Reinvented radiology reports seek renewed momentum

November 11, 2004

A radiologist sitting at a workstation views an abdominal CT study. Priors, matched slice-for-slice, accompany the patient's history and recent lab results. As the speech recognition reporting process begins, software evaluates the text and provides cues to speed and direct the rest of the report. The radiologist adds notes to the images that best display the pathology. Based on the radiologist's conclusion, the software offers links to similar cases and medical references.

A radiologist sitting at a workstation views an abdominal CT study. Priors, matched slice-for-slice, accompany the patient's history and recent lab results. As the speech recognition reporting process begins, software evaluates the text and provides cues to speed and direct the rest of the report. The radiologist adds notes to the images that best display the pathology. Based on the radiologist's conclusion, the software offers links to similar cases and medical references.

The next case, a CT colon study, is queued up and presented in the radiologist's preferred mode, coronal reconstructions. A CAD algorithm has already run and awaits review.

On the receiving end, the ordering physician reading the report on a modified version of the radiologist's workstation can pull up the key images, relevant notes, and links, as well as the patient's history and recent diagnostics. With a click, a patient-friendly version of the report prints out for the next office consultation.

This scenario is an improbable one today, but some radiology innovators suggest it's the way things could be done some day-and perhaps the way they should be done if radiology wants to retain its place at the clinical table. For all the training and expertise that radiologists accumulate, the radiology report is for the most part their only interface with the rest of the medical world. Their ability to lend diagnostic clarity boils down to a few hundred words that may reach the referring clinician a day or two after the initial request for imaging is made.

"The radiology report has always served partially as a PR vehicle, a chance to prove your worth to the rest of the medical enterprise," said Nancy Knight, Ph.D., a radiology historian.

In radiology's early days, the field risked becoming a hospital service rather than a medical specialty, and reports and face-to-face consultations were the most effective means of convincing clinical peers that radiology required specialization and could provide expert service.

"For most of the 20th century, referring physicians had to go to the radiology suite to see images, meet the radiologist, and have a conversation about the findings," Knight said. "With film going digital, some observers worry there's a danger of losing that contact, that a second 'crisis of identity' may be on the way."

A purely digital interaction isn't the only risk. Clinical specialties that are investing in their own imaging equipment may lose sight of radiology's expertise, and local clinical customers may eventually weigh whether to send studies to competitive radiology services in other states or countries. The radiology report, which in most respects contains the same information in the same format as it did a half-century ago, may be poised for evolution, Knight said.

Technologically, too, the time may have come.

"Despite being digital, not a lot has changed in PACS," said Robert Cooke, executive director of marketing for network systems at Fuji. "It's still benchmarked against what is possible with film. A great example of this is the use of the term 'hanging protocols.' We need to think about what's possible in the digital world and with automation."

In a fully wired healthcare world, patient information would flow back and forth from an electronic medical record through the HIS, RIS, PACS, and workstations. Anyone caring for a patient or performing diagnostic work would have at his or her fingertips a full accounting of the patient's history and current care. Taken a step further, patient data would be standardized, aggregated, and designed to be mined for best practice protocols and more efficient care delivery. Research that would take hundreds of hours of file-diving today could be completed at the touch of a button. The radiology report, the diagnostic starting point for many cases, would be a key player.

THE INNOVATORS

If the goal is to make a radiology report more valuable to its intended audience, it makes sense to first ask members of that audience what, exactly, they want. What they want, according to Dr. Annette Johnson, chief of neuroradiology at Indiana University, is accuracy, clarity, completeness, and timeliness.

In a survey of IU physicians that netted 160 responses, accuracy came out as the top priority, Johnson said. Two-thirds of respondents ranked timeliness as a top problem, although this radiology department's average is a fairly swift 12 to 13 hours. To the surprise of many radiologists, referring physicians also placed great importance on including pertinent negative findings in reports.

The survey was part of a larger ongoing project to develop structured reporting techniques and determine whether structured reporting facilitates better quality reports than traditional narrative reporting. IU residents will read neuroscience cases in free narrative, and a panel will evaluate those cases for completeness and accuracy. Three months later, half the residents will read the cases again the same way, while half will use structured reporting. The second sets of reports will be evaluated against each other and against the original round.

Indiana is a beta site for eDictation, a reporting software used in a number of private practices. Its template system is meant to simplify and streamline the reporting process, but Johnson is trying to take it further, setting up cues that will help residents and radiologists provide reports that meet their clinical colleagues' expectations for thoroughness in a more efficient way.

