Radiological Reports: A Comparison between the Transmission Efficiency of Information in Free Text and in Structured Reports

Abstract

INTRODUCTION:This work proposes to improve the transmission of information between requiring physicians and radiologists.OBJECTIVES:Evaluate the implementation of a structured report (SR) in a university hospital.METHODS:A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting.RESULTS:For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/−4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/− 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/−3.8) minutes for thyroids with nodules and 3.67 (+/−2.51) minutes for thyroids without nodules. Most of the radiologists (76.2%) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80% preferred the SR.DISCUSSION:From the requiring physicians’ perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists.CONCLUSIONS:The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.

Structured reporting of x-rays for atraumatic shoulder pain: advantages over free text?

“…As the ratings of SR and FTR differed significantly for all items, the results clearly implicate that the referring physicians who rated the reports in our study prefer SR for the radiographic evaluation of atraumatic shoulder pain. This is in line with previous studies that underline the preference for SR by referring physicians [ 9 , 15 ].…”

A Survey on Ontology-Based Systems to Support the Prospection, Diagnosis and Treatment of Breast Cancer

“…Additionally, other benefit brought by the use of ontologies in the medicine field is the possibility of organizing and structuring medical reports [1][21] [25]. This is useful to represent the knowledge, improving the information transmission and facilitating the search of clinical data with the standardization of the terms to fill this document.…”

European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy – a quality control study

“…Some studies have suggested guidelines for the specific content of referral letters within different medical specialties (72)(73)(74)(75) and some have shown a beneficial effect of referral templates/form letters on the quality of referral letters (76)(77)(78)(79)(80). Structured templates have also been effective for improving documentation in other medical records, particularly in reports from examinations/procedures (81)(82)(83)(84). Thus, the evidence indicates that some degree of structure/form is warranted when the objective is to improve documentation quality.…”

“…Studies evaluating the effect of checklists on other medical documents have also shown do improve the documentation quality, e.g. for radiology reports (83,84) and for reports from endoscopic procedures (81).…”