Cohort Study of Structured Reporting Compared with Conventional Dictation

Johnson, Adam G.; Chen, Michael Y. M.; Swan, J. Shannon; Applegate, Kimberly E.; Littenberg, Benjamin

doi:10.1148/radiol.2531090138

Cited by 118 publications

(87 citation statements)

References 18 publications

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“…However, relatively little has been published regarding the efficacy of checklists in improving the diagnostic accuracy of radiologic studies, particularly among radiologists-in-training. The one study we are aware of that has addressed this question found a decrease in accuracy and completeness scores in resident reports for a preselected set of 25 brain MR imaging cases when using a structured reporting software system when compared with free-text dictation [22]. However, the study was limited by sparse training of resident subjects on the structured reporting software system and performance of the study outside of the clinical setting, without subject blinding.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of a Checklist-Style Structured Radiology Reporting Template in Reducing Resident Misses on Cervical Spine Computed Tomography Examinations

2014

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The increasing use of medical checklists to promote patient safety raises the question of their utility in diagnostic radiology. This study evaluates the efficacy of a checkliststyle reporting template in reducing resident misses on cervical spine CT examinations. A checklist-style reporting template for cervical spine CTs was created at our institution and mandated for resident preliminary reports. Ten months after implementation of the template, we performed a retrospective cohort study comparing rates of emergent pathology missed on reports generated with and without the checklist-style reporting template. In 1,832 reports generated without using the checklist-style template, 25 (17.6 %) out of 142 emergent findings were missed. In 1,081 reports generated using the checklist-style template, 13 (11.9 %) out of 109 emergent findings were missed. The decrease in missed pathology was not statistically significant (p=0.21). However, larger differences were noted in the detection of emergent non-fracture findings, with 17 (28.3 %) out of 60 findings missed on reports without use of the checklist template and 5 (9.3 %) out of 54 findings missed on reports using the checklist template, representing a statistically significant decrease in missed non-fracture findings (p = 0.01). The use of a checklist-style structured reporting template resulted in a statistically significant decrease in missed non-fracture findings on cervical spine CTs. The lack of statistically significant change in missed fractures was expected given that residents' search patterns naturally include fracture detection. Our findings suggest that the use of checklists in structured reporting may increase diagnostic accuracy.

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Section: Discussionmentioning

confidence: 99%

Efficacy of a Checklist-Style Structured Radiology Reporting Template in Reducing Resident Misses on Cervical Spine Computed Tomography Examinations

2014

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“…Several studies report that SRs provide more complete information than the NRs. 4,[23][24][25][26][27] In other specialties, par ticularly in pathology, synoptic reporting has been widely embraced, which has improved interdisciplinary com munication and led to more effective coordination of clinical care for individual patients. [28][29][30] There is wide acceptance of SRs by clinicians who prefer the readability of SRs over NRs.…”

Section: Discussionmentioning

confidence: 99%

Quality of narrative operative reports in pancreatic surgery

et al. 2013

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Background: Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy. Methods:We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness. Results:We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration. Conclusion:The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care. Conclusion :Les NO sont souvent incomplètes et leur qualité laisse à désirer. Des éléments importants, dont le protocole opératoire et les données oncologiques, étaient souvent manquants. Ainsi, les NO constituent une source inadéquate de données en ce qui concerne les IQ. Il faudra encourager la mise au point et l'utilisation d'autres types de rapports, dont des synopsis opératoires standardisés, pour mieux documenter les soins chirurgicaux prodigués et pour en évaluer la qualité. Q uality improvement is an important component of health care systems. Quality in health care can be evaluated in terms of the structures, processes and outcomes of care.

