Abstract
Structured reporting is emerging as a key element of optimising radiology’s contribution to patient outcomes and ensuring the value of radiologists’ work. It is being developed and supported by many national and international radiology societies, based on the recognised need to use uniform language and structure to accurately describe radiology findings. Standardisation of report structures ensures that all relevant areas are addressed. Standardisation of terminology prevents ambiguity in reports and facilitates comparability of reports. The use of key data elements and quantified parameters in structured reports (“radiomics”) permits automatic functions (e.g. TNM staging), potential integration with other clinical parameters (e.g. laboratory results), data sharing (e.g. registries, biobanks) and data mining for research, teaching and other purposes. This article outlines the requirements for a successful structured reporting strategy (definition of content and structure, standard terminologies, tools and protocols). A potential implementation strategy is outlined. Moving from conventional prose reports to structured reporting is endorsed as a positive development, and must be an international effort, with international design and adoption of structured reporting templates that can be translated and adapted in local environments as needed. Industry involvement is key to success, based on international data standards and guidelines.Key Points• Standardisation of radiology report structure ensures completeness and comparability of reports.• Use of standardised language in reports minimises ambiguity.• Structured reporting facilitates automatic functions, integration with other clinical parameters and data sharing.• International and inter-society cooperation is key to developing successful structured report templates.• Integration with industry providers of radiology-reporting software is also crucial.
Highlights
In 2006, Michael Porter published his book BRedefining health care^ [1] and in 2009 and 2010 he published additional articles regarding creating value in health care [2, 3]
The American College of Radiology introduced Imaging 3.0TM as a strategic initiative to introduce the concept of the imaging value chain
Boland et al published about this topic in the Journal of the American College of Radiology [4, 5] and pose the question of how radiologists can add value to patient care
Summary
In 2006, Michael Porter published his book BRedefining health care^ [1] and in 2009 and 2010 he published additional articles regarding creating value in health care [2, 3]. In practice the design of a structured reporting tool is very challenging in terms of usability [19], and for many more reasons: the need to avoid human errors, the need for automatic management of dependent components of the report and the need for flexibility in importing precise image references and observations from companion reports (e.g. measurements, observations from CAD reports), and so on Such capabilities often require interoperability with other information systems such as Computerised Physician Order Entry systems (to access details of the clinical request), or Radiology Information Systems (e.g. to automatically retrieve the relevant reporting template, as well as the description of the image acquisition and image processing processes) or with the Electronic Patient Record. The usage of structured reporting should be encouraged by national societies and subspecialty societies and ideally could be part of quality audits for radiology departments
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