Structured Reporting in Radiology

Radiology reports are vital for patient care as referring physicians depend upon them for deciding appropriate patient management. Traditional narrative reports are associated with excessive variability in the language, length, and style, which can minimize report clarity and make it difficult for referring clinicians to identify key information needed for patient care. Structured reporting has been advocated as a potential solution for improving the quality of radiology reports. The Association of University Radiologists—Radiology Research Alliance Structured Reporting Task Force convened to explore the current and future role of structured reporting in radiology and summarized its finding in this article. We review the advantages and disadvantages of structured radiology reports and discuss the current prevailing sentiments among radiologists regarding structured reports. We also discuss the obstacles to the use of structured reports and highlight ways to overcome some of those challenges. We also discuss the future directions in radiology reporting in the era of personalized medicine.

Introduction

The radiology report is vital for patient management. Radiologists play a major role in patient care by the accurate interpretation of imaging studies and appropriate communication of imaging findings to referring physicians. Although some referring clinicians may interpret imaging studies by themselves, radiologists’ reports have been shown to be more accurate and comprehensive, resulting in improved patient care . To improve patient care, it is imperative for the reports to be timely and accurate and to answer the clinical question. For a health-care system, these may be the most important, readily available metrics by which the value of radiology service could be measured.

Although learning how to report imaging studies is an essential component of radiology residency training programs, formal training on how to frame a radiology report often receives less than 1 hour/year . Instead, most trainees learn the art of reporting by observing faculty, senior residents, fellows, and peers.

Traditionally, radiology reports were created using free-text, narrative language. Studies show that the use of nonstructured reports using narrative language may serve as an obstacle to optimal patient care. Excessive variability in language, length, and style can minimize report clarity, making it difficult for referring physicians to identify key information needed for patient care .

Structured reporting has been advocated as a potential solution for improving the quality of radiology reports. A tiered approach to structured reporting has been described . At its basic level, a structured report should be organized with headings, such as clinical history, indication, technique, findings, and impression ( Fig 1 ). The next tier of structured reports is where the “findings” section is organized with subheadings, such as the various organs (or anatomic structures) imaged ( Fig 2 ). At the highest tier, the structured radiology report has all of the previously mentioned characteristics and uses a standardized language based on a universally accepted lexicon ( Fig 3 ). Increasingly, academic centers are using structured radiology reports containing templates, macros, or prepopulated checklists.

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Advantages of Structured Reporting

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Table 1

Benefits and Limitations of Structured Radiology Reports

Benefits Limitations and Challenges Disease-specific report templates can improve report clarity and quality, and ensure consistent use of terminology across practices. Radiologists may be resistant to change. Checklist style reports can reduce diagnostic errors (such as failing to report incidental renal cell carcinoma in a magnetic resonance spine performed for back pain). Learning curve associated with new reporting style may negatively impact radiology workflow and productivity. Can reduce grammatical and nongrammatical digital speech recognition errors Potentially increased error rates if used improperly (eg, failing to remove the prepopulated phrase of “normal gallbladder” in a patient who is status post cholecystectomy). Ensures completeness of radiology report documentation and thereby improves radiology reimbursement Interruption of visual search pattern may increase reporting time. May be financially rewarding under the new Medicare Merit-based Incentive Payment System Including unnecessary or irrelevant information in a template report may negatively impact the coherence of the report and its subsequent comprehension by referring physicians. Positively impacts research in radiology by facilitating data mining Provides opportunities for quality improvement Can help promote evidence-based medicine by integrating clinical decision support tools with radiology reports

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Obstacles to Structured Reporting

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Overcoming Challenges

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Future Directions

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Structured Reporting in Radiology

Introduction

Advantages of Structured Reporting

Obstacles to Structured Reporting

Overcoming Challenges

Future Directions

References

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