The radiology report is definitely the most important document produced by radiologists. Radiology transcription service companies convert radiologists’ dictation into reports and upload them on the EMR/EHR or Radiology Information System (RIS) system. These reports are the radiologist’s written interpretation of the imaging study such as an X-ray, CT, MRI, or other diagnostic imaging exam. Once uploaded to the electronic health record, the referring physician can view the reports. Today, even patients can directly access their radiology reports and medical images via EHRs secure patient portals.
In a recently published Diagnostic Imaging article, Eduardo Mortani Barbosa, MD, assistant professor of radiology and director of CT modality in the thoracic imaging section at the University of Pennsylvania Perelman School of Medicine sums up the importance of the radiology report: “The report is the center of what we do. It’s documentation of what we did. It’s important to billing compliance, and it’s our best defense… overall, it’s a communication tool of our thought process from patient diagnosis to prognosis to treatment management.”
Errors in Radiology Reports may be Inevitable, say Studies
Radiology reports are error prone, and according to recent reports, can be as high as 4 percent. A study on error and discrepancy in radiology practice published in Insights Imaging in February 2017, noted that in many cases there is a considerable discrepancy between the radiologist’s message in a radiology report and the understanding of that report by the referring clinician. Among the reasons identified for the misunderstanding of the intent of reports are:
- Poor structure or organization
- Poor choice of vocabulary
- Errors in grammar or punctuation
- Failure to identify or correct errors introduced into the report by sub optimal voice recognition software
The study notes that the use of voice recognition software has been found to lead to significantly increased error rates relative to dictation and manual medical transcription services. The author acknowledges that radiologist reporting performance cannot be perfect, and some errors are inevitable, but that there are strategies to minimize error causes and to learn from errors made.
Improving Radiology Reporting – Insights from RSNA 2017
At the 103nd Scientific Assembly & Annual Meeting of the Radiological Society of North America Annual Meeting (RSNA) held in Chicago in November 2017, many discussions focused on radiology reporting and improving the ability of radiologists to efficiently create consistent, high-quality reports, which is critical for the process of care. Curtis P. Langlotz, MD, PhD, professor of radiology at Stanford University Medical Center in Stanford, California pointed out that radiology reports often failed to answer the clinical questions asked and that clinicians or referring physicians are sometimes not satisfied with what’s in the reports. Radiology Business listed the best practices recommended by this expert when creating a radiology report:
- Pay attention to the summary: The expert stresses that the summary is important. The radiologist should provide a complete and accurate summary of the key imaging findings in the report impression at the end of the report. The summary is critical, as according to him, only 38 percent of referring physicians read the radiology report fully and 43 percent read only the summary of longer reports. The summary should include only answers to the clinical questions asked and list the relevant findings in order of importance.
- Ensure clarity, specificity and conciseness: Appropriate construction, clarity, and clinical focus of a radiology report are necessary for high quality patient care. Langlotz recommends using “short, declarative sentences, expressing uncertainty and quantifying severity” when reporting findings. Using specific language when framing sentences will improve the clinician’s understanding. An observation sentence should include elements such as anatomy, anatomy modifiers, observation, observation modifiers, spatial relationship uncertainty and location on the images.
- Recognize the value of the word “normal”: The word “normal” is a powerful, definitive one and radiologists should use it when they are certain that all all abnormalities have been considered and excluded.” “Normal” is good news for the patient as well as the clinician.
Other Recommendations to improve Radiology Reports
A new study published in the Journal of the American College of Radiology discusses the importance of providing patient-friendly radiology reports to better connect with patients. Radiology reports usually contain complex, highly technical vocabulary, which can be difficult for an ordinary person to understand. Earlier, referring physicians conveyed the results of imaging studies to patients. However, today, patients directly view their records using portals and providing patient-centric radiology reports is critical to improve patient and family-centered care (PFCC), says the study. Reports that are easier for patients to understand can reduce anxiety and promote patient satisfaction.
The research published in Insights Imaging discusses the use of structured reporting which is advocated as a strategy to reduce errors in radiology reports. The study notes that over 80 percent of referring clinicians prefer standardized reports, using templates and separate organ system heading. Structured reporting is useful in some types of studies, and can improve report content, comprehensiveness and clarity in body CT. However, the researcher cautions that standardized reports pose the risk of the clinician missing unexpected significant findings outside the specific area of clinical concern. Therefore, the radiologist should take special care to minimize this risk while creating the report. It must be noted that while structured reporting increases efficiency, lowers cost, and improves outcomes, this is only possible when reports are comprehensive, consistent, and clear.
Radiology Transcription Outsourcing – A Practical Strategy
Radiology transcription companies provide EHR or PACS/RIS system integrated documentation solutions. Experienced medical transcription companies can ensure quality reports and will work with radiologists to review the transcripts and ensure that they are correct, complete and confirmed, and communicate the results clearly and effectively.