing to regional staff. Consensus reached to remove the dashboard from the homepage. Steady progress achieved during this reporting period on researching the development of business intelligence tools to enable ad-hoc reports by management. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 21 Objective Activities Measures of effectiveness D. Perform recoding audits Data Time-frame for assessing progress Quarterly status updates Staff Responsible Develop audit Reduction of discrepancies CTQ reports Snipes, UCD plan/schedule in visual review Edit error Sub-award Completion of Accuracy rates lists one central registry recoding audit with final report and recommendation s to CCR management. Interim Progress Report July-December 2013: Significant accomplishments to date: A Lung Recoding Audit was performed in each region during this reporting period. A PEER review method was utilized wherein both a primary and secondary auditor independently audited cases and then compared and reconciled their results. Final audit results were distributed to regional directors in December. A comprehensive statewide report is currently in progress with an anticipated completion date of January 2014. Major problems encountered: None Strategies for problem solving: Statewide discrepancies will be analyzed and an action plan developed. Typically, the action plan includes a timeline for discrepancy correction in the database, development of education and training modules, analysis for one or more of the following: a) updating Volume I with appropriate clarifications (if needed); b) submitting an edit revision or new edit request; c) determining whether to develop an automation business rule; and/or d) repeating a Lung Recoding audit 3-6 months following implementation of action plan(s). Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Lung Recoding Audit was finalized by UCD staff and distributed to CDPH. UCD staff included recommendations and lung abstracting tips/reminders in their quarterly bulletin that is distributed to statewide registrars. The majority of the issues identified were with regard to code Collaborative Stage Site Specific Factors. Regional spreadsheets DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 22 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress with identified discrepancies were distributed. Audit Coordinator confirmed that discrepancies were corrected in the database. With the transition to directly coded TNM, the importance of these site specific factors for coding future lung cases is unknown. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None E. Enhance education program for registrars Web-based and Training plan updated CTQ reports Quarterly status Snipes, UCD in-person In-person and web-based Edit error updates Sub-award training trainings scheduled lists Incorporate Accuracy rates Audit reports audits results Participant evaluation Participant Pilot an Pilot apprenticeship Evaluation apprenticeship program initiated Reports program for new CTRs Interim Progress Report July-December 2013: Significant accomplishments to date: Requirements were gathered to determine if new training programs were needed for CTRs. It was determined that SEER*Educate, an online training platforms, fulfills this need and a program does not need to be developed by the CCR. A presentation for CTRs regarding 2014 Data Changes is currently being developed and will be completed by next reporting period. Additionally, four training events occurred:  A History of the CCR – A look at the Standard Setting Agencies  Coding Pitfalls Workshop – CCRA Annual meeting in San Diego  How we code Race – A close look at the rules  Lung Odyssey – Coding Lung Cancer Correctly - Region 8 abstractors DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 23 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: Training Coordinator presented 2014 Data Changes to one region at their educational conference. A PowerPoint presentation as well as recorded webinar was also developed. The presentation was provided to all regions for their use at their educational conferences. The recorded webinar was posted on the ccrcal.org website with a notification distributed to statewide registrars. During this time period the Auditor/Training Coordinator resigned his position. A replacement candidate was interviewed and hired by June 2014 that has extensive background in TNM coding. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None V. Five-year Goal: Expand the use, relevance, and application of cancer registry data for public health and research A. Develop and produce Prepare annual Data updates are posted to CCR Data updated at Bates, Kwong, core cancer surveillance cancer incidence website Website least annually Burgos, Rico, reports and and mortality UCD Sub-award communications tables for CCR Website Prepare cancer survival, trends, DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 24 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible stage data Prepare maps of variations in late-stage diagnoses Interim Progress Report July-December 2013: Significant accomplishments to date: During this reporting period, the Annual report for 1988-2009 was posted on website, as were the statistical tables for 1988-2010. The Annual report for 1988-2010 was produced but is still under review by UCD. A Report on obesity-linked cancers has been compiled and was submitted to CDPH for approval. Major problems encountered: Maps of late-stage diagnoses delayed due to departure of UCD research analyst. Strategies for problem solving: UCD cross-training research staff in ARC GIS software so GIS responsibilities can be completed by more than one staff person. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: During this reporting period, the statistical tables for 1988-2011 were posted to the CCR website. The report on obesity-linked cancers was approved by CDPH and released to the public. Due to vacant UCD analyst position, CDPH staff completed analysis and maps of late stage colorectal and breast cancer diagnoses. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 25 Objective Activities Measures of effectiveness B. Establish overall cancer surveillance and communications plans to guide CCR data products that meet program needs Data Time-frame for assessing progress Progress reviewed quarterly Staff Responsible Collaborate with Surveillance plan Publications Bates, Kwong, CCPCP to completed report Burgos, Rico, develop plans Communications plan UCD Sub-award, Establish completed Regional priorities and Evaluation plan completed Registries Subtimeline for awards cancer data use Establish evaluation plan Interim Progress Report July-December 2013: Significant accomplishments to date: Continued collaboration with CCPCP, Health Educator participates in all meetings and is scheduled to present two webinars in early 2014. Public and Patient Information tab was prepared and added to CCR website. A production calendar with priorities and timelines are developed for 2013-2014, and the production schedule for 2012-2017 was reviewed and modified. Document outlining the process for improving quality of publications and a publication dissemination plan was reviewed and modified. Major problems encountered: Publication report not completed. Strategies for problem solving: CDPH will work with UCD to define what publications should be in the publication report. UCD needs better guidance on what is considered a CCR publication and time frame to cover. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: UCD‟s continued collaboration with CCPCP resulted in two webinars discussing the use of the CCR‟s web based data query system. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 26 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress CDPH and UCD staff developed independent production calendars with timelines for 2014-2015. CDPH has met to discuss what publications and time frame should be included in the publications report, and has been communicated to UCD. UCD contract staff will not be doing publications report. State staff will be producing report and will incorporate into production calendar. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None C. Respond to public data requests and community cancer concerns Triage and Responses are monitored Public Activity Bates, Kwong, respond to all and tracked to completion Inquiry Log reviewed Rico, UCD Subinquiries quarterly award, Regional Track inquiries Registries SubPerform health awards events investigations Interim Progress Report July-December 2013: Significant accomplishments to date: The CCR and Regional Registries have responded to 39 inquiries as follows:  7 cancer assessments performed in Palo Alto, East Oakland, Ventura, San Bernardino, Burney, Irwindale, Malibu, and Hermosa Beach.  1 call requesting do not Contact for research.  19 requests for cancer rates and/or data analysis.  12 requests for general information or other requests. Major problems encountered: None Strategies for problem solving: N/A DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 27 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The CCR and Regional Registries have responded to 56 inquiries as follows:  10 cancer assessments performed.  1 call requesting do not contact for research.  31 requests for cancer rates, data analysis or data for research.  14 requests for general information or other requests. Major problems encountered: Technical problems with the current cancer concerns database Café has resulted in a underutilization by regional staff. Strategies for problem solving: UCD staff is developing a user friendly Access database that will be made available to all of the regions to collect information about cancer concern inquiries. Workplan revisions needed: None D. Support and promote use of CCR data for research Triage all Number of research Data Release Activity Bates, Kwong, requests for projects using CCR data Tracking reviewed Shipman, Rico, information System quarterly UCD Sub-award Track all data releases for compliance Create summary report of research uses of CCR data Interim Progress Report July-December 2013: Significant accomplishments to date: The CCR responded to various inquiries from outside researchers, including 15 requests from outside researchers for data to conduct research, and 20 datasets that were created for outside researchers, mostly through DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 28 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress linkages with other statewide databases such as Hospital Discharge and Birth Certificate Master files. A summary report of research uses of CCR data was reviewed and completed. