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Rapid Quality Report System (RQRS)
User Guide
Release Date
April 2016
Updated August 2016
1 Contents
Introduction .................................................................................................................................................. 3 Purpose ......................................................................................................................................................... 4 History ........................................................................................................................................................... 4 Quality Measure Development ................................................................................................................. 5 Operational Considerations .......................................................................................................................... 6 Application Overview .................................................................................................................................... 7 Technical Requirements ................................................................................................................................ 7 Enrollment ................................................................................................................................................ 8 Data Submission Requirements ................................................................................................................ 8 Submission Schedules ............................................................................................................................. 11 Navigation Guide ........................................................................................................................................ 12 Dashboards ............................................................................................................................................. 12 Cases included in the YTD Dashboard ................................................................................................. 13 Alerts ....................................................................................................................................................... 13 Case Alert Colors ................................................................................................................................. 16 Case List .................................................................................................................................................. 17 Columns .............................................................................................................................................. 17 Measure Exclusions ............................................................................................................................. 21 Compare .................................................................................................................................................. 22 Drill‐down reports will display: ............................................................................................................... 23 My Account ............................................................................................................................................. 23 RQRS Enrollment Instructions ..................................................................................................................... 25 RQRS Help ................................................................................................................................................... 26 2 Introduction
The Rapid Quality Reporting System (RQRS) is a quality tool of the National Cancer Data Base (NCDB). This tool was tested during an alpha and a beta test starting in 2008 and released to all CoC‐accredited cancer programs in 2011. RQRS was developed to assist CoC‐accredited cancer programs in promoting evidenced‐based cancer care at the local level. It is a Web‐based, systematic data collection and reporting system that advances evidenced‐base treatment through a prospective alert system for anticipated care which supports care coordination required for breast and colorectal cancer patients at participating cancer programs. WHATISRQRS?
The objective of the Rapid Quality Reporting System is to promote and facilitate evidence‐based cancer care at Commission on Cancer (CoC)‐accredited cancer programs. Participation in this program is voluntary. The RQRS serves to assess compliance with four National Quality Forum‐endorsed accountability performance measures for breast and colon cancers and one quality improvement measure for colon cancer in real clinical time HOWDOESRQRSWORK?
The RQRS is a Web‐based data‐collection and reporting system. All case information reported to the RQRS is collected by cancer registries at participating programs and entered into their registry database. On a locally determined schedule, but at least quarterly, cases are extracted from the cancer registry database and transmitted to the National Cancer Data Base (NCDB) using nationally standardized data transmission specifications established by the North American Association of Central Cancer Registries. No additional capital investment is necessary to participate in the RQRS. HOWARETHEPERFORMANCERATESUPDATED?
Reports available through the RQRS are based exclusively on the case records reported from the participating program’s cancer registry. Case records in the RQRS can be modified or updated via a resubmission of cases from the local cancer registry. Participating programs are responsible for monitoring and updating case records and may use the Alerts and Case Listing features of the RQRS to manage and facilitate any necessary updates. WHATDOESRQRSDOFORPATIENTCARE?
Cancer programs participating in RQRS receive real clinical time alerts for individual cases in which pending adjuvant treatment has not been reported to the system. These alerts have been developed to provide a warning system for cancer programs to prevent patients from “slipping through the cracks.” BUSINESSCONCERNS
Implementation of the RQRS is consistent with and honors the agreed upon terms outlined in the Business Associate Agreement between CoC‐accredited programs and the American College of Surgeons regarding the use of data submitted to the CoC 3 Purpose
To promote and facilitate high quality patient care through adherence to clinical quality of cancer care measuresby providing accurate, real‐time clinical data to the cancer team. The Rapid Quality Reporting System (RQRS): 
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Allows expedited data entry of a critical subset of items specifically relevant to anticipated standard of care treatments. Enables accredited cancer programs to report data on patients concurrently. Shows cancer programs up‐to‐date concordance rates relative to the state, other similar programs, and all CoC accredited programs across the country. Provides the hospitals timely notification of treatment expectations. By participating in RQRS, your cancer program can: •
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Improve patient care with access to real clinical time performance rates. Evaluate historical performance to compare with current practice. Use the information in RQRS to develop real clinical time interventions to enhance the quality of care in your cancer program. •
Monitor and prevent patients from experiencing a delay in treatment or catch patients who are at risk of “slipping through the cracks.” •
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Compare performance rates in your cancer program with other participating cancer programs. Encourage timely and accurate collection of adjuvant treatment information. Negotiate favorable reimbursement rates with payors through demonstrating current practices.
