1mcr.umh.edu/downloads/SectionIII.doc · Web viewNAACCR Procedure Guidelines for Cancer Registries Series III: The Policy and Procedure Manual January 2001 40 NPCR Program Standards

Missouri Cancer RegistryPolicies and Procedures – Hardware and Software:

Registry Operating System and Data Management

Subject: Hardware and Software

Function: Registry Operating System and Date Management

Revised

1. HardwareDescribe the hardware used by the registry. This may include:

A. Computer hardware and operating system software.1. Ownership.

Example: The CCR is part of the Health Department LAN.2. Configuration: model, RAM, CPU speed.3. Operating system.

Example: Windows954. Laptop computers.

B. Internet access.Example: The CCR Internet service is provided through the Department of Health and is accessible through the LAN system operated by the Health Department. List the file location and any restrictions.

C. Data storage media.D. Type of optical imaging system.E. Number of users on network.F. Other peripherals such as printers.

See NAACCR Standards for Cancer Registries, Volume III, Section V.A.2: Hardware Requirements.

University of Missouri Health Care: For a password to be effective, it should: Be a combination of six or more letters (both upper and lower-case),

numbers, the space character, and other special symbols (e.g. $, %, #, =, +, etc.).

Not be your name (nickname), the name of a family member or pet Not be found in the dictionary Not be a cultural word (e.g., Batman, hacker) Not be a geographical word (e.g., Lubbock, Beaumont)

Choose a password with an embedded number that looks the same as the letter: Tran5fer (the numeric five "5" replaces the alphabetic "S," transfer) B0nsai (the numeric zero "0" replaces the alphabetic "O," bonsai) F1ower (the numeric one "1" replaces the alphabetic "L," flower) Educat1on (the numeric one "1" replaces the alphabetic "I," education)

Missouri Cancer Registry Section III Date Revised: 11/20061



2. SoftwareDescribe all computer software programs used by the registry.

A. Data management program.1. Whether it is commercial or custom designed and developed.2. Primary components of the data management software.3. Database design: hierarchal versus relational.4. Parameter maintenance: how variables are updated.5. Internal database matching capabilities.6. External database matching capabilities.

Example: Matching to vital statistics death database for death clearance.

7. Storage of source documents.8. Geocoding capabilities and whether geocoding is provided in-house or by a commercial vendor. 9. Utility programs.

References:NAACCR Procedure Guidelines for Cancer Registries Series III: The Policy and Procedure Manual January 2001 40NPCR Program Standards II-A-6

B. Data analysis software.1. Statistical analysis software.

Example: SAS, SPSS, Systat, BMDP, Lotus 123, Microsoft Excel, QuattroPro, HIRS, EpiInfo, Microsoft Access, SEER*Stat, SEER*Prep.

2. GIS programs. – page 113

C. Management report program.D. Record linkage programs. Describe both internal and external programs such as Automatch, MatchWare, GRLS, custom design, and Linkpro. Indicate whether the program uses probabilistic or deterministic matching routines.




Inputs – 1. MCR staff will work with DHSS to maintain a central registry computer system

that supports all registry activities.2. In-house abstractors will use Abstract Plus, provided free of charge by the

CDC.3. Through the University of Missouri, MCR cannot accept e-mail attached files,

including zipped files.4. MCR will accept data submitted electronically, either via diskette/CD or an

encryption program approved by the University of Missouri IT department, such as Hypersend. Data security of external links?

5. MCR will work with University of Missouri IT staff to ensure that multi-level security features (firewalls, virus protection, etc.) are in place and operating normally at all times.

6. Access to MCR’s central registry database is restricted to authorized persons. 7. Back-up procedures?8. Off-site storage? 9. Disaster recovery?10. MCR’s data management software maintains a record of every transaction.

References:NAACCR Standards for Cancer Registries, Volume III, Chapter 5, Data Management

Confidentiality of databases is assured as follows:

Each member of the MCR staff shall have and use a unique password. Password usage for network is governed by University of Missouri policies.

Three User ID’s and passwords will be assigned for each Précis Central user. The Registry Database Manager shall maintain a list of User ID and passwords. Because access to the Précis database is based on security level of password, assigned password is to be used by assignee only.

All printers will be kept in a secure, locked office to prevent unauthorized access to confidential patient information on printouts.

Diskettes received from hospitals will be kept in a secure, locked office until loaded into Précis database. After loading and reviewing file for acceptance, diskettes will be filed in locked file cabinet.

