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Data Collection and

Submission Guide

for Medical Director

Women’s Cancer Screening Collaborative (WCSC)

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Contents

Reporting of data .................................................................................................................................... 3

Reporting timelines ................................................................................................................................. 3

Data submission spreadsheet ................................................................................................................. 4

Breast screen data – accessing Cancer Institute NSW data .................................................................... 5

Cervical screen data – accessing Cancer Institute NSW data ................................................................. 5

Submitting data ....................................................................................................................................... 5

Coding screening results so that Cat4 can report them ......................................................................... 6

Coding breast screen results ............................................................................................................... 7

Adding breast screen results manually ............................................................................................... 8

Coding cervical screening results ........................................................................................................ 9

Extracting breast screening data using Cat4 ......................................................................................... 10

Extracting cervical screening data using Cat4 ....................................................................................... 11

Manually Extracting breast screening data .......................................................................................... 12

The Renewal .......................................................................................................................................... 16

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Reporting of data

Quarterly reporting against the measures on page 44 of the Women’s Cancer Screening Collaborative (WCSC) handbook will help your practice to understand if the changes you are making are improving screening rates, and will help NCPHN to track and report the performance of the Collaborative overall.

This short ‘how to’ guide is to help you to understand how to extract and report data against the breast screening measures.

Remember, your Practice Support Officer is available to support you with your WCSC reporting.

Reporting timelines

Measure May 15th 2017

August 15th 2017

Nov 15th 2017

Feb 15th 2018

May 15th 2018

Breast screening

Baseline data due

Submit data Submit data Submit data Submit data

Cervical screening

No data due Baseline data due

Submit data Submit data Submit data

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Data submission spreadsheet

You will be asked to submit data using this spreadsheet. Save this spreadsheet in a safe place and add data to it each quarter, NCPHN will use the data you provide to prepare graphs that will be sent back to you. NCPHN will also create benchmark graphs, these will be anonymous but you will know which practice you are for the purpose of benchmarking:

Please send completed spreadsheet to: sgloede@ncphn.org.au

Practice

name:

BREASTSCREENING CERVICAL WHOLE POPULATION CERVICAL ABORIGINAL AND TORRES STRAIT

ISLANDER

Date data

extracted:

Numerator:

Number of

active

women aged

50-74 who

have had a

bilateral

breast screen

mammogram

in the past 2

years

Denominator:

The total

number of

active

female

patients

aged 50-74

Date data

extracted:

Numerator: The

number of female

clients aged 20-69

with 3 or more visits in

the past 2 years who

have not had a

hysterectomy and

have had a cervical

screen in the past 2

years

Denominator:

The number of

female clients

aged 20-69

with three or

more visits in

the past 2

years who

have not had a

hysterectomy Date data

extracted:

Numerator: The

number of female

ATSI clients aged

20-69 with 3 or more

visits in the past 2

years who have not

had a hysterectomy

and have had a

cervical screen in

the past 2 years

Denominator: The

number of female

ATSI clients aged

20-69 with three or

more visits in the

past 2 years who

have not had a

hysterectomy

Cat4 can produce a graph that shows you which women are coded as ‘ineligible’. Women Cat4 shows as ‘ineligible on their pie graph (see page 8) should be removed

from the numerator and denominator as they may have had a hysterectomy or have another reason for not being eligible for cervical screening. If your data is not yet

coded in a way that Cat4 can aggregate it accurately, we don’t expect you to go through all patient files to confirm hysterectomy status prior to submitting your

baseline. Your data will get more accurate over time as you improve your coding of ineligible women. Note: some women with hysterectomy still require vault

screening and should not be excluded – seek clinical advice.

We reco

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Breast screen data – accessing Cancer Institute NSW data

Most practices in the WCSC have reported that they don’t have a consistent way in which their practice records mammograms.

This means that it can be difficult to produce a one size fits all process for report against the breast screen measures and the solutions presented in this guide may not work perfectly for every practice.

That is why we encourage you to use the Cancer Institute NSW data request form to request a list of your patients who have screened via the Breast Screen service. Contact Sara on sgloede@ncphn.org.au for a copy of this form and for more information.

You can use the data in the Cancer Institute NSW list to create your baseline and as your starting point for creating an up to date recall and reminder list.

Whilst this baseline data won’t be perfect, it’s a good starting point that avoids too much manual work.

Because the release of the data from Cancer Institute NSW isn’t regular or ongoing, it is important that your practice work towards a systematic approach to coding mammograms so that in the future you can easily, at any time, identify what percent of women aged 50-74 in your practice have screened in the last two years, and which women are due for reminding.

Cervical screen data – accessing Cancer Institute NSW data

Like BreastScreen data, you can obtain a patient list from Cancer Institute NSW for women who have had a Pap smear in NSW by following this link:

https://www.csp.nsw.gov.au/information-and-resources-for-health-professionals/general-information/requesting-data-from-the-nsw-pap-test-register/

If you feel like your current Pap test data is not accurate, you can use the data in the Cancer Institute NSW list to create your baseline and as your starting point for creating an up to date recall and reminder list.

Whilst this baseline data won’t be perfect, it’s a good starting point that avoids too much manual work.

Note, from December 1st cervical screening will move to a national register.

Submitting data

You will be asked to submit this data via the data submission spreadsheet that will be emailed to you, and to then email the completed spreadsheet to Sara Gloede on sgloede@ncphn.org.au

The data submission spreadsheet can also be downloaded from the website: ncphn.org.au/wcsc – click on ‘measuring change’ and ‘data submission spreadsheet’.

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Coding screening results so that Cat4 can report them

CAT4 is a fantastic tool that produces really easy to use reports. However, like all aggregating tools, data does need to be recorded in your practice software in a certain way for Cat4 to be able to collect it and report it.

