Structured reports: 10 years experience in private radiology clinics

Transcription

1 Structured reports: 10 years experience in private radiology clinics Poster No.: C-2028 Congress: ECR 2014 Type: Educational Exhibit Authors: T. Laswad, D. Fournier, J. Moreau, H. Brat, M. Deac, T Tancredi, F. bonvin, T. Zand, P. Benedict ; Sion/CH, Morges/ 3 CH, Geneva/CH Keywords: Management, PACS, elearning, Quality assurance DOI: /ecr2014/C-2028 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 27

2 Learning objectives To review the principles of structured reporting in radiology. To share our 10-year experience starting from free-text reports to structured reports (SR) ending to structured standardized reports (SSR). To show some examples of adaptation and quality improvement of our structured reporting. To highlight advantages and disadvantages of SR for the radiologist, the secretaries and the referring doctors. Background The complexity of medical imaging has increased dramatically over the past few decades, providing radiologists with more and more numerous images to interpret and more imaging modalities to compare. Remarkably, despite these changes, the style and format of radiologic reports have generally remained unchanged. Most reports still contain freeform text, dictated or even sometimes typed, by the radiologist (1). As the radiologic report is the final product of the radiologist and is often the only way of contact with the clinicians, the radiologist has to pay a high attention to portray his report in the best form. The radiology report should meet the following two criteria: easy to read and to understand, not only for the clinicians but also for the colleague-radiologist for the next follow-up improve the quality of the patients care by precising the diagnosis and saving time and money. There are three different kinds of radiologic reports: 1. Free-text (prose) report is a simple conventional report without sections or paragraphs. it might contain an introductory section (summarizing the examination technique and clinical history), a main body (consisting of a paragraph or more describing the findings) with or without a brief overall conclusion section. The referring clinician is obliged to read all the text to understand the result. Page 2 of 27

3 Figure 1: an example of a free-text report with two basic sections: indication and description but no conclusion. Fig. 1: a free-text report in References: Institut de radiologie de Sion - Sion/CH Free-text reports have been widely criticized for a number of inherent deficiencies as (2) : Inconsistencies in content, structure and nomenclature Disorganization Ambiguities Not well understood by the prescribing doctors Descriptive and inconclusive (some times exhaustive, some times very short). An alternative to free-text reporting is structured reporting. 2. Structured reports (SR) involves the presentation of a check-list of items in a standard sequence (3). it contains pragraphs corresponding to an organ or anatomic segment. Each paragraph has to be dictated and typed. Figure 2: an example of a structured report (SR) in Page 3 of 27

4 Fig. 2: example of structured report of lumber spine CT. References: Institut de radiologie de Sion - Sion/CH 3.Structured standardized report (SSR) is a structured report composed of standardized headings with stock phrases already written describing the normal findings of each section. Thus, the radiologist had only to describe the abnormalities in the right paragraph. Figure 3: an example of our actual structured standardized reports (SSR) for a normal shoulder MR showing clarity, simplicity and good appearance. Page 4 of 27

5 Fig. 3: a standardized structured report for a normal shoulder MRI. References: Institut de radiologie de Sion - Sion/CH There is a copious evidence in the literature about the benefit of structured reporting in radiology compared to free-text reports: clarity simplicity appearance the use of a standardized language (4, 5). Structured reports have showed a strong preference among both referring clinicians and radiologists (6). Images for this section: Page 5 of 27

6 Fig. 1: a free-text report in Fig. 2: example of structured report of lumber spine CT. Page 6 of 27

7 Fig. 3: a standardized structured report for a normal shoulder MRI. Page 7 of 27

8 Findings and procedure details Evolution of our radiology reporting over the years. In 1994: At the beginning of our pratice, we used free-text reports with prose decription. every radiologist had his own language and his special reports. Figure. 4: one of our Free text-reports. Fig. 4: example of a free-text report. Critics of the above report: words surplus e.g "we put in evidence ", size of calcification not mentioned. References: Institut de radiologie de Sion - Sion/CH In 2000: The first step of the evolution toward structured reporting was to divide the report in 3 sections (indication, description, conclusion) with the exception of the simple X-ray examinations. Figure 5 shows an example of a free-text report (2002) with three sections (indications, description, conclusion). Page 8 of 27