Only authorized MCR personnel will have access to the Précis database based on their security level.




Paper abstracts received from hospitals will be stored in a locked office or locked file cabinet until forwarded to off-site registrars and/or entered into Abstract Plus (see 4.2.1). After data is finalized by off-site registrars, abstracts will be returned to central office and filed in hospital folder in locked file cabinets. Abstracts entered by central registry staff will be filed in hospital folder in locked file cabinets.

Copies of charts received from hospitals will be stored in a locked office or locked file cabinet until forwarded to off-site registrars and/or abstracted and entered into Abstract Plus. After a specific year’s data is finalized, charts will be shredded.

All printouts containing confidential patient information will be stored in a locked office or file cabinet. After review of data, printouts will be shredded and/or archived.

Any confidential patient data to be shredded will be stored in covered boxes in a locked office.

Confidential patient data files cannot be sent via e-mail. The files must be transmitted via HyperSend or other secure methods.

E-mail correspondence to hospitals regarding quality issues must not include patient identifiers (i.e., name, dob, social security number). Accession number or other non-confidential identification must be used.




Subject: Confidentiality and Data SecurityFunction: Administration Revised

11-06-06

OBJECTIVE: To guarantee data is processed and maintained in a secure environment.

DEFINITIONS:

POLICY: MCR primarily uses a secure Internet-based, FTP, or encrypted email mechanism to receive data from all reporting sources. Add HIPAA info???

PROCEDURE: MCR Network Security 4.13.1




STATEMENT OF WORKThe Missouri Cancer Registry Network Security Architecture

The Missouri Cancer Registry desires to exercise a strict control over network access and wants to set a standard networking model for UM Health Sciences Center. Therefore the Missouri Cancer Registry requires a reliable, robust and securable network environment, which is globally, centrally manageable, scalable to future needs and is capable of supporting external partners and clients.

The Missouri Cancer Registry also desires to minimize the Cost of Ownership of their existing WAN.

Thus, our proposed Firewall and VPN solution needed to support current operational LAN’s and had to be able to expand to meet increasing space and growing staffing requirements at geographically spread locations as well as reflect due diligence with respect to HIPPA requirements.

The solution we implemented was a Checkpoint Inc. FireWall-1 VPN gateway running on a Compaq Pentium server, using Windows NT server as the underlying operating system. This device creates a border between The Missouri Cancer Registry’s DEC server and the rest of the world. All potential users of the services on The Missouri Cancer Registry server – be they clients, partners, employees or customers – are queried for user name and password authentication by the firewall when they attempt access. If and only if this authentication is successful, then the predefined allowable protocols are strongly encrypted using the Triple DES algorithm and passesd by the firewall between the clients and server. All other network communications which do not meet these criteria are not allowed to reach the Missouri Cancer Registry server due to the firewall.

Currently, ITS Network Services provide the following services as part of our managed services of your Value Added Network (VAN):

24x7 Security monitoring via alerts, log analysis and active monitoring. Remote administration of the firewalled gateway properties and rulebase. CERT advisory notification. Regular maintenance including firewall backups, upgrades and patches. VPN client distribution and configuration consultations.

In my role as the project leader for UM Health Sciences network security infrastructure, I tightly control access to your firewall. Physically, it is kept in a locked wiring closet for which the key access is controlled. Only properly trained members of the ITS Network Services staff have administrative access to the




firewall, and an audit trail exists to document administrative access to this platform as well as configuration changes made.

(The Missouri Cancer Registry’s network segment is further protected by the enterprise firewalled gateway that exists at our border with the Internet.)

We have adopted the following support escalation process to ensure The Missouri Cancer Registry gets timely technical issue resolution. For technical assistance during working hours, please contact the ITS Help Desk at 884-xxxx. During off-business hours, please page the network services primary on-call staff at 441-xxxx. IATS staff have been assigned to serve as a liaison and dedicated ITS support staff to The Missouri Cancer Registry, but to ensure the most rapid response and resolution for your IT needs, it is most effective to follow this protocol.

We look forward to continued progress with you as we work toward enhancing the reliability, robustness and security of the Missouri Cancer Registry network.

Regards,

ITS Network Services

(Need to add: levels of security in Précis, back-up procedures, off-site storage.

This has yet to be developed.)

4.14 Data Security

Confidentiality

Employees: All documents which identify individual cancer patients, individual hospitals, individual physician or other reporting entities are regarded as confidential by the Registry and are subject to specific regulations for the maintenance of privacy. Current employees are reminded of their responsibility to protect the privacy of the patient’s files, and new employees are required to sign an agreement of confidentiality before beginning work with the Registry and annually thereafter.




