One of the initial challenges in establishing the Cancer Registry was to determine what discrete data was already available in our Electronic Health Records (EHR) and what data needed to be entered specifically for this purpose. In most cases we found the data either was not present or was not in a form that would allow transfer into a registry. Here are the various data collection forms created and utilized for this project:
State Report Flag – To designate patients that should be included in the Registry, providers enter a “Severity” of State Reported in the Active Problem in the patient’s chart.
TNM Staging Forms – TNM Staging information is collected in an administrative form in the EHR. These forms force more discrete data and provide a nicely formatted document for the providers and patients.
Tumor Checklists – The pathologists create checklists within their pathology reports using a Word Template we created. The templates, like the TNM Staging Forms, have list box options, check boxes, radio buttons and text fields when necessary. The templates allow the pathologists to create these checklists with predictable structure and defined vocabulary. They display cleanly in the final pathology report. Molecular markers are also included.
Oncology Summary Worksheet – Clinicians record treatment performed outside of NJH, the date the decision was made to discontinue treatment or not initiate treatment, hospice and palliative care, and diagnosis date for patients who have transferred their care to NJH in this worksheet. The ability to create worksheets resides in the order/results portion of the Allscripts EMR.
Planned Chemotherapy Worksheet – records the intended therapy including days, dosage, and cycles.
Oncology Infusion Worksheet – Clinicians record the details of each infusion session, including drug, dosage, adjustments, and supportive care.
Cancer Status – Clinicians use a dictation template within their clinical notes to note the cancer status at that time. The three choices – No evidence of Tumor, Evidence of Tumor, or Not able to determine – appear directly above the signature block.
Cancer Recurrence Form – This administrative form collects the recurrence diagnosis date and information about the original diagnosis. The original tumor diagnosis date format allows the entry of partial dates, e.g. January, 2010 or 2009, to allow for recollected dates.