California’s Mandated Epath Reporting

1. California’s Mandated Epath Reporting Dennis Deapen & Andrea Sipin Los Angeles Cancer Surveillance Program NAACCR / IACR Meeting June 11, 2019 Vancouver, British Columbia

2. Outline • E-path reporting legislation • Public information • Outreach • Registration • Progress to date • Challenges • New E-path pilot project • Next steps

5. California Cancer Registry Pathology Reporting Portal

6. California Cancer Registry Pathology Reporting Portal

7. California Cancer Registry Pathology Reporting Registration Portal

8. California Cancer Registry Pathology Reporting Registration Portal

9. Los AngelesPath Lab Outreach • For LA, CCR sent us a list of 413 candidate labs • Intro letter and survey were sent to all • 77 responded • 16 undeliverable • 336 no response • Follow-up phone calls were made to encourage registration on the CCR site

10. Lab Characteristics • Based on 77 completed questionnaires: • Approximate no. of paths + for cancer: 2-50,000 annually • 35 different EMR systems used • Most common: Meditech

11. Challenges • Electronic path reports may be stored in many different formats • Many pathology labs and small hospitals have no in-house IT support • Pathology labs and small hospitals lack CTR expertise Thus: • No one qualified to identify reportable path reports • No ability to upload electronic path reports Anticipated outcome: • Substantial numbers of false positives and missed cases • Incomplete data

12. Can We Develop an E-path Model for Small Volume, Low Tech Facilities? • Seek to: • Provide new approaches to multi-site data aggregation that can benefit cancer registries • Provide format agnostic, simple data capture • Provide reportabilility validation portal • Provide remote casefinding audit capacity • Provide centralized information extraction into national standardized metrics • Provide rapid case ascertainment (a “nice to have”) • Partner with technical partners for pilot testing

13. C: Reportable Case Identification Service (Automated Casefinding) ( Service Provider TBD ) A: Pathology Lab A D: Regional Casefinding E: Redox Message B: Redox Message Configuration and F: CCR Interface Engine Repository Configuration and Transfer Transfer ( Validates and loads to ( CSP LA Regional Fee for Service ( CCR Reportable Cancer ( All Patholgy Reports ) CCR Pre-Processing) Repository) Pathology Reports) A: Pathology Labs: Pathology Labs will be paying for a regional service to identify reportable cases of cancer which are required to be reported under AB2325. Participating labs are those who do not have the capability to filter out cancer reports on their own and who do not wish to invest in technology to do so. Pathology Labs will send a copy of data for a period of time to the Regional CasefindingRespository for the identification of reportable cancer cases. Business agreements for the transfer and temporary storage of data in the Regional Casefinding Repository must be established between participating pathology labs and the region. B: Redox Interfacing: Redox configures connection point to the Regional Casefinding Repository. Redox configures message transfer. Data must be stored in some way in order for the Reportability Service to be run. Needs Action: Redox: Message configuration TBD. Needs Action: Redox or HLA: Who has the scope for prelimary store of data so the engine can be run. A: Pathology Lab B

14. C: Reportable Case Identification Service (Automated Casefinding) ( Service Provider TBD ) A: Pathology Lab A D: Regional Casefinding E: Redox Message B: Redox Message Configuration and F: CCR Interface Engine Repository Configuration and Transfer Transfer ( Validates and loads to ( CSP LA Regional Fee for Service ( CCR Reportable Cancer ( All Patholgy Reports ) CCR Pre-Processing) Repository) Pathology Reports) A: Pathology Lab B C: HLA Reportability Engine: Cloud or on-premise reportability service to be installed, configured, run and maintained by Health Language Analytics Global (HLAG). Runs reportability engine logic against path reports received in the Regional Casefinding Repository. D: Regional Casefinding Repository: Redox transfers messages from participating labs. Data is parsed and stored as necessary to run the reportability logic. Output from the reportability service identifies and categorizes reports as 1) Reportable Cancers, 2) Possibly Reportable Cancers 3) Not reportable.

