toward “best practices” in radiology reporting
DESCRIPTION
Toward “Best Practices” in Radiology Reporting. Charles E. Kahn, Jr., MD, MS Medical College of Wisconsin Milwaukee, Wisconsin. Interpreting physician. Referring physician. Technologist. Imaging device. Interpreting physician. Referring physician. Decision support. CAD. - PowerPoint PPT PresentationTRANSCRIPT
Toward “Best Practices” in Radiology Reporting
Charles E. Kahn, Jr., MD, MSMedical College of Wisconsin
Milwaukee, Wisconsin
Referring physicianInterpreting physician
Interpreting physician Referring physician
CADDecision support
TechnologistImaging device
Interpreting physician Referring physician
Data mining
Administrator
RSNA Reporting Committee
Reporting Workshop Special report Radiology
Health Policy Statement Cardiovascular Imaging SR Joint statement of ACC, ACR, RSNA,
others Reporting Templates
Critical results reporting Clinical example
RSNA Reporting Workshop
June 2008 50+ participants
Radiologists Medical physicists Imaging informatics specialists Referring physicians
Cardiology Oncology Surgical pathology
Report Components
1) Administrative information
2) Patient identification
3) Clinical history
4) Imaging technique
5) Comparison
6) Observations
7) Summary or Impression
8) Signature
Consensus Statement
Report Components
Administrative information
• Imaging facility• Referring provider• Date of service• Time of service
Patient identification
• Name• Identifier (e.g., MRN or SSN)• Date of birth• Gender
Clinical history
• Medical history• Risk factors• Allergies, if relevant• Reason for exam (medical necessity)
Imaging technique
• Time of image acquisition• Imaging device• Image acquisition parameters
• Device settings• Patient positioning• Interventions
• Contrast materials / meds• Radiation dose
Report Components
Comparison
• Date and type of previous exams reviewed, if applicable
Observations
• Narrative description or itemization of findings
• Measurements• Image annotations• Key images
Report Components
Summary or Impression
• Key observations• Recommendations
Signature
• Electronic signature• Date and time• Each responsible provider• Attestation statement
Report Components
Critical Results
Finding Level of criticality
“Red” “Orange” “Yellow”
Person notified Date and time of notification
Report Views
DOE, Jane 123-456Report
“Object-oriented” reporting
One report Many views
Tailor presentation to reader’s needs
General practitioners
Specialists Radiologists Patients
General Physician View
DOE, Jane 123-456Report
Specialist View
DOE, Jane 123-456Report
Patient View
DOE, Jane 123-456Report
Modular Reporting
Based on the needs of the user
Reports elements dynamically... highlighted
de-emphasized
combined
Modular Reporting
Extremity Fracture
Template Library
Pancreatitis
Renal Mass
Body Trauma CT
Aortic Aneurysm
Body Trauma CT
Gallbladder Disease
Thoracic Aorta
Lungs
Body Trauma CT
Chest
AbdomenSolid organs
Lungs
Renal Mass
Operational Considerations
Patient throughput Report turn-around time Documentation of service Billing Regulatory compliance Quality assurance / improvement
Quality Metrics
Quality of examination Technical limitations Complications
Radiologist interpretation Completeness of report Discrepancy from preliminary interpretation Errors in interpretation
Appropriateness Match to appropriateness criteria Outcomes information
Technical Considerations
Reporting templates “Template for templates”
Extensible Markup Language (XML)
Information Interchange
International standards
DICOM Structured Reporting
HL7 Clinical Document Architecture (CDA)
XML Web Services
Consistent Language
Universally recognized vocabularies SNOMED-CT
Systematized Nomenclature of Medicine Clinical Terms
RadLex RSNA’s radiology lexicon
User / Developer Partnership
Integrating the Healthcare Enterprise Forum of healthcare professionals and
industry to improve information sharing Coordinates use of established standards
(DICOM, HL7)
