Top

Published in:

Open Access 01-12-2023 | Magnetic Resonance Imaging | Original Article

Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

Authors: Tobias Jorg, Moritz C. Halfmann, Gordon Arnhold, Daniel Pinto dos Santos, Roman Kloeckner, Christoph Düber, Peter Mildenberger, Florian Jungmann, Lukas Müller

Published in: Insights into Imaging | Issue 1/2023

Abstract

Background

To evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years.

Methods

We analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology.

Results

As of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes.

Conclusions

The increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR.

Key points

Structured reporting usage increased markedly since its implementation at our institution in 2016.

Mean usage for the ten most popular structured reporting templates was 77% in 2022.

Both radiologists and referring physicians preferred structured reports over free-text reports.

Our data shows that structured reporting can be successfully implemented.

We strongly encourage others to implement structured reporting at their institutions.

European Society of Radiology (ESR) (2021) paper on structured reporting in radiology European Society of Radiology (ESR). Insights Imaging 9:1–7. https://doi.org/10.1007/s13244-017-0588-8CrossRef

Dunnick NR, Langlotz CP (2008) The radiology report of the future: a summary of the 2007 intersociety conference. J Am Coll Radiol 5:626–629. https://doi.org/10.1016/j.jacr.2007.12.015CrossRefPubMed

Jorg T, Heckmann JC, Mildenberger P et al (2021) Structured reporting of CT scans of patients with trauma leads to faster, more detailed diagnoses: an experimental study. Eur J Radiol 144:109954. https://doi.org/10.1016/j.ejrad.2021.109954CrossRefPubMed

Brook OR, Brook A, Vollmer CM et al (2015) Health policy and practice: structured reporting of multiphasic CT for pancreatic cancer. Radiology 274:464–472. https://doi.org/10.1148/radiol.14140206CrossRefPubMed

Sabel BO, Plum JL, Kneidinger N et al (2017) Structured reporting of CT examinations in acute pulmonary embolism. J Cardiovasc Comput Tomogr 11:188–195. https://doi.org/10.1016/j.jcct.2017.02.008CrossRefPubMed

Wetterauer C, Winkel DJ, Federer-Gsponer JR et al (2018) Structured reporting of prostate magnetic resonance imaging improves interdisciplinary communication. Eur Urol Suppl 17:e2562. https://doi.org/10.1016/s1569-9056(18)33039-2CrossRef

Nobel JM, Kok EM, Robben SGF (2020) Redefining the structure of structured reporting in radiology. Insights Imaging 11:10. https://doi.org/10.1186/s13244-019-0831-6CrossRefPubMedPubMedCentral

Pinto Dos Santos D, Scheibl S, Arnhold G et al (2018) A proof of concept for epidemiological research using structured reporting with pulmonary embolism as a use case. Br J Radiol 91:1088. https://doi.org/10.1259/bjr.20170564CrossRef

Fink MA, Mayer VL, Schneider T et al (2022) CT angiography clot burden score from data mining of structured reports for pulmonary embolism. Radiology 302:175–184. https://doi.org/10.1148/radiol.2021211013CrossRefPubMed

10.

Roth CJ, Clunie DA, Vining DJ et al (2021) Multispecialty enterprise imaging workgroup consensus on interactive multimedia reporting current state and road to the future: HIMSS-SIIM collaborative white paper. J Digit Imaging 34:495–522. https://doi.org/10.1007/s10278-021-00450-5CrossRefPubMedPubMedCentral

11.

Pinto Dos Santos D, Hempel JM, Mildenberger P et al (2019) Structured reporting in clinical routine. Rofo 191:33–39. https://doi.org/10.1055/a-0636-3851CrossRefPubMed

12.

Nobel JM, van Geel K, Robben SGF (2022) Structured reporting in radiology: a systematic review to explore its potential. Eur Radiol 32:2837–2854. https://doi.org/10.1007/s00330-021-08327-5CrossRefPubMed

13.

Haroun RR, Al-Hihi MM, Abujudeh HH (2019) The pros and cons of structured reports. Curr Radiol Rep 7:1–4. https://doi.org/10.1007/s40134-019-0342-8CrossRef

14.

Sistrom CL (2005) Conceptual approach for the design of radiology reporting interfaces: the talking template. J Digit Imaging 18:176–187. https://doi.org/10.1007/s10278-005-5167-8CrossRefPubMedPubMedCentral

15.

Pinto dos Santos D, Kotter E (2018) Structured radiology reporting on an institutional level—benefit or new administrative burden? Ann N Y Acad Sci 1434:274–281. https://doi.org/10.1111/nyas.13741CrossRefPubMed

16.

Tran L, Wadhwa A, Mann E (2016) Implementation of structured radiology reports. J Am Coll Radiol 13:296–299. https://doi.org/10.1016/j.jacr.2015.06.040CrossRefPubMed

17.

Langlotz C (2013) IHE radiology technical framework supplement management of radiology report templates (MRRT) draft for public comment

18.

Larson DB (2018) Strategies for implementing a standardized structured radiology reporting program. Radiographics 38:1705–1716. https://doi.org/10.1148/rg.2018180040CrossRefPubMed

19.

Powell DK, Silberzweig JE (2015) State of structured reporting in radiology, a survey. Acad Radiol 22:226–233. https://doi.org/10.1016/j.acra.2014.08.014CrossRefPubMed

20.

Pinto dos Santos D, Klos G, Kloeckner R et al (2017) Development of an IHE MRRT-compliant open-source web-based reporting platform. Eur Radiol 27:424–430. https://doi.org/10.1007/s00330-016-4344-0CrossRefPubMed

21.

Radiological Society of North America (2020) RadReport Template Library. https://www.radreport.org/. Accessed 19 Dec 2022.

22.

Saris WE, Gallhofer IN (2007) Design, Evaluation, and Analysis of Questionnaires for Survey. Research Wiley Series in Survey Methodology. Wiley, Hoboken, New Jersey.

23.

Pinto Dos Santos D, Arnhold G, Mildenberger P et al (2017) Guidelines regarding §16 of the German transplantation act—initial experiences with structured reporting, RoFo fortschritte auf dem gebiet der rontgenstrahlen und der Bildgeb. Verfahren. https://doi.org/10.1055/s-0043-118129.

24.

Faggioni L, Coppola F, Ferrari R et al (2017) Usage of structured reporting in radiological practice: results from an Italian online survey. Eur Radiol 27:1934–1943. https://doi.org/10.1007/s00330-016-4553-6CrossRefPubMed

25.

Larson DB, Towbin AJ, Pryor RM et al (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267:240–250. https://doi.org/10.1148/radiol.12121502CrossRefPubMed

26.

Goldberg-Stein S, Walter WR, Amis ES et al (2017) Implementing a structured reporting initiative using a collaborative multistep approach. Curr Probl Diagn Radiol 46:295–299. https://doi.org/10.1067/j.cpradiol.2016.12.004CrossRefPubMed

27.

Hall WB, Truitt SG, Scheunemann LP et al (2009) The prevalence of clinically relevant incidental findings on chest computed tomographic angiograms ordered to diagnose pulmonary embolism. Arch Intern Med 169:1961–1965. https://doi.org/10.1001/archinternmed.2009.360CrossRefPubMed

28.

Machado LB, Dwyer AJ (2018) Multimedia-enhanced radiology reports: concept, components, and challenges. Radiographics 38:462–482CrossRefPubMed

29.

Jorg T, Mildenberger P, Stöhr F (2023) Interdisziplinäre Besprechungen. Die Radiol. https://doi.org/10.1007/s00117-023-01114-xCrossRef

30.

Bellomo R, Warrillow SJ, Reade MC (2009) Why we should be wary of single-center trials. Crit Care Med 37:3114–3119. https://doi.org/10.1097/CCM.0b013e3181bc7bd5CrossRefPubMed

Title: Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience
Authors: Tobias Jorg
Moritz C. Halfmann
Gordon Arnhold
Daniel Pinto dos Santos
Roman Kloeckner
Christoph Düber
Peter Mildenberger
Florian Jungmann
Lukas Müller
Publication date: 01-12-2023
Publisher: Springer Vienna
Keywords: Magnetic Resonance Imaging
Ultrasound
Magnetic Resonance Imaging
Computed Tomography
Computed Tomography
Ultrasound
Published in: Insights into Imaging / Issue 1/2023
Electronic ISSN: 1869-4101
DOI: https://doi.org/10.1186/s13244-023-01408-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

Abstract

Background

Methods

Results

Conclusions

Key points

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Key points

Please log in to get access to this content

Other articles of this Issue 1/2023

Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings

Mucosal healing assessment in Crohn’s disease with normalized iodine concentration from dual-energy CT enterography: comparison with endoscopy

Enhancing prediction of supraspinatus/infraspinatus tendon complex injuries through integration of deep visual features and clinical information: a multicenter two-round assessment study

Natural language processing for automatic evaluation of free-text answers — a feasibility study based on the European Diploma in Radiology examination

Preoperative prediction of Lauren classification in gastric cancer: a radiomics model based on dual-energy CT iodine map

An MRI-based grading system for preoperative risk estimation of positive surgical margin after radical prostatectomy