History
The Quality Problem
The quality of cancer care in America varies widely. Variation in care affects outcomes of cancer care ranging from quality of life and resource utilization, to cancer recurrence and long term survival. Addressing variation and quality of cancer care has become a national priority since the 1999 report National Cancer Policy Board of the Institute of Medicine outlined the scope of the problem and broad recommendations for quality improvement. The organization of cancer care makes quality evaluation in cancer a different challenge than, for example, cardiac care. Quality initiatives in cardiac care can focus primarily on single episodes of inpatient care (e.g. cardiac surgery outcome and treatment of acute myocardial infarction). Quality evaluation in cancer care cannot be limited to the inpatient setting. Cancer care is the sum of multiple episodes of care, often spread over weeks or months, administered by a number of providers across different specialties in a combination of inpatient and ambulatory settings. A significant proportion of cancer care for common malignancies is now administered in the ambulatory setting. 4 QualityMeasureDevelopment
Quality improvement requires evidenced‐based measures that can be applied with available data and are relevant to providers, institutions, and consumers. Using cancer registries, the RQRS prospectively collects data on patients diagnosed and treated for cancers and reports back to participating CoC accredited cancer programs comparative concordance rates for quality measures. Cancer registries at CoC accredited cancer programs use nationally established and open source data standards to routinely report cancer diagnosis and treatment to the ACS’s National Cancer Data Base (NCDB) on an annual basis. Quality improvement measures are intended to be used for internal monitoring of performance within an organization or group so that analyses and subsequent remedial actions can be taken, as appropriate. The quality measures for breast and colorectal cancer care reported through the RQRS are the same measures that have been endorsed by the National Quality Forum or identified though collaboration with other national medical and oncology organizations and societies. These measures are already reported to the CoC accredited hospitals using retrospective data. Measure specifications for the quality indicators for breast cancer and colorectal cancer are listed in on the CoC Quality Measures website. RQRS History The ACS recognizes its obligation to support each hospital’s commitment to assure comprehensive quality care. The Standards for the CoC’s accreditation program require hospitals to collect comprehensive cancer treatment data on patients who receive all or some portion of their care at the hospital and report these data to the National Cancer Data Base (NCDB). Previously, reporting has occurred retrospectively and analyses of clinical performance have been based on past practices. In order to facilitate quality improvement that will have the ability to encourage quality, evidence‐based care in a timely manner, the CoC has developed a mechanism, the Rapid Quality Reporting System (RQRS), that enables accredited cancer programs to report data on patients concurrently, provide hospitals notification of treatment expectations, and show a hospital its year‐to‐date concordance rate relative to the state, other similar hospitals, and hospitals at the national level. The primary objective of the RQRS is to promote evidenced‐based cancer care at the local level. RQRS does not test new interventions. Rather it simply utilizes a web‐based, systematic data collection and reporting system to promote evidenced‐base treatments through a web‐based alert system for anticipated care in order to support the scope of care coordination required for breast and colorectal cancer patients at the local level. Utilization of the RQRS is basically an intrinsic part of the normal health care operation. Implementation of the RQRS is consistent with and honors the agreed upon uses of data submitted to the CoC as stated in its BAA with each CoC accredited cancer program. Prior to releasing RQRS to all accredited cancer programs the CoC tested the RQRS in seven alpha and sixty five beta test sites to: 5 1.) Demonstrate the ability to utilize existing cancer registry operations and nationally established coding guidelines to collect a minimum necessary quantity of data elements for breast and colorectal cancer in order to support ongoing quality assurance programs using the RQRS. 2.) Identify the impact a web‐based data collection and reporting system has on promoting quality of care for breast and colorectal cancer cases through assessing the change in performance rate for each of the measures at participating hospitals. 3.) Assess the acceptability of the RQRS to providers through appraising factors such as size of cancer program, location of program, impact on registry operations, and availability of electronic medical records. 