You can find a complete list of the ‘data mapping’ that shows you how ethnicity, conditions, screening etc need to be recorded for Cat4 to pick it up here:

http://help.pencs.com.au/display/ADM/General+Data+Category+Mappings+MD3

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Coding breast screen results Breast screen results must be recorded as one of the following for Cat4 to report them:

o Breast Mammogram Screening

o Bilateral Mammography

o Ultrasound Breast Bilateral

o Wesley Breast Clinic Consultation Report

From September 2017 Cat4 will also recognise and report results recorded as:

o Breast – mammography

o Mammogram

o Mammogram – Normal

Breast Screening data must be entered into the Results tab in MedicalDirector in order for it to be recognised in search queries. The test name should be entered as ‘Breast Mammogram Screening’. The test result can be entered from the Patient record.

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Adding breast screen results manually

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Coding cervical screening results

Medical Director automatically recognises HL7 items as pap smear results if they are on this list.

PenCS asks that Practices check the test names appearing in the results tab and advise if there is a test name that should be added to this list.

PAP PAPR PAP NS PAPRNS PAP SMEAR PAP SMEARS PAP SMEAR(PAN-0) NON SCREENING SMEAR CERVICAL CYTOLOGY CERVICAL SMEAR CYTOLOGY GYNAECOLOGICAL (PAP-0) CERVICAL SMR GYNAECOLOGICAL CYTOLOGY CYTOLOGY GYNAECOLOGICAL

PAP TEST PAP (GEELONG) PAP (BALLARAT) CCSR CERVICAL – CONVENTIONAL SMEAR PAP-0 (PAP SMEAR) PAP SMEAR +/- THIN PREP CYG CYTOLOGY-PAP SMEAR PAP SMEAR\T\THINPREP (PAP-0)CYTOLOGY GYNAECOLOGICAL PAP (P150)

Cat4 will mark a patient as ‘ineligible’ if coded the following way:

Pap Smear Ineligible 1) Smear tab – ticked to exclude OR

2) Coded condition of Hysterectomy:

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Extracting breast screening data using Cat4

If you have installed Cat4, you may like to use the following “Cat recipe” to identify how many women in your practice have had a breast cancer screen in the past 2 years: http://help.pencs.com.au/display/CR/Identify+eligible+patients+never+screened+for+breast+and+bowel+cancer

This will produce a graph that gives you the total number of women in the age range, along with the total number of women screened in the past two years, it will look like this:

Your denominator is the total of all the groups minus ‘ineligible’

Your numerator is the number of women who have a mammogram recorded in the past two years

Over time, as your coding improves, the number of women in ‘not recorded’ should reduce and the accuracy of this pie graph will improve.

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Extracting cervical screening data using Cat4

There is a fantastic, printable ‘Cat Recipe’ that will step you through how to extract and

report cervical screening data. This ‘Cat Recipe’ also shows you how to set up reminders in

Topbar, you can download it here:

http://help.pencs.com.au/display/CR/Identify+eligible+female+patients+who+have+not+had+

a+pap+smear+recorded+in+the+last+4+years

Following this ‘Cat Recipe’ will produce a graph that looks like this:

Your denominator is the total of active female patients aged 18-69 (the Cat4 recipe shows you how to see this)

Your numerator is the number of women who have a smear recorded in the past two years (< 1 yr plus 1 – 2 yrs )

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Manually Extracting breast screening data

Open Medical Director

Click ‘Search’

Click ‘Patient…’

A Patient Search box will appear

Within the ‘Age greater than or equal to’ search, type ‘50’

Within the ‘Age less than or equal to’, type ‘74’

Within the ‘Sex’ box, select ‘Female’

Click ‘Search’.

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Now select whether these women have had a mammogram.

Select

Condition;

Check the ‘OR’ box

Mammogram, Mammogram – Normal, and Breast - mammography

Click ‘Add to Search Criteria’, the filters should then appear in the text box:

o “Female patients having (Breast – mammography or Mammogram or Mammogram – Normal) aged between 50 and 74”

Click ‘Search’.

You will now have a list of all female patients aged between 50 and 74 who’ve been coded as having a mammogram.

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Click, ‘Save’ at the bottom of the screen, name your file and select ‘Comma Separated Values’ as a document type, Click ‘Save’.

Open Excel and navigate to saved file, via ‘Open’.

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You will now have access to a saved list of all female patients aged between 50 and 74 who’ve had a mammogram.

Using the list, search each patient’s record or cross reference against the list of women who have screened provided by Cancer Institute NSW (if you requested this list) to establish which of these women have had a mammogram within the past 2 years.

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The Renewal

From December 1 2017, the National Cervical Screening Program will change. The two yearly Pap test for women aged 18 to 69 will change to a five yearly human papillomavirus (HPV) test for women aged 25 to 74. Women will be due for the first Cervical Screening Test two years after their last Pap test. The changes include:

women will be invited when they are due to participate via the National Cancer Screening Register

the Pap smear will be replaced with the more accurate Cervical Screening Test

the time between tests will change from two to five years

the age at which screening starts will increase from 18 years to 25 years

women aged 70 to 74 years will be invited to have an exit test.

As a result of the Renewal, the current cervical screening measure will change. These

changes are as follows:

You will be provided with information and support to collect and submit data on the new measure before December 2017.

Cervical Screening: HPV test or Pap test

Numerator The number of female regular clients, aged between 25 and 70 years, with 3 or more visits within the previous 2 years, who have not had a hysterectomy, and who have had a Pap test or a HPV test within the previous:

• 2 years (Pap test) OR

• 5 years (HPV test)

Denominator The number of female regular clients aged 25 to 70 years, with 3 or more visits within the previous 2 years, who have not had a hysterectomy