The Challenges, Opportunities, and Imperative of Structured Reporting in Medical Imaging

Despite dramatic innovation in medical imaging and information system technologies, the radiology report has remained stagnant for more than a century. Structured reporting was created in the hopes of addressing well-documented deficiencies in report content and organization but has largely failed in its adoption due to concerns over workflow and productivity. A number of political, economical, and clinical quality-centric initiatives are currently taking place within medicine which will dramatically change the medical landscape including Pay for Performance, Evidence-Based Medicine, and the Physician Quality Reporting Initiative. These will collectively enhance efforts to improve quality in reporting, stimulate new technology development, and counteract the impending threat of commoditization within radiology. Structured reporting offers a number of unique opportunities and advantages over traditional free text reporting and will provide a means for the radiology community to add value to its most important service deliverable the radiology report

Structured reporting: if, why, when, how—and at what expense? Results of a focus group meeting of radiology professionals from eight countries

Purpose: To determine why, despite growing evidence that radiologists and referring physicians prefer structured reporting (SR) to free text (FT) reporting, SR has not been widely adopted in most radiology departments. Methods: A focus group was formed consisting of 11 radiology professionals from eight countries. Eight topics were submitted for discussion. The meeting was videotaped, transcribed, and analyzed according to the principles of qualitative healthcare research. Results: Perceived advantages of SR were facilitation of research, easy comparison, discouragement of ambiguous reports, embedded links to images, highlighting important findings, not having to dictate text nobody will read, and automatic translation of teleradiology reports. Being compelled to report within a rigid frame was judged unacceptable. Personal convictions appeared to have high emotional value. It was felt that other healthcare stakeholders would impose SR without regard to what radiologists thought of it. If the industry were to provide ready-made templates for selected examinations, most radiologists would use them. Conclusion: If radiologists can be convinced of the advantages of SR and the risks associated with failing to participate actively in its implementation, they will take a positive stand. The industry should propose technology allowing SR without compromising accuracy, completeness, workflows, and cost-benefit balance

Structured reporting in cardiovascular computed tomography

While investigation techniques and image modalities become more and more advanced, radiology reports have remained in their classic form for the past decades. Structured reporting has shown its potential to increase the clarity, correctness, confidence, concision, completeness, consistency, communication, consultation and standardization of radiology reports. The increased report quality can mostly be attributed to a complete checklist like approach, standardized vocabulary through RadLex and RSNA provided templates which can be adapted to address very specific inquiries. Especially the interdisciplinary approach necessary to design and adapt those templates can ensure that all therapy influencing criteria are evaluated in the report. This may lead to a different therapy and outcome. Structured reporting also harbors great teaching opportunities, such as a checklist-like approach for young radiology residents and an image database of pathological findings. With a large analyzable database of reports, a statistical analysis becomes possible, which can e.g. lead to increasingly better screening algorithms. Technological challenges however, different data formats, varying degrees of quality of structured reporting systems and the concerns about work flow efficiency and report rigidity remain difficulties of structured reporting itself. Despite of this it also provides many future possibilities such as the implementation of medical guide lines into the report format, multi media reports, evaluation of radiation dose, management of follow-up appointments, automatic invoice and reimbursement systems and the improvement of data mining. Given the potential of structured reporting and its impact on patient care, we decided to evaluate its so far unknown benefit for patients with acute PE and PAD. For patients with APE, the structured reports were evaluated by two pulmonologists and two general internists and compared to the reports from the clinical routine of the same patient group. While all four referring clinicians perceived the structured CTPA reports as superior in clarity, only the pulmonologists found additional benefit in content and clinical utility. The structured reports did not alter patients’ management in patients with acute PE significantly. In the study concerning patients with diagnosed or suspected PAD the structured reports (run-off CTA/ lower extremities) were evaluated by two vascular surgeons and two vascular medicine specialists. The results showed, both groups regarded structured reports as superior in clarity, completeness, clinical relevance and usefulness. Especially vascular medicine specialists seemed to appreciate the structured reporting format. As in our PE study, structured reporting did not seem to alter further testing or therapy for the patients included in our study. Both studies demonstrate that referring clinicians prefer structured reporting of cardiovascular CT examinations over conventional reports

Patients’ Needs and Preferences Regarding Radiology Test Results on Patient Portals