4.) Expand the RQRS for participation on a voluntary basis to the all CoC accredited cancer programs across the United States. The initial alpha test involving seven sites in Georgia (Hamilton Medical Center, Archbold Memorial Hospital, Memorial Health, Dekalb Medical, West Georgia Health Systems, the Medical Center of Central Georgia, and University Health Care System) was undertaken to test the mechanics of the system. The primary purpose of the alpha test was to ensure that the developed RQRS software manages data and reports information in a manner consistent with the design specifications and can be independently verified by external users of the system. The beta test, which included 65 CoC accredited cancer program volunteers, was performed over two‐years, from July, 2009 to August, 2011. This phase focused on the scope of resources required to engage and sustain an active clinical monitoring system. Observations and recommendations from RQRS alpha and beta test participants have been used to develop enhancements to the system before its full release. In September 2011, the RQRS was rolled out on a voluntary basis to all CoC approved cancer programs which meet the minimum requirements for participation. As with the prior phases, the CoC has monitored and analyzed acceptance and use of the system. Beginning in January 2014, the CoC updated their standards to include participation in RQRS for commendation with Standard 5.2. Starting in January 2017, RQRS participation is required for all CoC‐accredited cancer programs. OperationalConsiderations
RQRS provides a unique mechanism that cancer programs can use to monitor cancer treatment in real clinical time. Its use may introduce changes in the way the cancer registry functions, and it may require time for registry personnel to develop new working routines in order to optimize the program’s experience. Half of RQRS participating registries stated they spend as much as six hours a week working on RQRS cases, once they have integrated RQRS into their work routine. Adequate staffing and support of the registry is necessary for RQRS participation to work most effectively. This requirement is particularly important during the initial phases of participation. Registries should be encouraged to adopt concurrent abstracting methodologies in order to optimize RQRS participation. POTENTIAL CHANGES IN REGISTRY OPERATIONS •
Concurrent abstraction may take time to master. 6 •
RQRS cases are followed from diagnosis through the end of treatment, which can be as much as one year after diagnosis. •
Registrars may need to follow up with treating physicians regularly to determine the treatment status of RQRS cases with alerts. •
RQRS case alerts may be reviewed in cancer conferences or at cancer committee meetings. Application Overview
Case Reporting – Registry Operations
Data are collected by cancer registries at the participating hospitals and entered into their cancer registry data base. On a locally‐determined schedule, but at least every three months cases are extracted from the cancer registry and transmitted to the RQRS using nationally standardized data transmission specifications established by the North American Association of Central Cancer Registries (NAACCR). Transmission of cases to the RQRS will utilize established secure electronic data transmission protocols utilized by the NCDB since 2001. Modifications or changes to case records can only occur at the cancer registry. Quality reports available through the RQRS are based exclusively on the case records reported from the participating programs’ cancer registry. Participating programs are responsible for monitoring and updating case records, and may use the alerts and case listing features (see below) of the RQRS to manage and facilitate any necessary updates. The RQRS is designed to complement the continuing large‐scale retrospective collection by the NCDB while allowing real‐time quality of cancer care assessment to emerge as a critically important component of the services it provides to CoC‐accredited cancer programs. The conceptual framework for the RQRS uses data collection and management procedures that are almost identical to those utilized in the NCDB’s traditional Call for Data while incorporating additional processes to accommodate extra levels of communication and transparency necessary to support a standardized reporting format using the NQF endorsed measures. The RQRS has been designed to assist cancer programs to ensure that submitted data are an accurate reflection patient care. RQRS provides the opportunity for hospital registries to examine data at the local level and verify that these performance rates are representative of the care provided at their institution. Each participating hospital may use the RQRS to examine data completeness of tumor characteristics, surgery, stage, and treatment. The RQRS process of data transmission and flow is cyclical in design. Every data submission or resubmission by the participating cancer program registry invokes specific actions by the RQRS. Feedback in the form of reports are generated by the RQRS and returned to the reporting registry. Technical Requirements
Minimum Operating System Requirements All RQRS user’s workstations must be equipped with Adobe Flash Player v10.3 and one of the following internet browser programs: 7 •
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Internet Explorer 8 and above Google Chrome 13.0 and above Mozilla Firefox 3.6 and above Safari 5.1 Enrollment In order to enroll in RQRS a program must: •
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Be currently CoC accredited. Have a Cancer Committee Chair (CCC), Cancer Liaison Physician (CLP), Cancer Program Administrator (CPA), and Hospital Registrar (HR) with CoC Datalinks access. *If contact information is out of date, it must be updated in the Manage Contacts portion of CoC Datalinks or, in the case of CLPs, contact [email protected] prior to RQRS enrollment.
