Recent studies have highlighted the need to improve radiology reports sent to oncologists. Typically, a radiology transcription service provider’s task involves documenting the radiologist’s dictation pertaining to the patient’s medical condition and needs. However, experts point out that radiology reports could do with improvement. A recent article in Diagnostic Imaging carries the views of a Stanford University professor of radiology and biomedical informatics on the matter:
“The days are numbered when we can simply start with a blank page, pick up a microphone, and tell a story about what we see. Referring clinicians, payers, and patients are all demanding higher quality, which requires some degree of consistency and organization,” says Dr. Curtis Langlotz.
The present need, according to the expert, is to make it easy for the referring physician to identify critical information in the report. As oncologists are short on time, radiologists need to provide them with concise, straight-forward reports that follow a consistent pattern. This would streamline workflow and patient care. Outsourcing medical transcription can go a long way in achieving this goal.
Need for Consistent Creation of Useful, Updated Radiology Reports
Currently, medical transcription service providers deliver accurate and timely radiology reports in a standard format. Besides the patient’s demographic details, the report would include patient history, reason for study, diagnostic and procedural statement, whether the exam is limited or complete, number and type of views taken, contrast material used, as appropriate, separate details of each study performed on the patient, and recommendations for follow-up exam or additional studies needed. Such quality documentation helps radiologists meet medical coding requirements and receive proper, timely reimbursement.
The report in Diagnostic Imaging points out that, in the face of changing payment systems and increasing quality reporting requirements, radiologists need to overcome several challenges while drafting a radiology report, such as
- avoiding clinically significant errors
- answering all clinical questions
- meeting the needs of referring clinicians
- are not unnecessarily hedging the diagnoses
Besides ensuring quality dictation and transcription, radiologists need to master advancements in technology in order to upgrade and update their reports. Besides clear, concise information, the reports need to include clinically meaningful and actionable information.
Suggestions for Radiology Report Redesign
Experts offer the following suggestions to improve radiology reports to meet the needs of oncologists and reimbursement requirements:
- Use tools that will accommodate bold face, underlying, tables, and multimedia components in radiology reports. It is expected that this will prompt EHR vendors to develop systems that include more consistent and efficient reporting formats
- Develop structured reports – as currently used by academic medical center radiology departments
- Create succinct radiology with easily-identifiable information
- Incorporate all the requirements prescribed by the Centers for Medicare & Medicaid Services (CMS) in the Physician Quality Reporting System (PQRS)
- Place clinical considerations at the top of radiology reports as well as other relevant information, such as patient history and notes from technologists
Fulfilling these requirements is crucial in 2016 to optimize Medicare reimbursement payments in 2017 and further on.
A professional medical transcription services company can help radiologists meet these new requirements and deliver quality reports to oncologists. Moreover, by providing radiology transcription service, a reliable company would allow radiologists to spend more time with their patients, build trust, and support them in their health care journey.