Structured Radiology Reporting

Structured radiology reporting encompasses a variety of report generation techniques and data entry. Given the primary role that information technology will take part in the future of health care providing, the clear benefit of structured radiology reporting systems is evident. These systems can potentially lead to a rapid turnaround time of reports, a reduction of reporting costs, improved communication, boost in satisfied referring providers, as well as a simplified quality and reporting compliance.

The general format of reports remains unchanged. Radiologists comment on this technique, state our findings, list several limitations, and give a summary. The format and structure vary from each individual, group, and study. If this already works, why is there a need to change it?

For the purpose of having a more consistent method of patient care, practitioners must adapt to changes and improvements in their traditional practices. Summarily, through structured radiology reporting, it is easier to utilize a dictation phone and craft a report using free association. In a few seconds, the reports will emerge from a transcription box.

Advantages of Structured Reporting
Structured radiology reporting may provide the following improvements as compared to conventional reporting, depending on the degree of the structure and the usability interface:
* Save time spent on dictating – routine reports are made faster than via conventional dictation

* Save time on editing reports – compared to human-generated reports, those made with a computer have less errors than speech recognition

* Prompt turn-around reports – reports can be approved as well as sent at any time

* Receive help with difficult cases – gamut, templates and other forms of decision support are available in real-time

* Cost savings – transcription expenses are eliminated from the budget of operations

Accurate, complete and appealing reports – the physicians will better appreciate focused, multi-media and clear reports
These advantages are very important, especially for practitioners and hospital administrators who continue to seek ways to improve their services and offer help to more patients.

Challenges of Structured Reporting

Meanwhile, structured radiology reporting also has its share of challenges that potentially slows down user’s adoption of this reporting system. As we have pointed out earlier, this integration will not be a smooth and quick one. We list here some of the challenges:

* Potential for an increase in “look-away time”
Like other speech recognition systems, some of the structured reporting systems may cause the user to monitor the report while it is being produced. This added task could reduce the time spent by the radiologist in examining the images. Although literature on the relationship between interpretation accuracy and time is variable, the higher look-away time can affect the accuracy.

* Imaging lexicons are currently not routinely available
Although some imaging lexicons like Breast Imaging Reporting and Data System (BIRADS) from the American College of Radiology have been adopted widely, and others are currently being developed for cross-sectional breast imaging and chest imaging, the wide adoption of the structured reporting systems require the availability of lexicons for the entire imaging disciplines.

* Converts production task to a search task
Structured radiology reporting derives many of its benefits from using consistent imaging term, requiring radiologists using structured reporting systems to be familiar with the preferred terms used in imaging findings. For unfamiliar findings, the user needs to initiate a search using the proper term instead of improvising with an approximate synonym.

* Challenge in integrating the report along with the image
A majority of structured reporting systems provide for the link creations between locations on an image and imaging findings. However, these efforts are still in the early stages of creating this integration routine.

Overall, structured radiology reporting holds a lot of potential for its users and will provide great benefit after it has ironed out integration issues.