DataSubmissionRequirements
Case records are abstracted following nationally standardized cancer registration coding rules. Participating cancer programs utilize existing commercial registry software programs to submit case records to the RQRS in standard NAACCR record format. Records may be submitted as they are abstracted, and may be in varying states of completeness. The minimum data requirements are found in Table 1. Generally the NCDB needs the information from a pathology report and an assigned accession number and sequence number to assess cases for RQRS adjuvant therapy measures. Table 1 RQRS Minimum Required Fields Item NAACCR Item #
Definition
Facility Identification Number 540 Identifies the facility reporting the case Accession Number 550 Provides a unique identifier for the patient consisting of the year in which the patient was first seen at the reporting facility and the consecutive order in which the patient was abstracted. Sequence Number 560 Indicates the sequence of malignant and non‐malignant reportable neoplasms over the lifetime of the patient. Class of Case 610 Identifies whether the cancer program diagnosed and/or treated the reported case. Sex 220 Identifies the sex of the patient.
Birth Date 240 Identifies the date of birth of the patient. Age 230 Records the age of the patient at his or her last birthday before diagnosis. 8 Race 160 Identifies the primary race of the person. Spanish Origin 190 Identifies persons of Spanish or Hispanic origin. Primary Payor 630 Patient Zip Code at Dx 100 Identifies the patient’s primary payer/insurance carrier at the time of initial diagnosis and/or treatment Identifies the postal code of the patient's address at diagnosis.
Date of Diagnosis 390 Records the date of initial diagnosis by a physician for the tumor being reported. Primary Site 400 Identifies the primary site.
Tumor Histology 522 Identifies the microscopic anatomy of cells. Tumor Behavior 523 Records the behavior of the tumor being reported. The fifth digit of the morphology code is the behavior code. Tumor Size 2800 Records the largest dimension or diameter of the primary tumor. Regional LN Examined 830 Records the total number of regional lymph nodes that were removed and examined by the pathologist. Regional LN Positive 820 Records the exact number of regional lymph nodes examined by the pathologist and found to contain metastases. Clinical T 940 Evaluates the primary tumor (T) and reflects the tumor size and/or extension as recorded by the physician. Clinical N 950 Identifies the absence or presence of regional lymph node (N) metastasis and describes the extent of regional lymph node metastasis as recorded by the physician. Clinical M 960 Identifies the presence or absence of distant metastasis (M) as recorded by the physician. Clinical Stage Group 970 Identifies the anatomic extent of disease based on the T, N, and M elements as recorded by the physician. Pathologic T 880 Evaluates the primary tumor (T) and reflects the tumor size and/or extension as recorded by the physician. Pathologic N 890 Identifies the absence or presence of regional lymph node (N) metastasis and describes the extent of regional lymph node metastasis as recorded by the physician. Pathologic M 900 Identifies the presence or absence of distant metastasis (M) as recorded by the physician. 9 Pathologic Stage Group 910 Identifies the anatomic extent of disease based on the T, N, and M elements as recorded by the physician. ERA 2880 Estrogen Receptor Assay
PRA 2890 Progesterone Receptor Assay
Primary Site Surgery ‐ Summary 1290 Records the surgical procedure(s) performed to the primary site. Primary Site Surgery ‐ Facility 670 Records the surgical procedure(s) performed to the primary site at this facility. Cancer Directed Surgery Date 3170 Records the date of the most definitive surgical resection of the primary site performed as part of the first course of treatment. Chemotherapy 1390 Records the type of chemotherapy administered as first course treatment at this and all other facilities. If chemotherapy was not administered, then this item records the reason it was not administered to the patient. Chemotherapy consists of a group of anticancer drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. Chemotherapy Date 1220 Date of initiation of chemotherapy that is part of the first course of treatment. Hormone Therapy 1400 Records the type of hormone therapy administered as first course treatment at this and all other facilities. If hormone therapy was not administered, then this item records the reason it was not administered to the patient. Hormone therapy consists of a group of drugs that may affect the long‐
term control of a cancer's growth. It is not usually used as a curative measure. Hormone Therapy Date 1230 Date of initiation for hormone therapy that is part of the first course of treatment. Radiation Regional Rx Modality 1570 Records the dominant modality of radiation therapy used to deliver the most clinically significant regional dose to the primary volume of interest during the first course of treatment. Radiation Date 1210 Records the surgical procedure(s) performed to the primary site at this facility. Reason for no radiation 1430 Records the reason that no regional radiation therapy was administered to the primary site. Last Contact Date 1750 Records the date of last contact with the patient or the date of 10 death.
