Building Blocks for Effective Report Communication

Transcription

1 2016 SBI/ACR Breast Imaging Symposium Building Blocks for Effective Report Communication Richard L. Ellis, M.D. Breast Imaging Section Mayo Clinic Franciscan Health Care La Crosse, WI JW Marriott Austin Austin, TX April 7-10, 2016

2 Disclosure of Commercial Interest Consultant for Three Palm Software Breast Imaging Display System

3 Objectives Report Purpose Report Organization BI-RADS Lexicon BI-RADS Assessment Categories Breast Imaging Reports Patient Lay Letters Main Allegations of Litigation

4 Diagnostic Radiologists: How Do We Demonstrate Our Value? Perception Interpretation Communication

5 Recommended to the American Roentgen Ray Society that all candidates for members should submit 100 x-ray reports for evaluation of their clarity and diagnostic value - if they did not meet diagnostic standards then admission would be denied. Preston Hinkey, MD (1904) Editor of AJR Describes in detail what is seen on the film... but does not tell what he thinks about it, what conclusions he draws from it, and what it means to him. Charles Enfield, M.D. (1923)

6 Radiology report hedging refers to the use of ambiguous statements that avoid commitment on the part of the radiologist.

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8 Report Purpose Make your referring providers and patients hopelessly dependent upon what your say (reports) and do (procedures). Ward Parsons, MD (2001) In the land of the blind, the one-eyed man is king. Desiderius Erasmus s Adagia (1500)

9 Radiologist Report Value Very beneficial and helpful Sometimes beneficial and helpful Seldom beneficial and helpful

10 Who Are Your Two Best Friends in Radiology? Old Films Old (Experienced) Radiologists

11 Report Organization Indication for examination Succinct description of overall breast composition Clear description of any important findings Comparison to prior exam(s), if deemed appropriate Assessment Management

12 Any verbal discussions between the interpreting physician and the referring clinician or patient should be documented in the original report or in an addendum to the report.

13 Situations that may warrant nonroutine communication include the following: Findings that suggest a need for immediate or urgent intervention. Findings that are discrepant with a preceding interpretation of the same examination and where failure to act may adversely affect patient health. Findings that the interpreting physician reasonably believes may be seriously adverse to the patient s health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in an adverse patient outcome. ACR PRACTICE PARAMETER FOR COMMUNICATION OF DIAGNOSTIC IMAGING FINDINGS Revised 2014 (Resolution 11)*

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15 Breast Composition Categories Almost entirely fatty Scattered areas of fibroglandular tissue Heterogeneously dense Extremely dense

16 Almost entirely fatty

17 Scattered areas of fibroglandular tissue

18 Heterogeneously dense

19 Extremely dense

20 BI-RADS Mammography Lexicon Overview

21 BI-RADS Ultrasound Lexicon Overview

22 BI-RADS MRI Lexicon Overview

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24 Synoptic Reporting Improved reporting efficiency Ensure report uniformity, consistency & completeness Easier & faster to read Supports uniform reporting Allows improved auditing Supports clinical research data collection

25 Reporting Template/Synoptic driven Less likely to forget important information Report sign-off generates Patient lay letter Referring provider report Treatment team members Billing/Coding Easier & faster to read Uniform reporting

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27 BILATERAL SCREENING MAMMOGRAPHY EXAMINATION Comparison: [] Breast Composition: [] Findings: [] CONCLUSION: [] Mammography BI-RADS ASSESSMENT: []

28 BILATERAL SCREENING MAMMOGRAPHY EXAMINATION April 7, 2016 Comparison: February 22, 2014, April 2, 2015 Mayo Clinic, La Crosse, WI. Breast Composition: Scattered fibroglandular tissue. Findings: No suspicious masses, calcifications, or architectural distortion identified. CONCLUSION: 1. No mammographic evidence of malignancy identified. 2. Recommend continued annual screening, unless clinically indicated otherwise. Mammography BI-RADS ASSESSMENT: Category 1 Normal

29 LEFT BREAST DIAGNOSTIC MAMMOGRAPHY EXAMINATION Indication: [] Family History: [] Comparison: [] Breast Composition: [] Findings: [] CONCLUSION: [] Mammography BI-RADS ASSESSMENT: Category 0 []

30 LEFT BREAST DIAGNOSTIC MAMMOGRAPHY EXAMINATION April 2, 2016 Indication: 58-year-old recall from screening mammography. Family History: Sister, age 62, with breast cancer. Comparison: Jan. 1, 2013, Jan. 3, 2014, Jan. 12, 2005 Mayo Clinic. Breast Composition: Scattered fibroglandular tissue. Findings: Irregular, high-density mass measuring 13mm within the left 2 o clock position, middle depth. CONCLUSION: 1. Irregular mass within the left 2 o clock position. 2. Recommend left breast clinical breast examination aided with ultrasound for additional diagnostic evaluation. Mammography BI-RADS ASSESSMENT: Category 0 Need additional imaging evaluation

31 A great deal of confusion centers on the patient with a palpable lump finding and negative imaging. These reports should be coded with the final assessments based on the imaging findings and to follow this with a sentence recommending surgical consultation or tissue diagnosis, if clinically indicated. ACR BI-RADS Atlas, 5 th Ed., 2013, Assessment-Management Concordance, p 91.

