| Ontario Health - Cancer Care Ontario's Data Book - 2022-2023 |
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Updated December 2021
The College of American Pathologists (CAP) electronic Cancer Checklists (eCC) are a standardized list of common Question/Answer pairs used in reporting cancer surgical pathology data and were endorsed as a national standard by the Canadian Association of Pathologists on July 14, 2009. As of fiscal year 2010/11, CCO began implementing the CAP electronic Cancer Checklist standard with hospitals across the province. Now that all participating hospitals have completed implementation, the latest CAP eCC release is mandated across Ontario. The list of mandated CAP Cancer Checklists and Effective dates can be found in Appendix 4.1.
Cancer Registry Business Rules
1. To avoid future data transmission issues please do not make any changes to your LIS, the synoptic reporting forms, or the extraction tool/process used to extract pathology reports from your LIS (for transmission to CCO) without first consulting CCO and using the agreed upon change management procedures, test environment, and documentation.
2. Any identified issues on the hospital side of the transmission are the hospital’s responsibility for follow-up and remediation. CCO is responsible for any issues identified with either ePath or its transport mechanism.
3. The Pathology Header Information (including demographics) should be complete and adhere to the valid values and common reporting standards as described below. Valid values only must appear in the designated field.
4. Personal Health Information (patient identifying information like name, birth date, and address) are to appear only in the demographics section of the pathology report header and not in any part of the body of the Pathology report (to ensure PHI is not provided to researchers who may request de-identified pathology reports for a study).
5. Text for narrative sections of all reports should appear only under the appropriate Report Section ID.
a. Clinical History is to be reported under the “Clinical History” section and should not be reported anywhere else in the report (to avoid automated receipt of non-cancer reports).
b. Intra-operative Consultation Diagnosis ('Frozen Section') is not to be included in the Final Diagnosis section since it may be different from the Final Diagnosis. Frozen section data may be included under the Gross Pathology heading.
c. The Comments Section may be used for studies, results, or text that does not have any other appropriate heading.
6. Resections, excisions, bone marrow and certain biopsies are to be reported for all disease sites using the mandated CAP eCC checklists for and adherence to the NAACCR Volume 5, Version 4.0 (HL7 2.5.1.) messaging standard. They should be transmitted in discrete data field (DDF) format to CCO for data base storage purposes and indicator reporting
7. It is expected that 90% of resection reports for all mandated CAP checklist disease sites are targeted to be in synoptic DDF format. CCO has set the synoptic DDF reporting target at 90% to allow a 10% window for situations that we expect will not fit appropriately into the standard CAP template.
8. 90% of pathology reports sent to CCO in DDF format are targeted to be complete as per the CAP eCC standard. Any report missing one or more mandatory values and/or having one or more invalid values/CKeys (for either a mandatory or optional field), will be flagged as incomplete.
9. Where there is a synoptic DDF pathology report: If a diagnosis is updated or amended due to consultation, re-evaluation, or correction, the synoptic DDF section should be updated to match the revised/amended diagnosis.
10. Where there is a synoptic DDF pathology report: ICD-O-3 disease classification by CCO cancer registry staff will be assigned from the primary site and histologic type fields in the DDF section of the report. CCO’s assumption is that the narrative final (or amended) diagnosis and comments will match the synoptic fields as outlined in #9. Please ensure that this holds true, especially when amending/correcting reports.
11. Consults completed on a specimen from an outside facility should be sent to CCO by the consulting facility. It is at the pathologist’s discretion whether or not the consult report is sent in synoptic DDF format.
a. CCO has supplemented the NAACCR Volume 5, Version 4.0 (HL7 2.5.1) messaging standard with the addition of a “Consult Indicator” data element. The ‘Consult Indicator’ should be used for all consult reports completed on specimens from an outside facility. Details for this indicator are provided below
12. Where possible consults, test results, amendments or addenda should be sent (by the originating hospital) attached to the original (electronic) pathology report under the Addendum section (LOINC section code: 3525-8^Path report.addedum spec^LN), Comments section (LOINC section code: 22638-1^Path report.comments^LN) or within the Final Diagnosis section (LOINC section code: 22637-3^Path report.final diagnosis^LN) of the report.
a. Where a hospital requests and receives an external consult on a specimen, it should annotate its own original pathology report to state whether there is agreement or disagreement with the consulting diagnosis. Any amendment to the diagnosis, based on the consult, should be clearly stated in the report body of the original hospital’s report.
i. NOTE: Until such time as the above recommended practice becomes universal, the diagnosis within the consultation report shall be the pathological diagnosis of record for the case within the Ontario Cancer Registry.
13. Where a pathology report contains diagnoses for multiple primary tumours, synoptic templates should be submitted for each primary tumour reported..
14.
CCO
has supplemented the NAACCR Volume 5, Version 4.0 (HL7 2.5.1) messaging
standard with additional information to collect biopsy information under
the data element “Type of Report”. Please submit this information
based on the details provided under Data Book – Chapter IV, Specifications,
Pathology Reporting Messaging Standard.
Please note:
(1) If the pathology report contains only biopsy specimens it is a biopsy
report; (2) If the pathology report contains only resections (an excisional
biopsy is considered a resection) or it contains any mix of biopsy and
resection specimens it is a resection report type (P).
15. Bone
Marrow reports and associated test results are expected to be sent to
CCO in synoptic and/or narrative electronic format. If a hospital is unable to send bone
marrow reports electronically to CCO (in synoptic and/or narrative format),
the site will be expected to submit paper copies of all malignant bone
marrow reports and associated test results (until such a time that electronic
transmission becomes available).
16. The “Date of Death” data element must be provided for autopsy reports ONLY. All other report types (such as surgical pathology, bone marrow, cytology, etc) must have this field left blank. The “Date of Death” data element in PID-29 should be populated with the correct date of death (YYYYMMDD) for autopsy reports, and should be left blank (null) for all other report types. The “Vital Status” data element in PID-30 indicates whether or not the patient is deceased in the format: “Y” or “N”. This field should ONLY be set to “Y” (deceased) if the report is an autopsy; all other report types (such as surgical pathology, bone marrow, cytology) must be set to “N” (alive).
17. Biomarker testing completed on a specimen from an outside facility should be sent to CCO by the consulting facility. Biomarker reports are to be sent in synoptic DDF format, for those templates mandated. Please refer to Appendix 4.1 for Biomarker Template effective dates.
Pathology Reporting Roadmap
In 2008, CCO embarked on a multi-year initiative with Ontario hospitals and pathologists to standardize pathology reporting across the province. In order to improve this effort, in 2010, CCO’s Pathology and Laboratory Medicine Program (PLMP) endorsed the adoption of the College of American Pathologist’s electronic Cancer Checklist (CAP eCC) and associated paper Cancer Protocols as the standard for synoptic pathology reporting in Ontario. All mandatory disease sites, procedures and template versions for synoptic pathology reporting will be confirmed after each annual CAP eCC release by CCO with approval and guidance from PLMP, CCO eCC Review Committee and the Ontario Cancer Registry. See Appendix 4.1 for the current list of mandated CAP eCCs.
Regarding the collection of patient and provider identification information (included as part of the pathology report header data), CCO will continue to support conformance to the NAACCR Vol 2 and Vol. 5 standards (which can be found at www.naaccr.org). Hospitals are also expected to provide pathologist and surgeon identification numbers as a five digit province wide standard, published by the College of Physicians and Surgeons of Ontario (CPSO number).
All inquiries regarding pathology reporting may be sent to:
OH-CCO_Pathology@ontariohealth.ca