Structured Reporting in Clinical RoutineArticle in several languages: English | deutsch
06 December 2017
04 May 2018
13 August 2018 (eFirst)
Background The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.
Method In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.
Results The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.
Conclusion Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.
Structured reports have numerous advantages over conventional narrative reports.
The German Radiological Society is developing consensus-based and quality assured report templates.
Report templates are provided at www.befundung.drg.de under a free license.
Vendors are now encouraged to provide solutions for the implementation of structured reporting.
Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2018; DOI: 10.1055/a-0636-3851
- 1 Clinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988; 169: 825-826
- 2 Hall FM. Language of the radiology report: primer for residents and wayward radiologists. American Journal of Roentgenology 2000; 175: 1239-1242
- 3 Ridley LJ. Guide to the radiology report. Australasian Radiology. Blackwell Science Pty 2002; 46: 366-369
- 4 Bosmans JML, Weyler JJ, De Schepper AM. et al. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 2011; 259: 184-195
- 5 Johnson AJ, Chen MYM, Zapadka ME. et al. Radiology Report Clarity: A Cohort Study of Structured Reporting Compared With Conventional Dictation. JACR 2010; 7: 501-506
- 6 Schwartz LH, Panicek DM, Berk AR. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology 2011; 260: 174-181
- 7 Bosmans JML, Weyler JJ, Parizel PM. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. European Journal of Radiology 2009; 72: 354-358
- 8 Dunnick NR, Langlotz CP. The radiology report of the future: a summary of the 2007 Intersociety Conference. 2008: 626-629
- 9 Rubin DL. Creating and curating a terminology for radiology: ontology modeling and analysis. J Digit Imaging 2008; 21: 355-362
- 10 Morgan TA, Helibrun ME, Kahn Jr CE. Reporting Initiative of the Radiological Society of North America: Progress and New Directions. Radiology 2014; 273: 642-645
- 11 RSNA. [Internet]. rsna.org. [cited 2014 Aug 14]. Available from: Radiology Reporting Initiative. https://www.rsna.org/Reporting_Initiative.aspx
- 12 IHE Radiology Technical Committee. IHE Radiology Technical Framework Supplement Management of Radiology Report Templates (MRRT). 2017: 1-51
- 13 Kahn CE, Genereaux B, Langlotz CP. Conversion of Radiology Reporting Templates to the MRRT Standard. J Digit Imaging 2015; 28: 528-536
- 14 Kahn CE. Incorporating intelligence into structured radiology reports. Law MY, Cook TS. , editors. SPIE Medical Imaging. 9039 SPIE; 2014: 90390M-90390M–6
- 15 Towbin AJ, Hawkins CM. Use of a Web-Based Calculator and a Structured Report Generator to Improve Efficiency, Accuracy, and Consistency of Radiology Reporting. J Digit Imaging 2017; 147: 333-335
- 16 European Society of Radiology (ESR). Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights Imaging 2011; 2: 93-96
- 17 Kahn Jr CE, Langlotz CP, Burnside ES. et al. Toward Best Practices in Radiology Reporting. Radiology 2009; 252: 852-856
- 18 Douglas PS, Hendel RC, Cummings JE. et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. Journal of the American College of Cardiology 2009; 53: 76-90
- 19 Flusberg M, Ganeles J, Ekinci T. et al. Impact of a Structured Report Template on the Quality of CT and MRI Reports for Hepatocellular Carcinoma Diagnosis. Journal of the American College of Radiology 2017; 14: 1206-1211
- 20 Sahni VA, Silveira PC, Sainani NI. et al. Impact of a Structured Report Template on the Quality of MRI Reports for Rectal Cancer Staging. American journal of roentgenology 2015; 205: 584-588
- 21 Nörenberg D, Sommer WH, Thasler W. et al. Structured Reporting of Rectal Magnetic Resonance Imaging in Suspected Primary Rectal Cancer: Potential Benefits for Surgical Planning and Interdisciplinary Communication. Invest Radiol 2017; 52: 232-239