Reporting

Confidentiality of databases is assured as follows:

Each member of the MCR staff shall have and use a unique password. Password usage for network is governed by University of Missouri policies. Each employee has a unique password to access Precis. Based on their security level of password, the assigned password is to be used by assignee only.

Diskettes received from hospitals will be kept in a secure, locked office until loaded into Precis database. After reviewing file for acceptance and loading file into current database, diskettes will be filed in locked file cabinet.

Only authorized MCR personnel will have access to the Precis database based on their security level.

Paper abstracts received from hospitals will be stored in a locked office or locked file cabinet until forwarded to off-site registrars and/or entered into Abstract Plus. After data is finalized by off-site registrars, abstracts will be returned to central office and filed in hospital folder in locked file cabinets. Abstracts entered by central registry staff will be filed in hospital folder in locked file cabinets.

Copies of charts received from hospitals will be stored in a locked office or locked file cabinet until forwarded to off-site registrars and/or abstracted and entered into Abstract Plus. After data is finalized by off-site registrars or by central registry staff, charts will be shredded.

Visual Quality Review or other printouts containing confidential patient information will be stored in a locked office or file cabinet. After review of data, printouts will be shredded and/or archived.

Any confidential patient data to be shredded will be stored in a locked office.

Electronic Reporting

Confidential patient data files that are sent electronically are sent and/or received through Hypersend, an secure encryption service, and additionally enclosed in an encrypted envelope to comply and exceed HIPPA rules for confidentiality. All files that are exchanged that include any confidential patient information are encrypted.

One hospital submits data via secure site.




Precis is located on a separate SQL server behind the University’s firewall. The security and integrity is maintained by an IT specialist assigned to the project and the database manager for Precis. Precis maintains logs of access to the database and record and change of record. Further technical support is provided by the University’s server team. Daily backup is done for the entire Registry database and the SQL server master database. The same backup files are transferred off site every night for off site backup. All off site nightly back up is stored for one month length of time. There is also a weekly in house backup done every Friday kept on an external storage media.

WEB PLUS SECURITY

In progress.




REFERENCES:Other policies?NPCR Program Standards II-A-11NPCR Program Standards V-CNPCR Program Standards III-E

Approved:

_________________________________________




Subject: Data Edits

Function: Hardware and Software Revised11-06-06

OBJECTIVE: To utilize standardized computer edits to enable registry staff to focus on activities requiring human judgment, analysis or interaction. DEFINITIONS: Edits: Data edits are logical rules, typically embodied in a computer algorithm, that evaluate to “true,” “false,” or “maybe,” for any value(s) of (a) data item(s). Central registry edits are applied to all records to check for item validity, internal consistency, and inter-record consistency. Data edits may involve a single field, multiple fields in a single record, multiple fields in different records within one database, or multiple fields in multiple databases. (NAACCR Volume III)

POLICY: MCR will use the central registry software NPCR edit set in Precis until a customized Missouri edit set is finalized.

PROCEDURES:1. Registry software will be set to NPCR Central Version 11: NPCR Required. 2. MCR staff will prepare a customized version to replace the NPCR Central

Version 11: NPCR Required. 3. Registry staff trained in abstracting and coding will assist in the design and

implementation of customized edit sets. 4. Registry staff trained in abstracting and coding will track and correct edit

failures. 5. QA staff may recommend changes to the edit set to the Project Manager. 6. Recommended changes will be made after thorough review.

REFERENCES:MCR Policies and Procedures – Quality Control, Computerized EditsNAACCR Standards for Cancer Registries, Volume III, 3.1., Data Quality, Structural RequirementsNAACCR Standards for Cancer Registries, Volume III, 5.8.1, Edits

Approved:

_________________________________________




Subject: Office Management

Function: Hardware and Software Revised 11-06-06

OBJECTIVE:

POLICY: MCR will use the office management software required by the University of Missouri - Columbia.

PROCEDURES:

1. The University’s IT department requires the use of Microsoft Office including: WORD Excel Access Outlook

2. MCR will update this software as required by IT.3. Other software applications may be utilized with permission of IT.

REFERENCES:NAACCR Standards for Cancer Registries, Volume III, Section IV.A.3: SoftwareRequirements

Approved:

_________________________________________




Subject: Data Security – General

Function: Hardware and SoftwareRevised11-06-06

OBJECTIVE: Data security procedures must adequately assure data security.