Vital Status 1760 Records the vital status of the patient as of the date entered in Date of Last Contact or Death SubmissionSchedules
Data submission schedules can be led by local requirements, and are sensitive to availability of information and knowledge of clinical events. However, the CoC requires all RQRS participants to make RQRS submissions at least every three months to ensure the validity of RQRS performance rates and reliability of comparison rates. Registries submit their cancer records via the password protected CoC DataLinks web portal supported by the ACoS Submission files and individual case reports are validated and an initial data quality report utilizing nationally standardized cancer registry edits software are immediately made available to participating program registries. Records that have passed these preliminary levels of validation and review are written to the RQRS database. Records failing these initial assessments are identified for the participating programs to review and resubmit. Registry Software Providers should allow RQRS users to adhere to the following expectations: CoC Accredited cancer program registries transmitting case records to the RQRS should have the option to select cases to be included in the transmission file. Cases ought to be selected on the basis of: 1.) A range of diagnosis dates selected by the participating registry (including at least 2 full years of follow‐up information); and 2.) A specific range of primary sites (currently breast, colon and rectum). These selection criteria are different than those established for the annual NCDB Call for Data. The RQRS is designed to identify non‐applicable cases based on a broad set of criteria, including primary site, histology, behavior, stage, class of case, and type of reported surgical therapy. •
The RQRS will only accept NAACCR incidence records, record type I – incidence only record type (non‐confidential coded data). This transmission requirement is consistent with NCDB Annual Call for Data reporting guidelines. •
All cases must be transmitted to the RQRS in the current standard NAACCR form New cases, and updates to previously reported cases, can only be reported to RQRS through a (re)submission of the case records from the cancer registry. In order to assure that the information shown in RQRS is a direct reflection of the data in the cancer registry, RQRS does not support on‐line updating of cases. All data files will be stored and archived under the link for ‘RQRS Submission History and Edits’. Use this link to monitor file processing. 11 Navigation Guide
Dashboards
The Dashboard tab is the first screen presented to users when they enter RQRS. The six rating dials, one for each of the measures monitored and reported through RQRS, show the current facility performance rate. The rates shown in these dials indicate the proportion of patients for whom adjuvant therapy was expected to be started within the last 365 days. The colon cancer measure for the number of nodes removed and pathologically examined reflects the proportion of patients who were diagnosed within the last 365 days and for whom 12 or more regional lymph nodes were examined. Figure 1 RQRS Dashboard All the information displayed on these dials is updated nightly. Rates may change if new cases are submitted to the RQRS; if previously reported cases are updated with new treatment information; or as reported cases “age” with respect to the time period associated with a particular measure. Year-to-date Performance Rates
Year‐to‐date performance rates are represented in the individual dials. Each part of the dial is described below: Red needle: Shows the current facility‐specific performance rate. EPR and N: The exact value of the performance rate appears in the box in the center of each dial along with the total number of cases included in the denominator of the calculation (n). Shading: The orange area behind the needle represents the potential performance rate for your cancer program if none of the patients currently reported to RQRS as pending adjuvant therapy are provided the expected treatment. 12 The shaded areas in the outer edge of each of the dashboards designate the range of performance rates for the top three quartiles for all RQRS participating cancer programs. •
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Green: Top quartile, 75th – 100th percentile. •
Camera: image of the corresponding ratings dial will be captured and stored in the My Account tab, and can be down‐loaded as a PowerPoint file at any time during your session. You may add slides to your PowerPoint file at any time throughout your RQRS session. •
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Orange triangle: links the user directly to the case alerts list for the selected measure. Yellow: 50th ‐75th percentile. Red: 25th – 50th percentile Arrow: By hovering your mouse over the upper left upper left corner of each measure box a camera, alert triangle and a blue ‘?’ will appear ?: Displays additional information about the information being viewed Figure 2 ACT Year‐to‐Date Compliance Rate Dial CasesincludedintheYTDDashboard
The Dashboards include cases in which treatment was expected to be received within the
previous 365 days. The following table describes the amount of time cases are included on the
Dashboards for a given measure based on the amount of time a case has to receive expected
adjuvant therapy. This is updated every night as a rolling calendar year.