9 Fig. 5: 2002: we shifted to partially structured reports with the three main items, indications, description and conclusion. References: Institut de radiologie de Sion - Sion/CH In 2003, in order to improve the communication to the physicians and to standardize our practice, we decided to shift from free-text to structured reports. For this purpose, we developped 71 templates of structured reports for all our radiologic modalities (X-ray, US, mammography, CT, MRI). Adaptation of these templates have been regularly performed according to proposals of the radiologists (paragraphs, layout, inclusion of key images) in order to maximize clarity our reports and better communication. Figure 6 shows the evolution toward structured reporting in 2003 : Paragraphs of items in the descriptionmcorresponding usually to an organ or anatomic segment Inclusion of key-images at the end of the report with arrows in the to outiline the abnormalities. Inclusion of key-images was well appreciated by our the prescribing clinicians. Page 9 of 27

10 Fig. 6: 2003: a structured report with subparagraphs in the description and we included key-images at the end of the report, with arrows to outiline the abnormalities. References: Institut de radiologie de Sion - Sion/CH In 2004, we shifted to structured standardized reports (SSR) for the 71 available templates: Page 10 of 27

11 - creation of a pre-written phrase "ready stock phrases describing normal findings" for each paragraph. - The radiologist has only to dictate/modify the corresponding paragraph. Figure 7: example of a normal abdominal CT standardized structured report. Fig. 7: example of abdominal CT structured report. References: Institut de radiologie de Sion - Sion/CH In 2005: we improved the clarity in the "description section" by : - changing the subparagraphs alignment - highlighting the abnormal findings which are typing ''in italic''. Page 11 of 27

12 This step had lead to a clear improvement in the finalization of our reports (reduction in reports turn-around-time) by economizing time and effort of the secretary and the radiologist. Figure 8 shows improvement of the clarity in the description section with new alignment of the stock phrases. Fig. 8: improved in lay-out/lisibility of a standardized structured report for an abdominal CT. References: Institut de radiologie de Sion - Sion/CH Page 12 of 27

13 Figure 9: a recent structured standardaized report with abnormal findings. Page 13 of 27

14 Page 14 of 27

15 Fig. 9: a recent structured standardaized report with abnormal findings distinguished in italic. References: Institut de radiologie de Sion - Sion/CH 2010 was the year of the integration of our standard templates in the new RIS-PACS: - before typing the report, the secretary had to choose the right template (figure 10) according to the title of the examination (the radiologists are asked to mention the right title of the template to help the secretary) - once the report is typed, it appears in the RIS-list of the corresponding radiologist to be validated and signed (electronic signature). This integration has improved the work-flow and lead to a significant reduction of the turnaround-time (TAT) of the reports. Figure 10: integration of our standard templates in the new RIS-PACS. Fig. 10: Integration of our standard templates in the new RIS-PACS References: Institut de radiologie de Sion - Sion/CH Many referring clinicians are now directly connected with our RIS-PACS by a teleradiology software system to consult the images and also to directly receive the reports of their patients. Page 15 of 27

16 Pros and cons of our structured standardized reports Advantages - Secretaries Time saving Less effort and less errors in typing the reports Less turn-around-time of the reports (TAT). - Radiologists Time saving (has to dictate only the abnormal findings) Use of a common language Less errors (every organ/anatomic area had to be checked) Reduced turn around time (TAT) of the reports Permanent quality control and improvement Perfectly integrated in the RIS-PACS (HL7, DICOM) system Possibility to search by key-word. Benefit from previous structured standardized reports with clear conclusion and key-images making the problem quick to understand and /or facilitating the task for the colleague radiologist next time - Prescribing clinicians Clarity of reports and ease of understanding the findings Clear conclusion supported by key images with arrows facilitates communication of the results Better satisfaction Direct access to RIS-PACS for iand receiving the report by and fax. Disadvantages: - Mainly by radiologists cultural resistance to change: «medicine is a different profession and I used to do like this». Some radiologists see free text reporting as an "art of prose". adaptation time (which anomaly in which paragraph) concentration on the template can distract from image interpretation. Our most frequent errors in standardized reporting: Page 16 of 27

17 The most frequent reporting errors were: Inappropriate study title. Discrepancies between conclusion and description e.g post.cholecystectomy while the standard paragraph is still there: gallbladder: normal Wrong matching of the pathologic finding to the appropriate item paragraph. Forget to remove the standard normal conclusion phrase together with the positive abnormal one. Other general mistakes: Vague conclusion, and not answering the clinician's question. Size and location of the lesion not mentioned. Lack of grading of the pathologic finding (mild, moderate, severe). Not mentioning the impact of secondary findings e.g leave me alone lesions. Lack of propositions about the anomalies e.g follow up or not, how and in which time delay? Internal recommendations for improvement Following this study, we designed a checklist (Figure 11); for all pertinent criteria that must be included/checked in every structured report in our institution. Page 17 of 27

18 Page 18 of 27

19 Fig. 11: checklist of criteria that must be included/checked in every structured report. References: Institut de radiologie de Sion - Sion/CH What do the referring clinicians want? Quick communication of the result. Quick delivery of the reports and images. Use of standardized language they can understand. Concise description with less abbreviations. Clear conclusion that contain only the diagnosis the relevant findings. Diagnostic recommendations but absolutely not therapeutic ones. They appreciate key images with arrows and 3D demonstrations. Images for this section: Fig. 4: example of a free-text report. Critics of the above report: words surplus e.g "we put in evidence ", size of calcification not mentioned. Page 19 of 27

20 Fig. 5: 2002: we shifted to partially structured reports with the three main items, indications, description and conclusion. Fig. 6: 2003: a structured report with subparagraphs in the description and we included key-images at the end of the report, with arrows to outiline the abnormalities. Page 20 of 27

21 Fig. 7: example of abdominal CT structured report. Page 21 of 27

22 Fig. 8: improved in lay-out/lisibility of a standardized structured report for an abdominal CT. Page 22 of 27

23 Page 23 of 27

24 Fig. 9: a recent structured standardaized report with abnormal findings distinguished in italic. Fig. 10: Integration of our standard templates in the new RIS-PACS Page 24 of 27

25 Page 25 of 27

26 Fig. 11: checklist of criteria that must be included/checked in every structured report. Page 26 of 27

27 Conclusion According to our 10 years practice with structured reporting, we can conclude that: Structured reports (SR) have more advantages than disadvantages. SR have improved our workflow. SR are appreciated by the secretaries and the radiologists. SR are clearly preferred by the referring doctors compared to free text reports. Inclusion of key-images in the report gives better communication with the referring doctors and also helps the colleague radiologist doing the next follow-up study. by using a common language, thanks to structured standardized reporting, radiologists communicate better with the referring clinicians and also with each other. Personal information References Gagliardi RA. The evolution of the X-ray report. AJR Am J Roentgenol Reiner et al, Radiology reporting, past, present, and future: the radiologist's perspective. J Am Coll Radiol Bell DS, Greenes RA. Evaluation of Ultra-STAR: performance of a collaborative structured data entry system. Proc Annu Symp Comput Appl Med Care Lawrence.H et al. Improving Communication of Diagnostic Radiology Findings through Structured Reporting. Radiology. July Langlotz CP, Meininger L. Enhancing the expressiveness and usability of structured image reporting systems. Proc AMIA Symp Naik SS, Hanbidge A, Wilson SR. Radiology reports: examining radiologist and clinician preferences regarding style and content. AJR Am J Roentgenol Weiss DL, Langlotz CP. Structured reporting: patient care enhancement or productivity nightmare? Radiology Practice Management Feb 26, 2013, Oct 04, 2012 (SECTRA report). RSNA Nov 29, Page 27 of 27