POLICY: MCR, along with the University of Missouri – Columbia, will establish data security policies and procedures that address general confidentiality practices, electronic data security, paper record security, education programs for central registry staff, network security, etc.

PROCEDURES:1. MCR will develop policies and procedures for precautions of both physical

and electronic security of confidential data.2. MCR will follow security guidelines set forth by the University of Missouri –

Columbia IATS department.a. The IATS security team will be involved in security procedures.

3. MCR will follow the University of Missouri Health Care guidelines on retention and disposal of confidential data.

4. No one other than MCR will have keys to MCR offices. This includes other University staff (HMI, custodians, etc.).

5. Training and demonstration of computer systems will be performed with fictitious datasets.

6. MCR staff will sign a confidentiality agreement annually.

REFERENCES:NAACCR Standards for Cancer Registries, Volume III, 2.2.8.1., Standards for

Policies and Procedures for Data SecurityMCR/University of Missouri Policy: Retention and Disposal of Confidential

RecordsMCR Policy: Confidentiality

Approved:

_________________________________________




Subject: Data itemsFunction: Hardware and Software Revised

11-06-06

OBJECTIVE: To provide a list of required data items to all reporting entities.

DEFINITIONS: Reporting entities: Hospitals, pathology laboratories, ambulatory surgery centers, freestanding cancer clinics and treatment centers, physicians and long-term care facilities

POLICY: MCR will publish annually a list of required data items in keeping with NPCR/NAACCR requirements.

PROCEDURE:1. MCR will use and require a standardized, NPCR-recommended data

exchange record layout for the electronic exchange of cancer data. For abstract reports: The NAACCR record layout version specified in Standards for Cancer Registries Volume II: Data Standards and Data Dictionary.

2. For pathology reports: The NAACCR Standards for Cancer Registries Volume V: Pathology Laboratory Electronic Reporting.

3. For all NPCR required reportable cases, the MCR will collect or derive all required data items using standard codes as prescribed by NPCR.

4. MCR will use a standardized, NPCR-recommended data exchange format to transmit data to other central cancer registries and NPCR.

5. An updated list will be posted on the MCR website. (see list on next pages)

REFERENCES:NAACCR. Standards for Cancer Registries, Volume III. Standards for Completeness, Quality, Analysis, and Management of Data.NPCR Program Standards II-A-03NPCR Program Standard III-A-01NPCR Program Standard III-A-02NPCR Program Standard IV-ANPCR Program Standard IV-B

Approved:




_________________________________ Item Item Name NPCR MCR

Collect Transmit40 Registry ID . R R50 NAACCR Record Version . R R70 Address at DX – City R . R80 Address at DX – State R R R90 County at DX R R R

100 Address at DX – Postal Code R R R150 Marital Status at DX . . R160 Race 1 R R R161 Race 2 R R R162 Race 3 R R R163 Race 4 R R R164 Race 5 R R R190 Spanish/Hispanic Origin R R R220 Sex R R R230 Age at Diagnosis R R R240 Birth Date R R R250 Birthplace R* . R310 Text – Usual Occupation R* . R320 Text – Usual Industry R* . R340 Tobacco History . . R350 Alcohol History . . R390 Date of Diagnosis R R R400 Primary Site R R R410 Laterality R R R420 Histology (92-00) ICD-0-2 RH RH R430 Behavior (92-00) ICD-0-2 RH RH R440 Grade R R R450 Site Coding Sys – Current R R R470 Morph Coding Sys – Current R R R490 Diagnostic Confirmation R R R500 Type of Reporting Source R R R522 Histologic Type ICD-0-3 R R R523 Behavior Code ICD-0-3 R R R540 Reporting Hospital R R R550 Accession Number – Hospital . . R560 Sequence Number – Hospital . . R570 Abstracted By . . R580 Date of 1st Contact R R R610 Class of Case R R R630 Primary Payer at DX R R R759 SEER Summary Stage 2000 RH RH R760 SEER Summary Stage1977 RH RH R820 Regional Nodes Positive . . R830 Regional Nodes Examined . . R

1200 RX Date – Surgery . . R1210 RX Date – Radiation . . R1220 RX Date – Chemo . . R1230 RX Date – Hormone . . R1240 RX Date – BRM . . R1250 RX Date – Other . . R1270 Date of 1st Crs RX – COC R# R# R




