Key words
diagnostic radiology - education - health policy and practice - QA/QC - technology
assessment - economics, medical
Introduction
Radiology is an integral part of the diagnosis and treatment of numerous diseases.
From X-ray images of the chest and skeletal system to MRI scans of the liver and prostate,
diagnostic radiology has become an essential part of the clinical routine. The trend
toward personalized imaging-based medicine increasingly requires specialized knowledge
in order to be able to answer the particular clinical questions of referring specialists.
The majority of the communication with referring clinicians typically occurs via the
report written by the radiologist. Describing and interpreting the imaging findings
and providing the probability-based differential diagnosis are the radiologist’s main
responsabilities in this context.
Radiology reports are traditionally written as a free-form narrative. The variations
in language use and vocabulary result in significant differences with respect to the
form and content of the description and the evaluation of radiological findings. Less
structured reporting may also result in important information for the further management
of a patient being incomplete or difficult to understand in the report. Such information
is then ultimately subsequently discussed and communicated in interdisciplinary meetings
and tumor conferences in a time-consuming process. It would be desirable for all relevant
information to be already provided in the primary report.
The goal of this review is therefore to provide an overview of current efforts to
improve reporting, particularly with respect to the creation of structured reports
using corresponding report templates. In addition, solutions that can already be used
in the clinical routine are presented and discussed. Also, information on current
and planned projects of the German Radiological Society (DRG) is provided.
Structured reporting
Publications evaluating and discussing radiology reports have been available since
the 1980 s [1]. The goal of all of these publications was to define quality criteria for radiology
reports, thereby helping to create high-quality reports. Many of the early publications
were only theoretical considerations regarding the formulation of free-text reports
and provided only minimal scientifically sound evidence [2]
[3]. However, there was strong consensus already early on that both report completeness
and clear formulations using terminology that is as uniform as possible are desirable.
This has since been able to be confirmed by multiple surveys of radiologists and referring
clinicians and is supported by corresponding evidence [4]
[5]
[6]
[7].
In 2007, the American College of Radiology (ACR) was one of the first major societies
to publish results of an intersociety conference clearly calling for more structured
reporting [8]. At the same time, the Radiological Society of North America (RSNA) developed and
published the RadLex, a lexicon of standardized radiology terms [9]. In addition, a technical standard for structured radiology report templates was
developed as part of a reporting initiative launched by the RSNA [10]
[11]. This initial XML-based standard was ultimately replaced by an HTML-based standard
at the initiative of IHE (Integrating the Healthcare Enterprise) and comprehensively
described in the MRRT profile (Management of Radiology Report Templates) [12]
[13]. In addition, this profile allows the integration of logic for reporting for radiologists
so that automatic classifications and recommendations can be made as a function of
individual input, for example [14]
[15].
Numerous professional societies have since spoken out in favor or structured reporting
[16]
[17]
[18]. The German Radiological Society has also addressed this topic and in 2016 defined
it as a key project for the coming years.
The additional advantages of structured reports could be shown in various studies.
For example, in oncology, there have been significant improvements in the quality
of reports and the communication of findings. Therefore, it was able to be shown that
the use of a report template based on defined criteria produced more complete and
precise reports in patients with hepatocellular carcinoma (HCC) than conventional
free-text reports [19]. Similar results have also been seen in the case of rectal and pancreatic cancer.
Multiple studies were able to independently show that the use of structured report
templates resulted in significant improvements in the comprehensibility and completeness
of reports [20]
[21]
[22]. In a study on structured reporting in pancreatic cancer, the surveyed referring
surgeons reported that only 25 – 42 % of narrative reports contained all findings
relevant for surgical planning while an increase to 69 – 98 % was seen in the case
of structured reports [22]. This was confirmed in other studies regarding reports on rectal cancer. The authors
found that the use of a corresponding report template was able to increase the percentage
of reports evaluated as optimal from 38 – 70 % [20] and the percentage of relevant information contained in the report from 38 – 98 %
[21].
It was able to be shown even outside of oncology that structured reporting results
in a relevant increase in quality. Reports for simple chest X-rays [23] as well as for complicated examinations like CT enterography [24], MRI examination of the shoulder [25], CT angiography of the pulmonary circulation [26] and MRI examination in multiple sclerosis [27] benefit greatly from the use of structured report templates. In all cases significantly
more relevant information was contained in the corresponding reports and referring
clinicians preferred the structured reports to the conventional free-text format.
Structured reporting could yield advantages even beyond the communication of findings.
For example, the automatic communication of data regarding contrast agent or patient
radiation exposure with subsequent integration in the report would be easy to achieve
given the corresponding technical implementation [28]
[29].
Despite all of these promising developments and the fact that some guidelines and
certification procedures already require structured reporting, it has not yet become
established in the clinical routine. A survey of Italian radiologists found that the
majority of those surveyed had heard of structured reporting but only a minority of
them regularly use it in their clinical work [30]. Reasons for this include the current lack of usable report templates and the minimal
availability of software solutions for structured reporting.
Current implementation in the clinical routine
Current implementation in the clinical routine
Radiology reports have always been structured to some extent. Structuring of the report
according to “clinical data”, “clinical problem”, “findings”, and “diagnosis” can
be considered the most basic form of structuring. However, structured reporting entails
more than this and requires additional structuring within the individual sections.