32 Suggested Report Conclusion: year-old presents for evaluation of suspicious palpable lump in the right breast. 2. No mammographic evidence of malignancy identified. 3. Any subsequent management should be based upon clinical breast exam and degree of clinical concern. Mammography BI-RADS 1 - Negative

33 Suggested Report Conclusion: year-old presents for evaluation of suspicious palpable lump in the right breast. 2. No mammographic evidence of malignancy identified. 3. Recommend clinical breast exam aided with ultrasound. Mammography BI-RADS 1 - Negative

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35 CLINICAL BREAST EXAMINATION LEFT BREAST ULTASOUND April 8, 2016 Indication: 58-year-old presents for additional diagnostic evaluation. Family History: Sister, age 62, with breast cancer. Comparison:... Clinical breast exam: External inspection and palpation of both breast no abnormalities identified. Left breast ultrasound:.... Results and management options were reviewed and discussed with the patient. Recommend ultrasound-guided needle biopsy. Patient agrees with the recommended biopsy. Approximately 11 minutes was provided in direct patient counsel. CONCLUSION: 1. Non-palpable, irregular mass identified within the left 2 o clock position. 2. Recommend left breast ultrasound-guided needle biopsy for definitive tissue diagnosis. Ultrasound BI-RADS ASSESSMENT: Category 5 Highly suggestive of malignancy.

36 Recommendation. Proposal as to the best course of action, especially one put forward by an authoritative body. Consider. Think carefully about something, typically before making a decision. Patient Elects. Informed consent based upon options offered and explained to the patient.

37 BREAST MRI Indication: [] Comparison: [] Protocol: [] Breast Tissue: [] Background Enhancement: [] Findings: [] Conclusion: [] MRI BI-RADS: []

38 BREAST MRI April 5, 2016 Indication: 42-year-old presents for screening breast MRI due to high risk for breast cancer (Tyler-Cuzick 47.3%). Comparison:... Protocol: 1.5T GE Optima, dedicated 8 channel breast coil. T2 axial STIR, T1 axial without fat sat, T1 axial with fat sat followed by dynamic contrast enhancement series with reformatted coronal and sagittal views. Aegis CAD software used to aid interpretation. 0.1 ml/kg gadobutral (Gadovist) injected IV. Breast Tissue: Heterogeneously dense. Background Enhancement: Moderate background nodule enhancement. Findings: No abnormal enhancement or masses identified. Conclusion: 1. No abnormal enhancement or masses identified. 2. Recommend continue annual screening. MRI BI-RADS: 1 - Negative

39 Imaging-Guided Breast Biopsy Reporting Protocol Conclusion: 1. Brief History: [] Mode of Detection: [] Breast/Location: [] Imaging Presentation: [] Physical Exam Presentation: [] Tumor Size: [] Focality: [] Nodal Evaluation: [] Tumor Type/Grade: [] Contralateral Breast: [] Rad-Path Concordance: [] Complications: [] 2. Disposition: []

40 Imaging-Guided Breast Biopsy Reporting Protocol Conclusion: year-old with successful left breast ultrasound-guided needle biopsy. No family history of breast cancer. Mode of Detection: Screening Mammography Breast/Location: Left/2 o clock Imaging Presentation: Spiculated mass Physical Exam Presentation: Non-palpable Tumor Size: 12 mm Focality: Unifocal Nodal Evaluation: No adenopathy Tumor Type/Grade: Invasive ductal carcinoma, grade II Contralateral Breast: Negative Rad-Path Correlation: Concordant Complications: No 2. Patient scheduled to follow up with Dr. Surgeon on April 14, 2016.

41 Patient Lay Letters Hand directly to diagnostic patients Reduce conflict of information Reduce cost of postage Reduce personnel cost Eliminate letters mailed to incorrect address Patient Lay Letter Costs: $ $1.48/letter

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43 Main Allegations of Liability Perceptual error Interpretation error Failure to suggest next appropriate study or action Failure to communicate timely and appropriate manner

44 Diagnostic Radiologists: How Do We Demonstrate Our Value? Perception Interpretation Communication

45 Q1: 37-year-old with a probable benign 16mm palpable fibroadenoma in the right 10 o clock position. A1: Report focused H&P, clinical breast exam, and imaging finding. Report review & discussion of findings and management options with the patient. Report patient s election in the conclusion.

