If you were to search for images of radiology reports on the internet, you might be surprised at the variance in how the findings are presented.  One of the challenges we, as radiologists, face with disparate reporting formats is that each report becomes its own archeological dig, where the communication of vital patient information can be buried within the narrative or, in other cases, bulleted out, leaving the door open for misinterpretation.  As we see our patient volumes increase, our time to track down and speak directly with clinicians decreases, so the clarity of these reports is critical, and the lack of consistency can have harmful effects on patient care. 

There have been many studies done on the use of structured reporting and the findings reveal that, overall, these reports are preferred by both radiologists and clinicians as they improve clarity as well as the presentation of content.  As a result, the ease of reading these reports often enables physicians to make faster decisions regarding the treatment options for their patients.  With the goals of improving radiologist-clinician communication and decreasing reporting errors, we recently instituted standardized reporting at my organization and have seen several benefits, including: improved communication, information consistency, decreased time, fewer errors and the ability to data mine.

The American College of Radiology (ACR) created reporting guidelines that identify key pieces of information that need to be included in all reports.  At Cincinnati Children’s we used these elements to design our structured format for all reports: Clinical History, Comparisons, Procedure Comments, Findings and Impression.  Having a consistent organization of information means radiologists communicate the same type of information for each patient, and clinicians receiving the reports know what to expect and where to find the content that is pertinent to them.

Best Practices for Structured Report Formats
There are two ways to arrange content in a structured radiological report – lists or narratives.  While both are viable options, we use different formats to convey varying information:

List format: We found that a list format is best to convey specialty findings.  For instance, a CT of an abdomen may be reviewed by both a gastroenterologist and a nephrologist; however each may only be interested in the information pertinent to their specialty.  The tabs used in a list format makes finding relevant information much easier for these specialists.

Narrative format: We use narrative formats for general studies and radiography.  Because of its flexibility, it is ideal for reporting descriptive findings and pertinent negatives.  This type of reporting is often faster for less complex, common studies that are performed in higher numbers.

As is the case with any large scale implementation, it takes the right strategy, leadership and education.  These steps set our organization up for success.  We now have more than 270 standardized structured reports, which accounts for more than 99 percent of the studies conducted by our department.  While the radiologists in the department were at first reluctant to implement structured reporting, they now believe that it has improved their ability to communicate efficiently.  After surveying our department, 91% of radiologists now prefer structured reporting and 100 % believe that structured reporting has improved overall efficiencies.

As the industry shifts from volume-based care to value-based care, the communication of accurate, high quality reports is essential.  In order to create these data-rich, actionable reports, radiologists should consider adopting a structured approach that will continue to drive efficiencies and consistencies throughout this transition.  As we enter this new era of healthcare, we need to maintain our focus on streamlining information that can be easily translated into treatment plans for our patients.

 

Tags: , ,

About Dr. Alexander J. Towbin

This was a contributed post by Alexander J. Towbin, MD, Neil D Johnson Chair of Radiology Informatics at Cincinnati Children’s. If you're interested in more content like this, visit the Healthcare section of the blog.