13 Table 2 RQRS Dashboard Timeframes # of months to receive therapy Breast Hormone Therapy (HT) Radiation following BCS (BCSRT) Radiation following mastectomy (MASTRT) Breast & Colon Adjuvant Chemotherapy (ACT & MAC) Colon Removal of 12 regional lymph nodes (12RLN) # of months cases found in RQRS dashboards 12 months 24 months 4 months 16 months 0 12 months Another way of thinking of the Year‐to‐Date Dashboard calculation is to consider the timeframe that a case has to receive adjuvant therapy and see if this fits is within the previous 365 days. As described in Figure 3 below. Each submitted case is included on the year to date dashboard for a specific amount of time for each applicable measure based on the amount of time allowed for treatment to be received. So for each case you would have the 1. Diagnosis Date, (in example: 11/20/14) 2. The case’s Measure Expected Treatment Date (diagnosis date + the measure‐specific number of months), (in example: 11/20/2015) 3. The range of dates included in the YTD calculations; today’s date back through today’s date‐365 days, (in example: 8/8/2016 – 8/8/2015) Figure 3Assessing case included in year‐to‐date dashboard If the case’s Dashboard Inclusion Date falls within the YTD date range, then the case is still included in the Dashboard calculations. If the case’s Dashboard Inclusion Date is earlier than the beginning of the YTD date range day (i.e., falls outside of the YTD date range), the case is no longer included in the Dashboard calculations 14 Alerts
The Alerts screen identifies cases for which pending information regarding administration of adjuvant therapy has not been reported to the RQRS. This is an important part of RQRS, programs which submit their cases in a timely manner will receive prospective alerts. This screen also displays the number of days until cases lapse into measure non‐concordance. Cases that lapse into non‐concordance will remain posted on the Alerts screen for 120 days to ensure sufficient opportunity for programs to review the status and coordination of the patient’s care. •
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All the information displayed on this screen is updated nightly. •
Any displayed list of cases can be downloaded to a user’s local computer by clicking on the Excel icon appearing in the bottom‐left Excel Download panel of the screen [not shown]. Other measures for which a case is applicable are shown in ‘Related Measures’. Cases can be sorted by clicking on any of the column headings. Case‐specific information can be viewed by double clicking on a row. A pop‐up screen showing case detail information including patient demographic, treatment, and registry administrative data items reported to RQRS will be displayed. RQRS allows users to generate a PDF print‐out Treatment Summary from the case‐detail pop‐up. Figure 4 RQRS Case Alerts 15 CaseAlertColors
All cases pending adjuvant therapy are associated with one of five colors. A lack of alerts for any measure could mean: 1.) Based on what has been submitted by the registry there are no cases eligible for the measures or 2.) Based on what has been submitted by the registry there are no cases pending adjuvant therapy for one or more of the measures. The relationship between the color of the alert and the number of elapsed days is sensitive to each measure:
Table 3 Case Alert Color Status by Measure Measure Alert Color – Based on the # of Days Until Expected Administration of non‐Surgical Therapy White Yellow Orange Red Radiation therapy is administered within 1 year (365 ≥241 240‐181 180‐91 ≤90 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer (BCSRT) Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis ≥91 90‐61 60‐31 ≤30 for women under 70 with AJCC T1cN0M0, or Stage IB – III hormone receptor negative breast cancer. (MAC) Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) ≥211 210‐151 150‐76 ≤75 of diagnosis for women with AJCC T1cN0M0, or Stage IB – III hormone receptor positive breast cancer. (HT) Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of ≥241 240‐181 180‐91 ≤90 diagnosis of breast cancer for women with ≥ 4 positive regional lymph nodes. (MASTRT) Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients ≥91 90‐61 60‐31 ≤30 under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. (ACT) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. No Alerts (12RLN) Dark red: Non‐concordant; lapsed due to lack of information describing expected adjuvant therapy. These cases are retained in the alerts for 120 days following their lapse into non‐concordant status. 16 ALERTS MAY BE USED TO: •
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Identify patients who are expected to receive adjuvant therapy so that intervention can be timely. Spot patients who are at risk of “slipping through the cracks.” Particular attention may be paid to ensure these cases receive adjuvant treatment. Facilitate review, as alerts can be sorted by accession number or alert color. Shared with the cancer care team and physicians and discussed at cancer conferences or in cancer committee meetings.