- 22 Brook OR, Brook A, Vollmer CM. et al. Structured Reporting of Multiphasic CT for Pancreatic Cancer: Potential Effect on Staging and Surgical Planning. Radiology 2015; 274: 464-472
- 23 Marcovici PA, Taylor GA. Journal Club: Structured radiology reports are more complete and more effective than unstructured reports. American journal of roentgenology 2014; 203: 1265-1271
- 24 Wildman-Tobriner B, Allen BC, Bashir MR. et al. Structured reporting of CT enterography for inflammatory bowel disease: effect on key feature reporting, accuracy across training levels, and subjective assessment of disease by referring physicians. Abdom Radiol (NY) 2017; 1: 2
- 25 Gassenmaier S, Armbruster M, Haasters F. et al. Structured reporting of MRI of the shoulder – improvement of report quality?. Eur Radiol 2017; 3: 35
- 26 Sabel BO, Plum JL, Kneidinger N. et al. Structured reporting of CT examinations in acute pulmonary embolism. J Cardiovasc Comput Tomogr 2017; 11: 188-195
- 27 Dickerson E, Davenport MS, Syed F. et al. Effect of Template Reporting of Brain MRIs for Multiple Sclerosis on Report Thoroughness and Neurologist-Rated Quality: Results of a Prospective Quality Improvement Project. J Am Coll Radiol 2017; 14: 371-379
- 28 Goldberg-Stein S, Gutman D, Kaplun O. et al. Autopopulation of Intravenous Contrast Type and Dose in Structured Report Templates Decreases Report Addenda. J Am Coll Radiol 2017; 14: 659-661
- 29 Lee MC, Chuang KS, Hsu TC. et al. Enhancement of Structured Reporting – an Integration Reporting Module with Radiation Dose Collection Supporting. J Med Syst 2016; 40: 852
- 30 Faggioni L, Coppola F, Ferrari R. et al. Usage of structured reporting in radiological practice: results from an Italian online survey. Eur Radiol 2017; 27: 1934-1943
- 31 Balleyguier C, Ayadi S, Van Nguyen K. et al. BIRADS classification in mammography. European Journal of Radiology 2007; 61: 192-194
- 32 Segrelles JD, Medina R, Blanquer I. et al. Increasing the Efficiency on Producing Radiology Reports for Breast Cancer Diagnosis by Means of Structured Reports. A Comparative Study. Methods Inf Med 2017; 56: 248-260
- 33 Goebel J, Hoischen J, Gramsch C. et al. Tumor response assessment: comparison between unstructured free text reporting in routine clinical workflow and computer-aided evaluation based on RECIST 1.1 criteria. J Cancer Res Clin Oncol 2017; 22: 779
- 34 Larson DB, Towbin AJ, Pryor RM. et al. Improving Consistency in Radiology Reporting through the Use of Department-wide Standardized Structured Reporting. Radiology 2013; 267: 240-250
- 35 Goldberg-Stein S, Walter WR, Amis ES. et al. Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach. Curr Probl Diagn Radiol 2017; 46: 295-299
- 36 Pinto dos Santos D, Klos G, Kloeckner R. et al. Development of an IHE MRRT-compliant open-source web-based reporting platform. Eur Radiol 2017; 27: 424-430
- 37 Bosmans JML, Neri E, Ratib O. et al. Structured reporting: a fusion reactor hungry for fuel. Insights Imaging 2015; 6: 129-132
- 38 Ganeshan D, Duong PAT, Probyn L. et al. Structured Reporting in Radiology. Academic Radiology 2018; 25: 66-73
- 39 Johnson AJ, Chen MYM, Swan JS. et al. Cohort study of structured reporting compared with conventional dictation. Radiology 2009; 253: 74-80
- 40 Hanna TN, Shekhani H, Maddu K. et al. Structured report compliance: effect on audio dictation time, report length, and total radiologist study time. Emerg Radiol 2016; 23: 449-453
- 41 Pons E, Braun LMM, Hunink MGM. et al. Natural Language Processing in Radiology: A Systematic Review. Radiology 2016; 279: 329-343
- 42 Margolies LR, Pandey G, Horowitz ER. et al. Breast Imaging in the Era of Big Data: Structured Reporting and Data Mining. American journal of roentgenology 2016; 206: 259-264
- 43 Durack JC. The value proposition of structured reporting in interventional radiology. American journal of roentgenology 2014; 203: 734-738
- 44 Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol 2008; 39: 359-367