Radiology must make move to structured reporting
“Despite dramatic innovation in medical imaging and information system technologies, the radiology report has remained stagnant for more than a century,” wrote author, Bruce I. Reiner, MD.
Reiner holds that a good radiology report follows the eight C’s:
Although not part of the eight C’s, Reiner noted that timeliness and standardization are critical components of a “good” radiology report.
Structured reporting was developed in order to provide organization and address well-documented deficiencies in report content. As the medical environment stands currently, the radiologist has little, if any contact with the patient. The radiologist interprets the imaging exams and the referring clinician translates the results to the patient. At the same time, due to recent advancements in PACS, physician and radiologist interaction has been cut down significantly.
Under these circumstances, a structured report from a radiologist can become a crucial tool for their referring clinician colleagues over conventional free text reporting, according to Reiner.
Almost all clinicians place a high priority on report timeliness, content quality, and communication of pertinent findings, Reiner believes.
“A reporting system that addresses these clinical priorities through automated (and verifiable) delivery, documented critical results reporting, and customizable content creation will be viewed in a positive light,” he wrote.
Perhaps the greatest benefit to the utilization of standardized terminology and structured reporting would be to bolster quality reporting initiatives such as the Physician Quality Reporting Initiative (PQRI).
“A new reporting strategy would have combined clinical, medico-legal, and economic value if it were to automate many of these reporting requirements through prospective creation of standardized data, formulation of structured databases, automated data mining, and derived outcomes analysis,” Reiner wrote. “The ability to create structured databases and perform automated data mining has a multitude of applications relating to research, education and training, and establishment of evidence-based medicine guidelines.”
One of the greatest roadblocks to effective data mining and the utilization of evidence-based medicine (EBM) in radiology is the lack of structured reports. According to Reiner, radiology must transition from its current free-text reporting information delivery paradigm to a structured reporting format.
“While EBM serves as the impetus for data-driven best practice guidelines, its applicability within radiology is currently limited by the non-standardized radiology report,” he wrote. “Without report standardization, it is impractical to perform large scale report data mining; which serves as a prerequisite to future efforts in clinical research, outcomes analysis, education, and training and the establishment of best practice guidelines.”