Item Item Name NPCR MCRCollect Transmit

1280 RX Date – DX/Stg Proc . . R1290 RX Summ - Surg Prim Site R R R1292 RX Summ – Scope Reg LN Sur R R R1294 RX Summ – Surg Other Reg/Dis R R R1296 Rx Summ – Reg LN Examined RH . R1340 Reason for No Surgery R R R1350 RX Summ – DX/Stg Proc . . R1380 RX Summ – Surg/Rad Seq R R R1390 RX Summ – Chemo R R R1400 RX Summ – Hormone R R R1410 RX Summ – BRM R R R1420 Rx Summ – Other R R R1430 Reason for No Radiation . . R1460 RX Coding System – Current R R R1570 Rad – Regional RX Modality R R R1639 RX Summ – Systemic Sur Seq R R R1646 RX Summ – Surg Site 98-02 RH . RH1648 RX Summ – Surg Oth 98-02 RH . RH1750 Date of Last Contact R R R1760 Vital Status R R R1770 Cancer Status . . R1910 Cause of Death R R R1920 ICD Revision Number R R R1940 Place of Death R . R1990 Over-ride Age/Site/Morph R R R2000 Over-ride SeqNo/X Conf R R R2010 Over-ride Site/Lat/SeqNo R R R2020 Over-ride Surg/DxConf R R R2030 Over-ride Site/Type R R R2040 Over-ride Histology R R R2050 Over-ride Report Source R R R2060 Over-ride Ill-defined Site R R R2070 Over-ride Leuk, Lymphoma R R R2071 Over-ride Behavior R R R2074 Over-ride Site/Lat/Morph R R R2110 Date Case Report Exported R . R2116 ICD-0-3 Conversion Flag R R R2170 Vendor Name . . R2220 State/Requestor Items

Tobacco Years (Col 1447-1448) Pathology Report No (Col 1449-1457) Toxic Exposure 1 (Col 1458-1477) Toxic Exposure 2 (Col 1478-1497) Toxic Exposure 3 (Col 1498-1517) Personal Hx 1 (Col 1518-1521) Year 1 (Col 1522-1525) Personal Hx 2 (Col 1526-1529) Year 2 (Col 1530-1533)

. . RR

RRRR




Item Item Name NPCR MCRCollect Transmit

2230 Name – Last R . R2240 Name – First R . R2250 Name – Middle R . R2280 Name – Alias R . R2300 Medical Record Number R . R2320 Social Security Number R . R2330 Address at DX – No and Street R . R2335 Address at DX – Supplemental R . R2380 DC State File Number R . R2390 Name – Maiden R . R2410 Institution Referred From . . R2420 Institution Referred To . . R2520 Text – DX Proc – PE R^ . R2530 Text – DX Proc – X Ray/Scan R^ . R2540 Text – DX Proc – Scopes R^ . R2550 Text – DX Proc – Lab Tests R^ . R2560 Text – DX Proc – Op R^ . R2570 Text – DX Proc – Path R^ . R2580 Text – Primary Site Title R^ . R2590 Text – Primary Histology Title R^ . R2600 Text – Staging R^ . R2610 RX Text – Surgery R^ . R2620 RX Text – Radiation (beam) R^ . R2630 RX Text – Radiation (other) R^ . R2640 RX Text – Chemo R^ . R2650 RX Text – Hormone R^ . R2660 RX Text – BRM R^ . R2670 RX Text – Other R^ . R2680 Text – Remarks . . R2690 Place of Diagnosis . . R2800 CS Tumor Size . . R2810 CS Extension R . R2820 CS Tumor SizeExt Eval . . R2830 CS Lymph Nodes R . R2840 CS Reg Node Eval . . R2850 CS Mets at DX R . R2860 CS Mets Eval . . R2880 CS Site – specific Factor 1 RS . R2890 CS Site – specific Factor 2 . . R2900 CS Site – specific Factor 3 RS . R2910 CS Site – specific Factor 4 . . R2920 CS Site – specific Factor 5 . . R2930 CS Site – specific Factor 6 . . R2935 CS Version 1st R . R2936 CS Version Latest R . R3200 Rad-Boost RX Modality . . R3250 RX Summ – Transplnt/Endocr R R R3270 RX Summ – Palliative Proc . . R


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1mcr.umh.edu/downloads/SectionIII.doc · Web viewNAACCR Procedure Guidelines for Cancer Registries Series III: The Policy and Procedure Manual January 2001 40 NPCR Program Standards