Monthly Alerts Reports
An additional feature of the alerts section of the RQRS involves monthly e‐mail notifications to participating cancer program staff ‐ including the cancer registry, cancer program administrator, Chair of the cancer committee, and the CoC’s cancer liaison physician. This notification is sent on the first Monday of the month and provides a summary report for each of the five measures highlighting the number of cases with un‐resolved or incomplete adjuvant therapy information, and an indication of the relative urgency of this information. An aggregate count of the number of cases marked with dark red (treatment past due), red (extremely delayed initiation of expected adjuvant treatment), or orange (moderately delayed initiation of expected adjuvant treatment) will be included in this report. No specific patient information is included within these reports, to review case‐specific information user must log‐in to CoC Datalinks. Users may be added to receive the Monthly Alerts Report by contacting [email protected] Case List
The Case List screen allows users to view any case reported to the RQRS and review specific demographic, treatment, and administrative information related to these cases. All the information displayed on this screen is updated nightly. Columns
YTD Cases included in the year‐to‐date performance rates in the Dashboard tab are identified by the speedometer icon in the left most column of the table marked YTD. The dials are color coded to represent the status for each of these cases.  Green: Concordant, treatment administered  Blue: Concordant, treatment considered not administered  Orange: Suspense, pending adjuvant treatment information  Red: Non‐concordant. Cases can be sorted by clicking on any of the column headings. 
Sorting on the YTD column will allow users to view and analyze the cases included in the measure rate calculation by sorting the case list by the YTD column. Bring all cases with a colored speedometer to the top of the list for review. 17 Case‐specific information can be viewed by double clicking on a row. A pop‐up screen showing case detail information, the Treatment Summary, including patient demographic, treatment, and registry administrative data items reported to RQRS will be displayed. Acc#: Case accession number. Note a case can be listed multiple times for each measure assessed. Seq #: Case sequence number Case Status: Provides a reason for the cases status with the measure selected. Related Measures: If a case is applicable to multiple measures it will be denoted. Notes: Create or read a Note by clicking either on the green ‘+’ or clipboard icon. Any displayed list of cases can be downloaded to a user’s local computer by simply clicking on the Excel icon in the bottom‐left Excel Download panel. Users may use the case list to confirm cases sequence number and measure status. This is especially useful when the monthly alerts reports are distributed. Figure 5 RQRS Case List RQRS Notes
The Alerts and Case Lists tabs include the ability for cancer programs to leave RQRS Notes about specific cases. RQRS Notes were developed to allow cancer programs to leave additional information or reminders about a case to assist local tracking, monitoring and updating activities. These notes are encrypted and may only be posted and viewed by individuals with a valid KEYRING that is associated with the cancer program. A KEYRING is an institutional password that is used to encrypt and decrypt the 18 contents of posted RQRS Notes. The KEYRING may be shared among personnel of the cancer program that use RQRS. The first individual in a cancer program to attempt to post a note will be prompted to set up a KEYRING. This KEYRING will be specific to the cancer program. Other RQRS users within a participating cancer program wanting to read or post RQRS Notes will be prompted to match the established KEYRING. The KEYRING will be stored in the Adobe cache of the user’s workstation; the KEYRING will not need to be entered every time a user posts additional notes or view existing RQRS Notes, unless the user is working from a different workstation, or the workstation’s cache has been cleared. If the KEYRING for your cancer program is saved on your workstation, a dialog pop‐up box will appear for you to add your note to the case. Users will be prompted for their program’s KEYRING if it is not saved on their workstation. To add a RQRS Notes to a case, click on the ‘+’ symbol appearing under the “Notes” column appearing in the Alerts and Case List tabs. To view RQRS Notes already left on a case click on the Clipboard icon. A display of all notes left for that individual case will be displayed. 19 The CoC and NCDB will NEVER know or ask for your KEYRING. The KEYRING must be kept a safe place. The NCDB cannot assist in the recovery of a KEYRING. If the KEYRING is lost, you will not be able to decrypt your notes and all information posted in NOTES will be rendered useless and permanently unavailable. The CoC is able to reset the KEYRING if needed. Resetting a KEYING: If you have a computer in which the KEYRING is still stored in the adobe cache you can copy your notes to Excel or another file to re‐import before the NOTES are deleted. If you need to reset your KEYRING here are the steps: 1.) Send an e‐mail with your facility name, FIN, state you want your KEYRING reset and your notes removed to [email protected] 2.) CC the cancer program administrator on this e‐mail 3.) The administrator will need to ‘Reply All’ to the e‐mail to confirm your request. 4.) Once we get the response from your administrator we can delete your notes and reset your KEYRING. We ask for confirmation of the request because besetting a KEYRING deletes all previous notes because they will not be able to be decrypted with the new KEYRING. Treatment Summaries
