Single-source tumor documentation - reusing oncology data for different purposes

We present a path towards single-source tumor documentation established at the Comprehensive Cancer Center Erlangen-Nürnberg (CCC-EN). Our goal was to derive data for cancer quality assurance and certification, cancer registry documentation and cancer research directly from routine care documentation. Therefore, clinical documentation activities were analyzed and a cancer data superset, containing these required elements, was developed. This superset was then split into appropriate clinical documentation packages, and the existing information technology infrastructure was analyzed and adapted to accommodate those documentation packages. A clinical documentation package is the amount of cancer-relevant data that can be captured within a clinical encounter. This grouping of data enables integration into existing clinical documentation workflows. We present examples in which single-source tumor documentation has been successfully established at the CCC-EN. The resulting cancer documentation reference model is described and its transferability to other institutions discussed.