Radiology reports are vital to promote appropriate medical decision making and optimize patient outcomes. Outsourcing radiology transcription allows radiologists to ensure accurate and timely EMR/EHR or Radiology Information Systems (RIS) reports as they focus on their core tasks. The adoption of structured reporting is being advocated as a means to improving the quality of radiology reports and patient management.
Imaging reports convey a vast amount of information on:
- The type of test performed and indications for it
- The results
- Differential diagnosis
- The radiologist’s recommendations for further evaluation and management
However, the use of free-text and narrative language in conventional reporting make it difficult for physicians to locate the information they need or understand the radiologist’s findings and recommendations. To be effective and promote proper patient care, the communication has to be clear, correct, and complete. Structured reporting is seen as the answer to these issues.
What is Structured Reporting in Radiology?
Conventional radiology reports have structured headings such as “clinical history,” “comparison,” and “findings”. However, advanced structured reporting is characterized by standardized or “constrained” language and consistent formatting. According to a 2014 article in Applied Radiology, structured reporting involves a three-tier system:
Tier I: Common, simple headings such as “Indication” and “Impression”
Tier II: Itemized reporting with sub-headings identifying categories such as organs and organ systems within the “Findings” section
Tier III: The use of standardized language, pick lists, buttons and other form elements. This tier is more difficult to implement than Tiers I and II.
Advantages of Structured Reporting in Radiology
With the adoption of EHRs, structured reporting is has been adopted in various medical specialities to satisfy Meaningful Use criteria. In radiology, structured reporting offers many benefits:
- Reduces ambiguity: Structured radiology reports have disease-specific templates. An article in Applied Radiology points out that structured reports reduce ambiguity by ensuring uniformity and the use of a consistent vocabulary by radiologists. The terms used in structured reports allow effective analysis, supporting research and quality improvement.
- Reduces diagnostic errors: Missed diagnosis is most common reasons for malpractice lawsuits against radiologists. A January 2018 article in Science Direct reported that review of literature shows that structured reports help radiologists and referring clinicians reduce the rate of diagnostic errors. The article notes that structured checklist style reports can reduce diagnostic errors such as not reporting incidental renal cell carcinoma in a spine MRI performed for back pain.
- Reduces the incidence of syntactic and semantic errors: The authors of the Science Direct article provided evidence to show that a high percentage (4%-60%) of free-text reports is associated with grammatical and nongrammatical digital speech recognition errors. While they may not be of much clinical importance, such errors make referring physicians and patients doubt the integrity of the radiological interpretation. Structured reports can reduce nongrammatical errors, including both omission and commission errors.
- Improves report quality and consistency: With structured reporting, radiologists can always provide complete and useful reports. This is especially important when radiologists come across uncommon conditions. A structured template will have all the required elements to remind the radiologist to report all important observations about the condition, including the location.
- Supports adherence to guidelines: The American College of Radiology (ACR) has developed guidelines to promote quality and safety in radiology practice. Structured templates allow standardized text with the necessary elements to be easily inserted into the radiology report at the time of dictation, improving compliance with guidelines. Adherence to guidelines improves quality and reduces costs.
- Allows data mining and statistical analysis: Structured reports make it easier for referring physicians, billing and coding specialists, medicolegal professionals, and researchers to mine and compare information from radiologic reports.
- May be financially rewarding: By ensuring the completeness of radiology report documentation, structured reporting allows radiologists to meet the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting System (PQRS) measures which can significantly improve reimbursement.
The Breast Imaging Reporting and Data System (BI-RADS) is considered the best example of how structured radiology reporting can be successfully incorporated in clinical practice. The system offers a clear and concise reporting style and also guides patient management.
Radiology Reporting Templates – Challenges Involved
While structured reports provide many benefits, there are certain challenges associated with their adoption:
- Resistance to change: Reports say that radiologists may oppose change as they are used to a particular style of reporting and think there is no clinical necessity for change.
- Reduce quality of reporting: As they value their freedom of expression, radiologists feel that using structured templates may downgrade the quality and scope of their reports. Use of free-text will allow more information to be included in the report. In complicated cases, templates may not be sufficient to include all the necessary information.
- Missed findings: The Science Direct report notes that adherence to rigid structured report templates may result in missed findings due to “eye dwell” or interruption of the visual search pattern. This happens when radiologists are focused on the template rather than the images. According to the report, structured reporting may be feasible for less complex studies such as x-rays or ultrasound rather than more complex studies such as CT or MRI.
- Time constraints: The time and effort required to develop report templates and enter information in them can have a negative impact on radiologists’ productivity.
Radiology Transcription Services for Quality Data
Reporting templates offer distinctive opportunities to improve the quality of radiology reports. Many professional societies including the Radiological Society of North America (RSNA) stress the importance of using structured reports to improve practice efficiency and patient outcomes. Using radiology transcription services is a great way to overcome many of the challenges associated with structured reports. Experienced medical transcription companies can ensure efficient dictation capture and also integrate and import medical transcripts into EMRs/EHRs or Radiology Information Systems (RIS).