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“…Johnson et al found a decrease in accuracy and completeness in repeated analysis of cranial magnetic resonance scans. In particular, a higher time consumption and the lack of "artistic freedom" was criticized by the radiologists [24]. The need for fast and reliable de-identification of plain text in medical reports will probably continue until precise and easy-touse structured reporting applications are developed and become the standard in the clinical routine and science.…”

Section: Discussionmentioning

confidence: 99%

Semi-automated De-identification of German Content Sensitive Reports for Big Data Analytics

Seuß

Dankerl

Ihle

et al. 2017

Fortschr Röntgenstr

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ZUSAMMENFASSUNGZiel Projekte bei denen verschiedene Institutionen in Kooperation miteinander stehen, erfordern einen Schutz von Patientendaten durch selektive Deidentifizierung von Wörtern oder Ausdrücken. Eine automatisierte Deidentifikations-Software wurde entwickelt und anhand verschiedener medizinischer Berichte, zuerst ohne und anschließend nach Anpassung des Algorithmus an die Textstruktur, getestet. Ergebnisse Nativ wurden 61,3 % der direkten und 80,8 % der indirekten Kennungen nachgewiesen. Nach dem Training erhöhte sich die Leistung (P) auf 91,4 % (P25), 96,7 % (P50), 99,5 % (P100), 99,6 % (P250), 99,7 % (P500) und 100 % (P1000) für direkte Kennungen und 93,2 % (P25), 97,9 % (P50), 97,2 % (P100), 98,9 % (P250), 99,0 % (P500) und 99,3 % (P1000) für indirekte Kennungen. Im Durchschnitt wurden 5,3 % der medizinischen Begriffe als kritische Daten gekennzeichnet, nach dem Training waren es 4,0 % (P25), 3,6 % (P50), 4,0 % (P100), 3,7 % (P250), 4,3 % (P500), 3,1 % (P1000). Etwa 0,1 % der Füllwörter wurden gekennzeichnet. institutions require data security via selective de-identification of words or phrases. A semi-automated de-identification tool was developed and evaluated on different types of medical reports natively and after adapting the algorithm to the text structure. Material und MethodenMaterials and Methods A semi-automated de-identification tool was developed and evaluated for its sensitivity and specificity in detecting sensitive content in written reports. Data from 4671 pathology reports (4105 + 566 in two different formats), 2804 medical reports, 1008 operation reports, and 6223 radiology reports of 1167 patients suffering from breast cancer were de-identified. The content was itemized into four categories: direct identifiers (name, address), indirect identifiers (date of birth/operation, medical ID, etc.), medical terms, and filler words. The software was tested natively (without training) in order to establish a baseline. The reports were manually edited and the model re-trained for the next test set. After manually editing 25, 50, 100, 250, 500 and if applicable 1000 reports of each type re-training was applied.Results In the native test, 61.3 % of direct and 80.8 % of the indirect identifiers were detected. The performance (P) increased to 91.4 % (P25), 96.7 % (P50), 99.5 % (P100), 99.6 % (P250), 99.7 % (P500) and 100 % (P1000) for direct identifiers and to 93.2 % (P25), 97.9 % (P50), 97.2 % (P100), 98.9 % (P250), 99.0 % (P500) and 99.3 % (P1000) for indirect identifiers. Without training, 5.3 % of medical terms were falsely flagged as critical data. The performance increased, after training, to 4.0 % (P25), 3.6 % (P50), 4.0 % (P100), 3.7 % (P250), 4.3 % (P500), and 3.1 % (P1000). Roughly 0.1 % of filler words were falsely flagged.Conclusion Training of the developed de-identification tool continuously improved its performance. Training with roughly 100 edited reports enables reliable detection and labeling of sensitive data in different types of medical reports.

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Cohort Study of Structured Reporting Compared with Conventional Dictation

Abstract: While there are many potential benefits of structuring radiology reports, such changes cannot be assumed to improve report accuracy or completeness. Any SRS should be tested for effect on intrinsic report quality.

Cited by 118 publications

References 18 publications

Efficacy of a Checklist-Style Structured Radiology Reporting Template in Reducing Resident Misses on Cervical Spine Computed Tomography Examinations

Efficacy of a Checklist-Style Structured Radiology Reporting Template in Reducing Resident Misses on Cervical Spine Computed Tomography Examinations

Quality of narrative operative reports in pancreatic surgery

Semi-automated De-identification of German Content Sensitive Reports for Big Data Analytics

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