Radiology Reports: Are Structured Systems The Answer?

CHICAGO - For clear, concise, easy-to-understand radiology reports, is structured reporting the way to go? For many in the industry, the verdict is still out.

There’s no question, experts say, the profession needs some type of uniform way to communicate findings not only to each other, but also to referring physicians and patients. The sticking point will be, however, whether one of the existing structured reporting systems can provide effective clarity for radiology without negatively impacting workflow.

“The purpose of structured reporting is to communicate to colleagues in a clear way and to make that reported information accessible to the software applications that are also meant to improve communication,” Curtis Langlotz, MD, PhD, said Monday at RSNA 2013. “They can also make our information available to the many electronic medical record systems. The support, based on this information, can make us better radiologists, clinicians, and decision-makers.”

The Case for Structured Reporting

While it’s true that radiology reports are most often perceived as letters between colleagues, they are now being used to determine reimbursement rates. Payers are increasingly likely to deny dollars when certain details are overlooked in a report.

But there is also evidence within radiology and other specialties that structured reporting might be a good idea. According to Langlotz, who is a radiology professor and vice chair of informatics at the University of Pennsylvania, 98 percent of residents receive no formal radiology report training, and 78 percent of that group learn the process from a fellow resident. In addition, 39 percent of physicians attest to occasional confusion when reading radiology reports.

“I would argue that radiology reporting needs a standardized format, consistent content, and pre-determined language,” he said. “And, given the proper tools, structured reporting is optimal.”

The Breast Imaging Reporting and Data System (BI-RADS) is an effective, successful example of structured reporting, he said. This initiative took an area of radiology that was rife with confusing descriptions and ambiguous recommendations and created a reporting process where each term correlated to specific imaging features, assessment terms, and outcome implications. The result, he said, is a system that not only enables radiologists to produce easy-to-understand reports, but that can also be an excellent training tool.

“Using BI-RADS can support the consistent teaching of breast imaging interpretations. We can teach anyone in radiology to be a good mammographer,” Langlotz said. “The system also lets us know where each radiologist stands. Who’s meeting the benchmarks, and who’s the outlier for good or bad.”

The University of Pennsylvania has also developed a similar system for abdominal imaging. Known as Code Abdomen, this initiative categorizes studies into seven levels that have defined criteria and recommendations. So far, Langlotz said, the system has helped create consistent, formatted radiology reports that referring physicians prefer; it’s maximized efficiency when using speech recognition software; and it’s reduced the risk of communication errors, opening the door for the facility to take advantage of federal performance incentives.

The Argument Against Structured Reporting

According to Richard Gunderman, MD, PhD, structured reporting isn’t anything new - and any pushback to the concept isn’t focused on the overall idea. Instead, the real question, he said, is how rigid does such a system need to be?

“How you feel about structured reporting likely depends on the vantage point from which exams you’re reading. There’s free text with headers, fill-in-the-blank, free text with auto-formatting, standard lexicon, point-and-click-trees,” he said. “There’s so many to choose from that either variability is difficult to do away with or it has some advantages.”

While Gunderman, a radiology professor and vice chair from Indiana University, agreed that structured reporting removes much of the potential for human error and ensures more information is included in the report, he pointed out that structured reporting reviews among practitioners remain mixed. This response is especially true, he said, in more complex cases.

For many providers, he said, adapting to a new reporting system can slow down their workflow, leading them to cut corners in reporting in an effort to maintain their productivity. Boiling down information for a fill-in-the-blank system could also lead to fragmented reporting and a provider’s impeded ability to synthesize data. Structured systems also limit a radiologist’s flexibility to customize a report with various end-users in mind.

In other cases, Gunderman said, some types of structured reporting can be distracting.

“Any menus or templates that require you to look away from the image will likely present challenges,” he said. “Right now, I look only at the image and dictate the report, but if I need to look away to fill in a template, it will take me a while to refocus, both visually and cognitively, on the image.”

Increased reliance on structured reporting systems that offer radiologists little wiggle room could also undermine the Accreditation Council for Graduate Medical Education’s (ACGME) newly-redesigned competencies. Rather than maintain five levels of skill acquisition that top out at “expert,” the ACGME added two more, making the highest level “mastery” - a provider who no longer operates solely by the rules, but who uses his or her intuition, as well.

“If you’re training a first-year resident in reporting on chest radiography, then structured reporting is great because it teaches them to think systematically,” he said. “But for someone, perhaps at the point of their fourth year of residency or their fourth decade of practice, they should be in the position to cast off the training wheels and function not just as experts, but as masters.”

Making Structured Reporting Work

Just because there are competing schools of thought about structured reporting doesn’t mean radiology can’t find a way to make such a system feasible.

To make structured reporting more effective, Gunderman suggested several accompanying steps that will enhance a referring physicians’ satisfaction with your reports. Whenever possible, he said, try to inspire your referring physicians and give them words of praise. Meet in-person as often as you can, and physically touch them, such as a handshake, whenever you have the opportunity. And, always make the attempt to learn something from them.

Langlotz agreed there is room for both mastery and strict data transfer in radiology reporting. Choosing the right system, he said, will prove beneficial for all parties involved.

“Radiology reporting is broken in many ways, but as leaderships continue to support structured reporting, change is now becoming feasible,” Langlotz said. “There are a number of products out there that offer structured reporting in a bunch of ways that won’t slow us down. We just need to make sure we choose the right ones because standardized communication saves lives.”