46 CLINICAL BREAST EXAMINATION LEFT BREAST ULTRASOUND Indication: 37-year-old presents for additional diagnostic evaluation for a palpable lump within the right upper outer quadrant. Family History:... Comparison:... Clinical breast exam: External inspection and palpation of both breasts, no abnormalities identified. Mobile, well-circumscribed, oval lesion in the right 10 o clock position. Left breast ultrasound:.... Results and management options were reviewed and discussed with the patient. Management options include a conservative follow-up (CBE aided with US at 6, 12, 24 months), ultrasound-guided core needled biopsy, or surgical excision. CONCLUSION: 1. History, physical exam, and imaging consistent with a 16mm benign fibroadenoma in the right 10 o clock position. 2. Patient elects ultrasound-guided core needed biopsy for definitive tissue diagnosis. ULTRASOUND BI-RADS ASSESSMENT: Category 3 Probable benign.

47 Q2: 53-year-old with request for stereotactic-guided core needle biopsy for calcifications in the right 1 o clock position. However, on your assessment the calcifications are most likely benign. What do you do? A2: Review & discuss your findings with the patient. Provide your management options. Report patient s election in the conclusion.

48 Diagnostic Mammography April 8, 2016 Indication: 53-year-old presents for requested stereotactic-guided biopsy of reported suspicious microcalcifications in the right 1 o clock position. Family History:... Comparison:... Left breast ultrasound:.... consistent with fibrocystic change. Results and management options were reviewed and discussed with the patient. Management options include a conservative follow-up (diagnostic mammography at 6, 12, 24 months) or stereotactic-guided biopsy. CONCLUSION: 1. Grouped amorphous calcifications consistent with fibrocystic change. 2. Patient elects..... MAMMOGRAPHY BI-RADS ASSESSMENT: Category 3 Probably benign.

49 Q3: Pathology results are discordant for the BI-RADS 4c spiculated mass in left breast? What do you do? A3: Consider direct discussion with the patient & referring provider. Amend/Update your image-guided biopsy report.

50 1. 58-year-old with successful left breast ultrasound-guided needle biopsy. No family history of breast cancer. Mode of Detection: Screening Mammography Breast/Location: Left/2 o clock Imaging Presentation: Spiculated mass Physical Exam Presentation: Palpable discrete suspicious mass Tumor Size: 22mm Focality: Unifocal Nodal Evaluation: No adenopathy Tumor Type/Grade: Fibrocystic change Contralateral Breast: Negative Rad-Path Correlation: Discordant Complications: No 2. Recommend open surgical biopsy given the radiography-pathologic discordance. 3. Results reviewed with Dr. General Practice on April 4, Patient scheduled to follow-up with Dr. Surgeon on April 14, 2016.

51 Questions?

52 Radiology Report References: 1. Hall FM. Language of the radiology report: primer for residents and wayward radiologists. AJR 2000;154: Berlin L. Pitfalls of the vague radiology report. AJR 2000;174: Hall FM, et al. The radiologic hedge. AJR 1990;154: Quint LE, et al. Frequency and spectrum of errors in final radiology reports generated with automatic speech recognition technology. JACR 2008;5: McCoubrie AW. The radiology report Are we getting the message across. Clin. Radiology 2011(66): ). 6. Wiener MD. Letter to the Editor: Speaking the language. JACR 2016;13(1) Kuzminski SJ. Stick and stones can break your bones, words can also hurt you. JACR 2016:13(1):7.

53 Radiology Synoptic Report References: 1. Marcovici PA, Taylor GA. Structured radiology reports are more complete and more effective than unstructured reports. American Journal of Roentgenology Dec;203(6): Lin E, Powell DK, Kagetsu NJ. Efficacy of a checklist-style structured radiology report template in reducing resident misses on cervical spine computed tomography examination. Journal of Digital Imaging Oct;27(5): Schwartz, LH. Panicek, DM, Berk AR, Li Y, Hricak H. Improving communication of diagnostic radiology findings through structured reporting. Radiology Jul;260(1); Larson DB, Towbin AJ, Pryor RM, Donnelly LF. Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology Apr;267(1): Sistrom CL, Honeyman-Buck J. Free text versus structured format: Information transfer efficiency of radiology reports. American Journal of Roentgenology Sep;185(3):