Introduction and significance: Radiology exams are an important part of health care. To enhance the quality of health care, health care services need to be delivered in ways that meet patients’ needs and preferences. Patients were found to be interested in the timely receipt of radiology test results. One of the easiest and fastest ways to deliver radiology test results to patients is via online patient portals. It seems, however, that the method of providing radiology test results through patient portals has not reached its full maturity; it still needs a great deal of improvement. Therefore, participation of the end-readers (i.e., the patients) in the shape of radiology test results on patient portals is crucial. Moreover, making the radiology test results readily available to patients can encourage them to be more involved in their health care. To the best of our knowledge, this is the first study that covers this topic from this angle. The findings of this study can be used to improve the quality of health care services by making radiology test results on the patient portal meet patients’ needs and preferences. Objective: The aim of this study was to investigate the needs and preferences of patients regarding radiology test results delivered via patient portals. Method: This study used a cross-sectional, quantitative approach design using a questionnaire survey with close-ended questions. The distribution method used for this study was a self-administered questionnaire, on paper and online. The sample size of this study was 615 participants. There were three main research questions that this study aimed to answer: 1. Is there a relationship between patients’ level of education and how much they understand from the radiology report? 2. Does health literacy have a main role in patients’ understanding of the radiology report? 3. Does adding a statement at the end of the radiology report in lay terms summarizing the content of the report improve patients’ understanding of the report? In addition, this study also explored the following issues: 4. How much do patients understand from a typical radiology report? 5. Which type of radiology reporting do patients prefer (structured versus free-text)? 6. Do patients think that the type of radiology reporting affects their understanding of the report? Data analysis: The collected data were analyzed using the Pearson Chi-square test with Cramer\u27s V, Spearman’s correlation test, Fisher’s exact test, and Wilcoxon signed rank test with effect size. Results: No relationship was found between patients’ level of understanding of a radiology report and health literacy or level of education. An association was found between health literacy and level of education, where people with a lower level of education tended to have limited health literacy. No correlation was found between laypersons’ level of understanding of a typical spine MRI report and gender, age, race, previous radiology exam experience, or native language. There also was no correlation between laypersons’ level of understanding of a typical brain MRI report and gender, race, native language, or previous radiology exam experience. However, there was a very weak relationship between laypersons’ level of understanding of a typical brain MRI report and age, where elderly people tended to not understand the typical brain MRI report. Most of the participants (69%) wanted to receive their radiology test results through the online patient portal. Most of the participants (61%) also preferred the structured radiology report to the free-text report. Sixty one percent of the participants thought that the type of radiology reporting affected their level of understanding, around 75% of whom preferred structured radiology reporting. Most of the participants did not understand the typical radiology reports (Mdn=2). Most of the participants understood the MRI report with the patient summary statement (Mdn=4). The vast majority of the participants (84%) thought that adding a summary statement at the end of the radiology report summarizing the content of the report in lay terms was a good method for improving their understanding of the report. The Wilcoxon signed rank test revealed that adding a summary at the end of a radiology report summarizing the content of the report in lay terms can significantly enhance the participants’ level of understanding of the reports with a very large effect size (Z = 17.271, p \u3c 0.001, r = 0.723 for the spine MRI report and Z = 17.239, p \u3c 0.001, r = 0.721 for the brain MRI report). Conclusions: Most patients will not understand their radiology report regardless of their level of education and their health literacy skills. Adding a summary at the end of the radiology report in lay terms summarizing the content of the report significantly improves patients’ understanding of the report. Structured radiology reporting is the preferred type of reporting for most patients, and most of them think that the type of radiology report affects their level of understanding of the report