For MR in cases of clinically suspected stroke, for example, neuroscience faculty said they wanted to know if a study showed hemorrhage, evidence of infarct, or herniation.

"In training institutions in academic radiology especially, we might benefit from a checklist of relevant findings, so that once we decide the lesion is in the frontal lobe, then we get a list of findings descriptors. Once we decide which pathology is most likely, we get a list of possible pathologies," Johnson said. "When it's done and you say you think it's ischemia, the checklist should remind you to describe all of the relevant findings-including pertinent negatives-for the benefit of the clinician."

Johnson has completed such prompts for brain and stroke studies and says the same process could be applied to other subspecialties.

"One great advantage of structured reporting over voice recognition is that we are able to search for any abnormality or diagnosis easily within these data that are coded when entered," she said.

The Mayo Clinic took a different approach to putting tools in clinicians' hands with a homegrown image viewing system. All physicians, including radiologists, can add notes or measurements to key images they select for each case. Upon logging in, a referring physician can see the report and the key images at a glance and scroll through other medical records and previous lab and imaging reports sorted by date or body part.

Using a stripped-down radiology workstation for clinicians didn't fit the bill, said Dr. Bradley Erickson, an associate professor of radiology at Mayo. The modified clinical workstation allows more room for text instead of images and saves screens as well.

"It's common for clinicians to key up the report and images and arrange them in a workroom before meeting with the patient, so they can retrieve that presentation to view with the patient in an efficient and organized fashion," he said.

Understanding the customer's ultimate needs, however, requires flexibility.

"We radiologists tend to think we know everything physicians need to know," Erickson said. "We can diagnose a renal cancer and select the images documenting that. But a surgeon planning an approach requires more images than those that prove the diagnosis. Diagnosis is just a starting point. The imaging application must support the whole episode of care."

Centers around the country are experimenting with ways to improve reports without compromising radiologists' time:

- The ultrasound department at Brigham and Women's Hospital in Boston uses structured reporting to allow technologists to do initial work on reports, indicating, for example, whether a scan is negative or has a lesion.

- University of Wisconsin radiologists flag key images for referring physicians and also create teaching files with them.

Referring physicians like having images embedded in reports as a visual reference, according to Dr. Bruce Reiner, director of radiology research at the VA Maryland Health Care System. In a study presented at the 2004 Society for Computer Applications in Radiology meeting, Reiner and colleagues asked clinical physicians to compare traditional and structured reports with and without images. While the clinicians showed no statistically significant preference for one reporting style over the other, they uniformly preferred having images available.

THE ROADBLOCKS

While a more comprehensive radiology report could bolster radiology's image, it's a tough sell all around. Radiologists are already overloaded and suspicious of changes that could increase their workload or introduce unfamiliar tasks. Hospital administrators, who saw immediate savings with speech recognition, are skeptical of anything without an established bottom-line value. Vendors don't necessarily want to put in the time and tweaking necessary without a groundswell of demand. And referring clinicians, having never seen proof that phenomena such as structured reporting can improve patient care, may be indifferent.

Integration and structure still represent a huge hurdle, according to Cooke. As data flow around the healthcare enterprise, they tend to be reduced to what the most primitive system can handle.

"The challenge for the industry is how to make the insides of the varying systems consistent," he said.

For radiologists to have complete patient information at their fingertips in the reading room, all hospital systems must be able to contribute to and interact with some sort of detailed patient record. The workstation, meanwhile, needs to take advantage of technology to simplify radiologists' jobs: measuring areas of interest, logging the measurement in the report automatically, comparing it with priors, and so on.

Such data would be more meaningful if they were consistent, if a suspected tumor were described the same way at one institution as at another. Consistency would facilitate research and in theory improve the clarity of reports.

"Radiologists can hide in a prose report, and except for BIRADS, they don't have to give a bottom line of their clinical concern," Reiner said. "You can't hide in structured reporting, and that takes radiologists out of their comfort zone."

In the face of such inertia, it's hard to picture the day when a report that integrates full clinical details, images, and more might circulate in and out of radiology. Nonetheless, Reiner, whose small hospital department uses traditional dictation and prose reporting with no bells or whistles at all, sees the evolution of the radiology report as central to the specialty's survival.

"Radiology is being commoditized, with third-party and global outsourcing. The radiology community right now is not looking at changes because we're fat and happy," he said. "We need perceived value and quality to reinvent ourselves. As demand increases, we'll be pressured to adopt new digital technologies and build our reports around specific needs."