Implementation of Structured Radiology Reports

Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

BACKGROUND

To evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years.

METHODS

We analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology.

RESULTS

As of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes.

CONCLUSIONS

The increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR.

KEY POINTS

1. Structured reporting usage increased markedly since its implementation at our institution in 2016. 2. Mean usage for the ten most popular structured reporting templates was 77% in 2022. 3. Both radiologists and referring physicians preferred structured reports over free-text reports. 4. Our data shows that structured reporting can be successfully implemented. 5. We strongly encourage others to implement structured reporting at their institutions.

Evidence of the benefits, advantages and potentialities of the structured radiological report: An integrative review

The structured report is a new trend for the preparation and manipulation of radiological examination reports. The structuring of the radiological report data can bring many benefits and advantages over other existing methodologies. Research and studies about the structured radiological report are highly relevant in clinical and academic subjects, improving medical practice, reducing unobserved problems by radiologists, improving reporting practices and medical diagnoses. Exposing the benefits, advantages and potential of the structured radiological report is important in encouraging the acceptance and implementation of this method by radiology professionals who are still somewhat resistant. The present review highlights the factors that contribute to the consolidation of adopting the structured radiology report methodology, addressing a variety of studies focused on the structuring of the radiological report. This integrative review of the literature is proposed by searching publications and journals databases (CAPES - Coordination of Improvement of Higher-Level Personnel, SciELO - Scientific Electronic Library Online, and PubMed - Publisher Medline) to develop a complete and unified understanding of the subject, so that it becomes a major part of evidence-based initiatives.

Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach

PURPOSE

To describe the successful implementation of a structured reporting initiative in a large urban academic radiology department.

METHODS

We describe our process, compromises, and top 10 lessons learned in overhauling traditional reporting practices and comprehensively implementing structured reporting at our institution. To achieve our goals, we took deliberate steps toward consensus building, undertook multistep template refinement, and achieved close collaboration with the technical staff, department coders, and hospital information technologists. Following institutional review board exemption, we audited radiologist compliance by evaluating 100 consecutive cases of 12 common examination types. Fisher exact test was applied to determine significance of association between trainee initial report drafting and template compliance.

RESULTS

We produced and implemented structured reporting templates for 95% of all departmental computed tomography, magnetic resonance, and ultrasound examinations. Structured templates include specialized reports adhering to the American College of Radiology's Reporting and Data Systems (ACR's RADS) recommendations (eg, Lung-RADS and Li-RADS). We attained 94% radiologist compliance within 2 years, without any financial incentives.

CONCLUSIONS

We provide a blueprint of how to successfully achieve structured reporting using a collaborative multistep approach.

Do Radiologists and Surgeons Speak the Same Language? A Retrospective Review of Facial Trauma

OBJECTIVE

The objective of the present study is to examine the concordance of facial fracture classifications in patients with trauma who underwent surgery and to assess the epidemiologic findings associated with facial trauma.

MATERIALS AND METHODS

Patients with trauma who underwent facial CT examination and inpatient operative intervention during a 1-year period were retrospectively analyzed. Patient demographic characteristics, the mechanism of injury, the radiology report, the surgical diagnosis, and clinical indications were reviewed. Fractures were documented according to bone type and were classified into the following subtypes: LeFort 1, LeFort 2, LeFort 3, naso-orbital-ethmoidal, zygomaticomaxillary complex (ZMC), orbital, and mandibular. Concordance between the radiology and surgery reports was assessed.

RESULTS

A total of 115,000 visits to the emergency department resulted in 9000 trauma activations and 3326 facial CT examinations. One hundred fifty-six patients (4.7%) underwent facial surgical intervention, and 133 cases met criteria for inclusion in the study. The mean injury severity score was 10.2 (range, 1-75). The three most frequently noted injury mechanisms were as follows: assault (77 cases [57.9%]), a traffic accident (21 cases [15.8%]), and a fall (20 cases [15%]). The three most frequently noted facial bone fractures were as follows: mandible (100 cases [75.2%]), maxilla (53 cases [39.8%]), and orbit (53 cases [39.8%]). The five descriptors most frequently found in the radiology and surgery reports were the mandibular angle (25 cases), the orbital floor (25 cases), the mandibular parasymphysis (22 cases), the mandibular body (21 cases), and ZMC fractures (19 cases). A classification was not specified in 31 of the radiologic impressions (22.5%), with 28 of 31 radiologists expecting the surgeon to read the full report. The descriptors used in the radiology and surgery reports matched in 73 cases (54.9%) and differed in 51 cases (38.3%). No classifications were used by one or both specialties in nine cases (6.8%).

CONCLUSION

For 38.3% of patients needing facial surgery, descriptors used in the radiologic and surgery reports differed. Speaking a common language can potentially improve communication between the radiology and surgery services and can help expedite management of cases requiring surgery.