Clinical audit and quality assurance in the imaging process

Recent decades have witnessed a large and rapid expansion of medical imaging technologies with the development of digital imaging, computed tomography (CT), intervention radiology (IR), magnetic resonance imaging (MRI) and positron emission tomography (PET). The average effective dose per capita in Finland, received from X-ray examinations and interventional radiology has risen within reasonable levels, but the proportional CT scan dose sustained by the population out of the total population dose has increased and is currently over 50% from the total population dose in medicine. These technical developments and an increase in diagnostic examinations have raised concerns regarding the quality and safety of imaging practices. Organizations using medical imaging modalities should have a documented quality assurance (QA) program, as well as methods to justify the use of new radiological procedures ensuring the safe operation and adequate quality of clinical images and the imaging process. According to decree 423/2000 departments using ionizing radiation should be audited in all essential aspects at intervals not exceeding five years. Clinical audits should be arranged to expediently complement the self-assessment of activities. Reports of the two clinical audit periods were evaluated at 14 diagnostic radiation departments in the Hospital District of Southwest Finland (I). Recommendations given during the first clinical audit period were largely implemented by the second run. Auditing appeared to positively affect radiological imaging quality in our study. The use of ionizing radiation always requires a safety license and on-site inspections. The Radiation and Nuclear Safety Authority (STUK) is Finland s regulatory body controlling safety aspects of radiation utilization, and ensuring that safety guidelines defined by the Radiation Act are followed. The contents of the clinical audits and regulatory inspections of radiological procedures were examined and overlaps were searched for in 20 radiological imaging departments in the Hospital District of Helsinki and Uusimaa (HUS) (II). Radiation safety organizations, examination and personal dosimeter usage guidelines, patient doses, the quality control of equipments and self-assessments were evaluated by both the clinical auditors and the inspectors. Clinical audits and regulatory inspections have partly addressed similar topics. The personal equivalent doses of 267 radiation employees were monitored using personal dosimeters at the HUS Helsinki Medical Imaging Center (III). A personal dosimeter was worn by a total of 116 radiologists and 151 radiographers. Exposure monitoring results exceeding the registration threshold were observed in the personal dosimeters of 59 radiologists and 14 radiographers during a five-year period. Only 10 angiography radiologists recorded doses above 10 mSv during the five-year period. Individual exposure monitoring is justified for radiologists working in interventional procedures. Report quality was examined at the HUS Helsinki Medical Imaging Center. An experienced chest radiologist re-reported 293 chest radiograph examinations in accordance with the original request and without identifying patients (IV). Two experienced radiologists compared the content of the initial and re-reported reports. Three referring physicians evaluated the usefulness of the reports. Radiologists mostly addressed the questions posed by referring physicians, but separate conclusions were seldom included. Significantly shorter reports were initially prepared by general radiologists (29 words on average) than by the chest radiologist (93 words on average) in her re-reported reports. Inter-observer agreement between the two radiologists revealed that identical opinions of the findings was low (0.31), due to unstructured reports containing differing quantities of information. Referring physicians considered the reports clear and intelligible.Röntgentoiminnan ja röntgenlausunnon laatu vaikuttaa suoraan potilasturvallisuuteen Viimeisten vuosikymmenten aikana röntgenissä käytettävät kuvantamistekniikat ovat kehittyneet huimaa vauhtia. Tekniset kehitysaskeleet ja tutkimusten lukumäärän kasvu on tuonut esille tarpeen arvioida kuvantamiskäytäntöjen laatua ja turvallisuutta. Ionisoivan säteilyn käyttö vaatii aina turvallisuusluvan sekä viranomaisen määrävälein tekemiä tarkastuksia, asiantuntijoiden tekemiä kliinisiä auditointeja ja henkilökunnan tekemiä itsearviointeja. Suomessa kliiniset auditoinnit suorittavat röntgenin asiantuntijat eli radiologi ja röntgenhoitaja. Fyysikko on mukana lähinnä yliopistosairaaloiden auditoinneissa. Auditoijat arvioivat yksikön toiminnan ja antavat kehittämissuosituksia. Tutkimuksen kohteena olleet röntgenit saivat ensimmäisellä auditointikierroksella 2000-luvun alussa 80 kehittämissuositusta, mutta toisella kierroksella viiden vuoden jälkeen enää 54 kehittämissuositusta. Ensimmäisen auditointikierroksen kehittämissuositukset oli suurimmaksi osaksi laitettu kuntoon ennen toista kierrosta, joten auditoinnilla on positiivinen vaikutus kuvantamisen laatuun. Säteilyturvakeskus tarkistaa säännöllisesti röntgenlaitteiden turvallisuuden. Kliinisissä auditoinneisssa ja viranomaistarkastuksissa arvioidaan säteilyturvallisuutta, henkilökunnan ohjeistusta, potilasannosmittausten tuloksia, laitteiden laadunvalvontaa sekä itsearvioinnin suorittamista ja niiden tuloksia. Kliinisissä auditoinneissa arvioidaan toimintaa hyväksyttyihin kliinisiin käytäntöihin nojaten, kun taas viranomaistarkastuksissa arvioidaan toimintaa laiteturvallisuuden kannalta. Tutkimuksen perusteella voidaan sanoa, että viranomaistarkastuksissa ja kliinisissä auditoinneissa arvioidaan osin samoja asioita. Radiologit tarvitsevat hyvät lähetteet, jotka sisältävät riittävät tiedot potilaan oireista ja mahdollisen kysymyksen siitä, mitä röntgentutkimuksella haetaan. Lähettävät lääkärit odottavat puolestaan selkeää, helposti ymmärrettävää ja sisällöltään riittävää lausuntoa. Radiologit vastasivatkin useimmiten lähettävän lääkärin esittämään kysymykseen, mutta yhteenveto tutkimuksesta puuttui usein. Eri radiologien röntgenlausuntojen sisällöissä oli huomattavia eroja, ja niiden vertailu oli vaikeaa radiologeille itselleenkin. Erot lausuntojen rakenteessa ja pituudessa viittaavat siihen, että tarvitaan selkeitä ohjeita ja koulutusta lausuntojen sisällöstä. Röntgentutkimuksista aiheutuvat henkilökunnan säteilyannokset vaihtelevat lähes minimaalisesta annoksesta keuhkokuvauksessa huomattaviin annoksiin monimutkaisissa läpivalaisutoimenpiteissä. Tutkimukseen osallistui 267 röntgenissä työskentelevää henkilöä, ja vain 10 angioradiologin rekisteröity annostulos ylitti 10 millisieverttiä viiden vuoden jaksolla. Henkilökohtaisten annosmittareiden käyttö on aiheellista läpivalaisutoimenpiteitä suorittavilla radiologeilla. Säteilyannosmittaus voidaan toteuttaa ns. aktiivisilla mittareilla, jolloin reaaliaikainen mittaus ja tulosten tarkastelu on mahdollista, mikä todennäköisesti johtaa työskentelytapojen systemaattiseen parantamiseen. Yhteenvetona voidaan todeta, että röntgenosaston toimintaa arvioidaan viranomaisten ja ulkoisten arvioijien toimesta sekä henkilökunnan tekemän itsearvioinnin avulla. Tarkastusten ja arviointien tulosten avulla röntgenosaston henkilökunta pystyy parantamaan oman toimintansa laatua ja tämä vaikuttaa potilaan turvallisuuteen ja palvelun laatuun