15. C: Reportable Case Identification Service (Automated Casefinding) ( Service Provider TBD ) A: Pathology Lab A D: Regional Casefinding E: Redox Message B: Redox Message Configuration and F: CCR Interface Engine Repository Configuration and Transfer Transfer ( Validates and loads to ( CSP LA Regional Fee for Service ( CCR Reportable Cancer ( All Patholgy Reports ) CCR Pre-Processing) Repository) Pathology Reports) E: Redox Interfacing: Redox configures connection point to CCR Interface Engine. Redox transfers 1) Reportable Cancers and 2) Possibly Reportable cancers to CCR ePath Pre-Processing in NAACCR Volume V format per CA constraints. CCR works to onboard Redox interface within the same process as all pathology reporting entities under AB2325. F: CCR Processing: CCR establishes end point for Redox connection. CCR validates message format and content. CCR performs secondary reportability scan. Loads reportable cases to CCR pre-processing. Reports identified as 1) Reportable Cancers bypass manual review for reportability determination. Reports identified as 2) Possibly Reportable are loaded to PPAQ where reportability determination can first be made. A: Pathology Lab B

16. Met at Sirius Computing Services at the Los Angeles Healthcare Information and Management Systems Society (HIMSS) conference • Sirius requested a call for further information, followed by on-site visit • Brought in Redox for technical support

19. Note: Redox engine does not have a reportability screening tool

20. Created E-Path with Region 9 starting in 1999. • Have worked with many of the reported LIS systems (Cerner, Co-Path, Meditech, Soft lab etc.)  It should not be a problem to receive pathology output from these systems. • To make it easy for the small labs, we could provide a secure web portal on the E-Path cloud system so they can upload pathology reports to the E-Path service in their native format.  This would require no software at the lab.  We would provide training on how to upload the reports. • The E-Path Cloud Service could be shared by the labs. • The E-Path Cloud Service would: • Convert each lab’s native format Pathology report to NAACCR standard HL7 message • Keep each lab’s reports in a separate folder structure • Distinguish between reportable and non-reportable documents (i.e. perform casefinding) • Include the Cancer Data Forwarding module • Include duplicate checking • Forward reportable documents to the registry • Allow each lab to download its positives from the service • Automatically purge negative reports on a scheduled basis • Maintain a count of reportable documents for each lab • Provide a disclosure report for each lab for HIPAA compliance

22. Invite Laboratory Partners • Responded to our survey • Have registered on California Cancer Registry portal • Have electronic path reports • Report small to moderate annual caseloads

23. Work in Progress • Email introduction/invitation with documentation about reporting regulation and proposed pilot implementation • Responses • Are introducing another solution • Haven’t decided how to report • Implementing a new EMR • No response • Telephone conversations

24. Possible Next Steps • Collect additional information from labs in IT capacity • Additional questions for path lab outreach from Redox: • Does your in-house IT team support your EHRs/PM Systems or is it outsourced to your vendor?  • Are those systems capable of sending and/or receiving HL7 or do they have web services, SFTP (or other) available for integration needs? • Do you have a list of existing HL7/web services that you have enabled that you wouldn't mind sharing?  • If you do not have HL7 feeds or web services enabled today, do you know what the engagement process looks like with the vendor? • Offer to introduce to labs/collect additional info • Have potential vendors propose solutions • LA would review for feasibility • LA would offer to assess preliminary data, i.e. review for accurate determination of reportability

25. Possible Next Steps • Assess overall interest in this capacity among SEER program • Conduct additional “street-level” dialogue with local cooperative labs to explore current status/best practices for registry success • Consider funding mechanisms • Let the market compete? • Demonstration project? • Other?

26. Ensuring Success • Acquisition of additional reporting facilities in 2019 under AB 2325 • Critical time for relationship-building • Establishing new procedures • Opportunity for improved reporting: • Need to understand challenges faced by the hospitals, pathology laboratories, and treatment centers affected by the law • Help identify potential solutions to ensure central registry success as acceptors of the incoming pathology reports • Ensure database allows for efficient processing • Identify opportunities for automation while recognizing areas that require manual review to maintain data quality

27. Thank You Dennis Deapen, DrPH Principal Investigator, Director ddeapen@usc.edu Andrea Sipin, MS, CPHI, CTR Program Manager asipin@usc.edu The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries, under cooperative agreement 5NU58DP006344; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute.  The ideas and opinionsexpressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors.