!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> Streamline Training & Documentation: Structured Radiology Reports

Sunday, August 23, 2009

Structured Radiology Reports

The subject of electronic medical records (EMR) is much in the news nowadays, and I know from one recent project I worked on just how complicated implementing a new or upgraded system is for a hospital. (I haven't had any direct experience with getting EMR up and running in a medical practice, but I have no doubt that the complexity and resource demands are daunting.)

The payoff from adopting a well-designed EMR system is also substantial, including as it does, more rapid. complete, and accurate communication among providers; better support of diagnosis and treatment planning; and reduced treatment errors. This is not to overlook caveats relating to privacy, security, and lack of standardization. It's simply to say that medicine needs to keep moving in the direction that other types of enterprises have gone, namely, taking advantage of the power of well-managed IT to increase productivity and quality.

(click to enlarge)
An example of a structured radiology report

As just one concrete example, I'd cite what is happening in the field of radiology. For some years now, radiologists have been moving toward use of computer-based structured reporting. A 2009 special report (pdf) from the Radiology Reporting Committee of the Radiological Society of North America (RSNA)1 explains:
Construed narrowly, structured reporting means the use of predefined formats and terms to create reports; in this sense, structured reports are those based on templates or checklists. In a broader sense, however, structured reporting can integrate additional information collected during the imaging procedure, such as clinical data, technical parameters, measurements, annotations, and key images.
Not only does structured reporting help communicate findings clearly, but it also makes the information in reports searchable, which can assist with research, teaching and clinical quality improvement. Structured reports also help with regulatory and billing compliance. Finally, as the RSNA report notes:
Because information in a structured report adheres to predefined format and vocabulary, it is easier to integrate that informtion with generalized knowledge-based resources. Thus, one can more easily integrate structured reporting process with clinical guidelines, collaborative staging tools, educational resources, and decision support.
To stay apprised of developments in structured radiology reporting, you can follow the RSNA Reporting Wiki.

1 The RSNA's definition of professionalism was the subject of yesterday's post.


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