Application of standardized biomedical terminologies in radiology reporting templates

Abstract

The Radiological Society of North America RSNA has been promoting structured radiology reports by creating “best practices” reporting templates. The RSNA Reporting Template Library has been developed with the goal of integrating reusable knowledge into the clinical reporting process, which has intentionally incorporated standardized biomedical terminologies to reduce communication errors caused by term ambiguity and inconsistency in radiology reporting. To date, only a few studies have evaluated the usage and coverage of biomedical terminologies in radiology reporting. This research addresses the gap with the objectives of assessing how well standardized biomedical terminologies represent radiological knowledge as reflected by the RSNA reporting templates, and of obtaining first-hand information to guide the enhancement of both standard terminologies and RSNA reporting templates from the user's perspective. We employed the RadMap software and NCBO BioPortal Annotator to identify matching terms from RadLex® and SNOMED CT® with the terms in the templates. The RadMap mapping results show that a majority of terms in the sample reporting templates were mapped at least partially to terms in the RadLex®. The reporting templates analyzed with the BioPortal Annotator yielded 38% to 53% coverage of the standardized terminologies. The findings provide useful estimates of how well the standardized terminologies capture the concepts that appear in reporting templates. The researchers believe that standardized terminologies play an important role in radiology structured reporting, and the incorporation of standardized terminologies into reporting templates will greatly improve the quality of radiology reports.