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The CCR responded to various inquiries from outside researchers, including 17 requests for data to conduct research. During the reporting period, CCR created 11 datasets for outside researchers, some of which included linkages with other statewide databases such as Hospital Discharge and Birth and Fetal Death Certificate Master files. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None VI. Five Year Goal: Maintain and expand collaborative relationships A. Establish Coordinated Participate in Number of meetings CCPCP Activity Bates, Kwong, Cancer Prevention & CCPCP and state attended Planning reviewed Rico, UCD SubControl Program (CCPCP) coalition Plan established Meeting quarterly award and actively participate in meetings/ Minutes planning and development workgroups Identify priorities Interim Progress Report July-December 2013: Significant accomplishments to date: The work of Coordinated Cancer Prevention and Control Program (CCPCP) is now guided DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 29 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress by the CCPCP Advisory Committee leadership which includes representatives of the Comprehensive Cancer Control Program (CCCP), the Coordinated Chronic Disease Prevention Program (CCDPP), the National Breast and Cervical Cancer Early Detection Program/Every Woman Counts (NBCCEDP/EWC), the California Colon Cancer Control Program (C4P), the California Cancer Registry (CCR), and the California Tobacco Control Program (CTCP). The leadership structure includes membership from a variety of engaged state cancer and chronic disease stakeholders that coordinate activities, and CCR is a key participant. Over the last six months, CCPCP has continued to invest its resources towards cultivating its leadership structure by building capacity. CCPCP has continued to benefit from its cooperative and established relationships with state cancer and chronic disease programs, including CCR. During the latter part of 2013, CCPCP has successfully merged resources between members from within the CCPCP Advisory Committee to assist in addressing the activities outlined in the CCPCP Work Plan 2013-2014. These activities include conducting a Surveillance Data Utilization Assessment, a comprehensive three-part webinar series was crafted in collaboration with CCR tailored specifically to meet the needs of state cancer and chronic disease programs as indicated in the assessment, and a year two CCPCP Surveillance Plan has been developed and finalized to further guide collaborative priorities with CCR. To better coordinate and guide the work of the CCPCP Advisory Committee, an internal document titled CCPCP Planning Tool was updated in July of 2013 by advisory committee members. CCPCP Advisory Committee members contributed in the development of a year two program plan and updated the 2013-2014 CCPCP Program Plan through attending monthly meetings. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The CCR continues to assist with building capacity in further establishing an effective and coordinated leadership structure within the Coordinated Cancer Prevention and Control Program (CCPCP). This work has included collaboration on several recipient activities in the CCPCP action plan related to strengthening program infrastructure and state cancer plan implementation. The CCR continues its participation on the CCPCP Advisory Committee assisting with accomplishing objectives in the CCPCP DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 30 Objective Time-frame Staff for assessing Responsible progress Surveillance Plan which includes ensuring cancer control stakeholders understand and utilize surveillance data. One activity related to this objective was facilitated in the first part of the year and completed by the end of the fiscal year. This activity was a successful three part webinar series training informed by a needs assessment. As a result of the comprehensive State Programs Surveillance Data Needs Assessment conducted in November of 2013, CCPCP, CCPCP, CCR, University of California Los Angeles, Center for Health Policy and Research (CHPR), and the Public Health Survey Program (PHSP) worked cooperatively to develop a three-part online webinar training series to state, county, university and community members interested in understanding and utilizing cancer surveillance data. Each webinar was well attended and received positive evaluations from participants. Evaluations from the series included several requests for advanced topics for the coming year. The combined number of participants for all webinars exceeded 230 persons. Below is a list of webinar series topics:    Activities Measures of effectiveness Data On January 21, 2014 an introductory webinar was offered by CCR called Accessing California Cancer Registry (CCR) Data “How to Find and Utilize CCR Data”. Topics of discussion included what data CCR collects, how the data is collected and the different ways to access it. On March 18, 2014 a second webinar was offered by CCR called Interpreting California Cancer Registry Data – “Making Sense of the Data”. The aim of the webinar was to explain some of the common misconceptions or areas of confusion encountered when interpreting cancer surveillance data. On May 14, 2014 a third webinar was offered by CHPR and PHSP called An Overview of Behavioral Risk Factor Surveillance System (BRFSS) and California Health Interview Survey (CHIS) – “Making CHIS and BRFSS Work for You”. This webinar provided an overview of the CHIS and the BRFSS. Information included in this webinar provided participants with a basic understanding of what information is collected by each source, how to access data, and how these sources may serve as tools to access data for annual reports and/or publications. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None B. Maintain current collaborations Collaborate with ACS on annual Meetings/events attended Facts & Figures report DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Meeting minutes Facts and Figures released Snipes, Bates, Kwong, Burgos Page 31 Objective Activities Measures of effectiveness Data Time-frame for assessing progress by October 2013 Staff Responsible “Facts & completed Figures” Maps prepared Collaborate with EWC and C4 on mapping cancer data Interim Progress Report July-December 2013: Significant accomplishments to date: The CCR completed the linkage between CCR and EWC in September 2013. The 2014 American Cancer Society “Facts and Figures” document was developed and will be released at upcoming California Division Board meeting. The CCR updated data requests received from EWC and C4P for breast, cervical, and colorectal cancer incidence by race, stage, and SES. These files were prepared by the newly hired Research Scientist in anticipation of development of medical service study area maps identifying areas of needed screening focus. Major problems encountered: Mapping activities delayed due to Research Scientist not being hired until November 2013. Strategies for problem solving: Research Scientist is now hired. Workplan revisions needed: None Annual Progress Report January-June 2014: Significant accomplishments to date: The CCR has continued to maintain collaborations with several partners essential in accomplishing many objectives. As a result of the strong collaboration with the CCCP, a progress report on California’s Comprehensive Cancer Control Plan, 2011-2015 (state cancer plan) was developed and disseminated. This Progress Report Update evaluated all progress made on measurable objectives in the state cancer plan. This effort included the work of a network of highly informed cancer control stakeholders, analysts, and epidemiologists affiliated with CCR, CCPCP, and CCCP. Select priority goals and objectives from the state cancer plan were assessed and measured by comparing projected baseline data for 2011 to actual 2011 data. The final Progress Report Update was disseminated to the California Dialogue on Cancer (CDOC) Executive Committee, the broader coalition and other cancer control stakeholders via online announcements and promotional emails. In addition, the strong collaboration with the CCPCP has resulted in the development of a successful webinar series that trained several cancer control stakeholders on understanding and utilizing surveillance data. Participation in the CCPCP Advisory DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 32 Objective Activities Measures of effectiveness Data Time-frame Staff for assessing Responsible progress Committee has also developed and facilitated collaborative activities with other committee members such as the California Colon Cancer Control Program (C4P) and the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Every Woman Counts (EWC). ACS Facts and Figures 2014 released in March 2014. Maps of late stage colorectal cancer completed and in the process of being reviewed. Maps have been shared with California Colon Cancer Control Program (C4P) and the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) Every Woman Counts (EWC), and CDOC. Major problems encountered: None Strategies for problem solving: N/A Workplan revisions needed: None C. Convene advisory committee Establish list of Committee meetings at Meeting Two meetings Snipes, Bates participants minimum 2x/year minutes/ held by June Extend notes 2014 invitations Convene committee Interim Progress Report July-December 2013: Significant accomplishments to date: List of participants was established by UCD, and plans have been made to extend invitations after consultation with CCR regional PIs on constitution of committee. Major problems encountered: Delay in agreement on constitution of committee. Strategies for problem solving: An initial advisory committee meeting will take place in June 2014. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 33 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible Workplan revisions needed: None. Annual Progress Report January-June 2014: Significant accomplishments to date: Minimal, no meeting convened in June 2014. Major problems encountered: UCD still has not constituted external advisory committee and little indication of progress. Strategies for problem solving: CDSRB will compose „internal‟ advisory committee independently of UCD‟s, consisting of regional and statewide reporting system grantees, CTRs, hospital and other reporting facilities representatives, ACS, CDOC, NCIdesignated cancer centers, CDPH chronic disease control programs, MU stakeholders, health systems (e.g., Sutter, Kaiser) stakeholders, CAP, cancer researchers, and others. Workplan revisions needed: None VII. Supplemental Goal: Collect CIN data A. Collect data on highProject meetings grade pre-cancerous Conduct data cervical lesions as directed collection by CDC activities Conduct training Conduct QA/QC Obtain IRB approvals where needed Support data analyses Assess completeness of casefinding Submit final Data files submitted that meet all standards for timeliness, accuracy and completeness DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Data CTQ reports E-path reports Complete activities by 628-2014 Deapen Region 9 Page 34 Objective Activities Measures of effectiveness Data Time-frame for assessing progress Staff Responsible report Interim Progress Report July-December 2013: Significant accomplishments to date: • 547 CIN III records were collected with date of diagnosis January 1 - December 31, 2013 (3254 total records collected and submitted to CDC since April 1, 2010) • Implemented audit protocol to evaluate completeness of electronic pathology (ePath) casefinding at 22 hospitals (at all other hospitals our registry staff performs casefinding). Audit and analysis is completed at 6 facilities; audit complete and analysis is in progress at 13 facilities; audit is to be scheduled at 4 facilities. Preliminary audit results for 6 facilities identified 8 CIN III pathology reports. The audit did not find any CIN III cases that would not have been identified using routine screening methods. Major problems encountered: • Time required to implement the audit protocol varies substantially for each facility depending on the facility approvals process by hospital administration and/or IT departments, priorities at each facility, and awaiting updated versions of AIM software. • Unable to perform NAACCR Hispanic Identification Algorithm (NHIA), since Region 9 is entering path reports without data on maiden name, birthplace or Indian Health Services (HIS) and does not have access to submit cases directly for linkage. Strategies for problem solving: • Coordinate with AIM to establish cooperative relationships with facilities facing obstacles or requiring more time. Move forward efficiently with facilities unencumbered by obstacles. • Registry transition to a paperless data collection environment with coding to capture CIN III primaries and continuing education of registry staff. Workplan revisions needed: • As indicated in the previous progress report, we will continue working with hospitals to complete the audit project due to the lengthy approval process and other obstacles at hospitals. Annual Progress Report January-June 2014: Significant accomplishments to date:  427 CIN III records were collected with date of diagnosis January 1 – June 30, 2014 (4,037 total records collected and submitted to CDC since April 1, 2010)  Completed audit and analysis of protocol to evaluate completeness of electronic pathology (ePath) casefinding at 18 hospitals. Audit to be implemented at 4 hospitals. Preliminary audit results for 18 hospitals identified 72 CIN III pathology reports. The audit did not find any CIN III cases that were not identified using routine screening methods. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Page 35 Objective Activities Measures of effectiveness Time-frame Staff for assessing Responsible progress  Poster reporting preliminary audit results presented at June 2014 NAACCR meeting: “An Audit of ePath Casefinding Completeness.” Major problems encountered:  Time required to implement the audit protocol varies substantially for each facility depending on the facility approvals process by hospital administration and/or IT departments, priorities at each facility, and implementation of updated versions of AIM software.  Unable to perform NAACCR Hispanic Identification Algorithm (NHIA) since Region 9 is capturing path reports without data on maiden name, birthplace or Indian Health Services (HIS) and does not have access to submit cases directly for linkage. Strategies for problem solving:  Continue to coordinate with AIM to establish cooperative relationships with 4 hospitals facing obstacles or requiring more time. Move forward efficiently with facilities unencumbered by obstacles.  Registry transition to a paperless data collection environment with coding to capture CIN III primaries and continuing education of registry staff. Workplan revisions needed:  As indicated in the previous progress report, we will continue to work with the 4 hospitals impeded by lengthy approval processes and other obstacles to complete the audit project. DP12-1205 - CA_NPCR_Annual Progress Report Year 2 Data Page 36