A treatment summary document, in the form of a modifiable PDF, can be generated from both the RQRS Alerts and Case Lists. The information provided in the RQRS Treatment Summary PDF is based on the most recent RQRS data submission from your cancer registry. The most recent date the case was submitted appears at the bottom of the document, as well as the initials of the case abstractor. The information presented in the RQRS Treatment Summary PDF is meant to serve as a guide for RQRS participating institutions. All treatment decisions remain the responsibility of the physician. This document may contain confidential information. It is the responsibility of the RQRS participating program to determine how best to use and share this information. 20 MeasureExclusions
Measure exclusions have been developed to account to exclude cases from the denominator of the measures based on reasons that make the case not clinically relevant to the measure but are not collected in the standard NAACCR record. Exclusions are measure specific to ensure they are appropriately applied for each measure. The current list of measure exclusions available in RQRS are: Table 4 Measure exclusions Code Primary site: Measure(s) Definition 80 Breast: BCSRT, HT, MAC, MASTRT Patient enrolled in a clinical trial that directly impacts Colon: ACT delivery of the standard of care 41 12RLN Perforation of the primary site 42 12RLN Acute obstruction Measure exclusions are found in the case list and alerts once you drill into a specific case. 1) Double click on the case, scroll to the bottom of the screen to Measure Exclusions. Click on Edit. 2) Select the measure and exclusion for the specific case and click Save. 3) The case’s measure status will update on the next business day. RQRS refreshes on a nightly basis, so the changes to case status will not be updated automatically. 21 Compare
The Comparison tab allows users to display the performance rate(s) for any of the six RQRS performance measures over time. These reports are updated quarterly. 
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Users may select and deselect any measure using the check boxes appearing under ‘Measure Selection.’ To compare your cancer programs performance to other RQRS participating programs, pick from among the categories of programs appearing under ‘Comparisons’. Under ‘Performance Rates’ users can: o Display Annual or Quarterly rates. o Use the scale tool to control the time‐period displayed in the figure. o Change the display to show lines or bar graphs. While comparing your cancer programs performance to other RQRS participating programs, click on the measure and the time period in the line or bar graph to examine stratified comparisons of performance rates by demographic or other patient information. Figure 6 RQRS Comparison 22 Drill‐downreportswilldisplay:
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A table with the case counts, performance rate and 95% confidence interval for each of the strata of the selected demographic or characteristic of interest. A bar chart showing the performance rates for your cancer program and selected comparison group of RQRS participating programs for the selected demographic or characteristic of interest. Caterpillar charts show your cancer program’s performance rate and 95% confidence interval in relation to that of all the other RQRS participating programs in the comparison a user has selected. Users have the option of highlighting or hiding their cancer program’s performance rate. MyAccount
The My Account tab can be used to monitor and review the numbers of case submitted to RQRS by time and organ site. 23 In addition, powerpoint slides selected during the RQRS session are hosted here for review and download. 
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Using the scroll bar at the bottom of the panell each slide can be reviewed, unwanted slides can simply be deleted by clicking on the red X. To download the selected slides to your local work‐station simply click on the download button. At the end of a session any selected images are lost. 24 RQRSEnrollmentInstructions
1.) Required enrollers logs into CoC Datalinks (http://web5.facs.org/cancer/home.mvc) 2.) Clicks on RQRS v1.1 in activity menu 3.) Select facility from facility list 4.) Confirm contact information for required users to enroll in RQRS. 5.) Agree to Terms & Conditions and RQRS Requirements
25 6) After completion you will receive a confirmation webpage and e‐mail. 7) An e‐mail will be sent to remaining users required to enroll to complete their enrollment using steps 1‐5. 8) After all four required roles have completed their individual enrollment an e‐mail will be sent with notification that the cancer program is enrolled in RQRS. After this the program may begin submitting cases to RQRS. Note: The confirmation email is NOT required for other users to begin the enrollment process. The email serves as notification that the process has been initiated and all other users have eight weeks to complete their individual enrollment. RQRSHelp
All RQRS questions can be sent to the RQRS mailbox [email protected]. Please include your FIN and any relevant accession numbers in your email. 26