Abstract No. 490 - Standardized reporting of interventional radiology procedures

Abstract

Current reporting practices in IR are widely variable across different practitioners and centers. This variability results in inconsistent completeness of procedural reports, and makes it difficult to extract data for research, billing, or quality improvement purposes. This investigation sought to create standardized reports for IR procedures that address these shortcomings, and to implement these reports in an academic IR practice. Standardized report templates were created for 10 common IR procedures based on existing, SIR-approved templates, and with input from academic experts. Compliance data on the use of the standardized templates were collected at 2 and 4 months post implementation. Data were collected on the completeness of all dictated reports (with respect to inclusion of all SIR-specified information) in a 2 month time period pre-intervention and post-intervention. In addition, data were collected on time required for dictation in the pre- and post-intervention periods. Structured surveys were sent to radiology residents and fellows, and to referring clinicians to elicit their feedback on the standardized reports. Compliance with use of the standardized templates was 53% in the first 2 months post-implementation, and 62% in the second 2 months. In the pre- and post-implementation periods, reports included 57.5% and 76.7% of SIR-specified information, respectively. Reports that used the standardized templates included 99% of SIR-specified information. Pre- and post-intervention average dictation times were 4.3 minutes and 13.3 minutes, respectively. Qualitative feedback from residents and fellows was mixed, some favoring the templates and others complaining that they took longer to complete. Feedback from referring clinicians was strongly positive, with 80% expressing an overall preference for the standardized reports. Standardized reporting for interventional radiology procedures has the potential to address shortcomings of current reporting practices. The implementation of standardized reporting in an academic IR practice is feasible, and may result in more complete reports.