An early solution that was implemented in radiology information systems (RIS) is the
use of text modules. Today, this very simple solution is employed in numerous hospitals
and practices and allows the use of reusable free-text modules that can be modified
as needed.
A more structured form of reporting is the use of text modules based on established
reporting systems with precisely defined terminology. The most well-known example
of this is BI-RADS (Breast Imaging Reporting and Data System) which is already comprehensively
used in the clinical routine [31]. For this concrete example, it was able to be shown that the use of IT-supported
structured reporting has no disadvantages and increases the quality of reports [32]. There are similar reporting systems for other clinical problems, for example LI-RADS
for hepatocellular carcinoma, lung-RADS for lung tumors, and TI-RADS for thyroid nodules.
Solutions are already commercially available for some of these reporting systems and
have been integrated by the manufacturers in their RIS systems, for example ([Fig. 1a]). Other manufacturers offer products for individual clinical problems independent
of RIS systems that attempt to structure and thus support reporting by radiologists
[33]. Mint Lesion (Mint Medical GmbH, Dossenheim) is one example ([Fig. 1b]). This software supports reporting of examinations for oncological problems with
respect to correct TNM classification and the evaluation of tumor response (for example
in the study setting according to RECIST 1.1, Cheson criteria or RANO).
Fig. 1 a RIS-based reporting with BI-RADS, i-Solutions (i-Solutions Health GmbH, Mannheim)
in this case. b Reporting for oncological cases with support for TNM and evaluation of tumor response,
mint Lesion (Mint Medical GmbH, Dossenheim) in this case. c Structured reporting with Smart Radiology (Smart Reporting GmbH, München). d Generic platform for structured reporting (www.mrre.org), integrated in i-Solutions (i-Solutions Health GmbH, Mannheim in cooperation with
DFC-Systems GmbH, München) in this case.
The fact that structured reporting can be practically implemented on a larger scale
and for clinical problems for which structured reporting systems are currently not
available has also already been able to be shown. In two published studies regarding
the practical implementation of structured reporting for almost the entire clinical
routine, report templates were integrated in language recognition software. As a result,
over 90 % of all reports were structured at the end of the observation periods [34]
[35]. The commercially available software SmartRadiology (Smart Reporting GmbH, Munich),
which provides report templates for a number of different clinical problems, could
potentially be used for this purpose ([Fig. 1c]).
All currently available structured reporting products seem to have in common that
either users must enter their own institution-specific report templates or the software
manufacturer provides proprietary report templates. More generic approaches that make
it possible to adopt and use report templates from the professional societies, such
as the corresponding collection of the RSNA (www.radreport.org), have only been published as prototypes and are not widely used in the clinical
routine [36]. However, the manufacturer i-Solutions Health GmbH, Mannheim in cooperation with
DFC-Systems GmbH, Munich was able to include this generic application in their RIS
solution ([Fig. 1d]).
Limitations in routine use
Limitations in routine use
The potential advantages of structured reporting have been sufficiently described
in recent years, particularly the improvement in the quality of radiology reports
and interdisciplinary communication [37]. There are many reasons for the continued lack of implementation of structured reporting
in the clinical routine.
While standardized and structured reporting may be easy and simple to implement for
numerous clinical problems, other radiological findings require greater flexibility.
Although a report template can be useful, for example, for a preoperative staging
examination, structured reporting can be used only on a limited basis in early postoperative
situations in particular due to the wide range of possible findings. As a result,
the percentage of unstructured free text will have to remain comparatively high in
these cases.
The currently available report templates represent another significant limitation.
Although there are already over 250 report templates on the website of the RSNA (www.radreport.org) and the website in cooperation with the ESR (open.radreport.org) that have been downloaded over 4.5 million times, they are primarily in English
and can therefore only be used in Germany on a limited basis and are of heterogeneous
quality. The templates available there are primarily suggestions from individual persons
or groups. Only a small number of the templates were the result of a formal consensus
process or were created in coordination with the corresponding clinical professional
societies.
The lack of quality-assured German report templates has been addressed by the German
Radiological Society and was recently defined as a key future project. AG Informationstechnologie
(AGIT) in cooperation with the other work groups of the German Radiological Society
has begun creating a comprehensive collection of quality-assured German report templates
which are available via the website www.befundung.drg.de for free non-commercial use. The report templates, which are approved at consensus
meetings, are intended to represent a minimum standard and should not contain any
information that is irrelevant for referring clinicians but can be adapted or expanded
to meet the needs of the particular facility or special wishes of referring clinicians
([Fig. 2]). The templates should be checked regularly and updated as necessary in order to
reflect the current state of scientific knowledge and the reality of care ([Fig. 3]).
Fig. 2 Example of an IHE-MRRE-compliant template, in this case for MRI in rectal cancer
(similar templates can be found at http://www.befundung.drg.de).
Fig. 3 Process of development, publication and continued updating of the report templates.
Interested users can already download these report templates and use them locally
or process them with a free web-based tool (EasyRad, IFTM GmbH, Solingen) and copy
the generated report via intermediate storage to their own RIS.
However, comprehensive use of structured reporting probably cannot be expected in
the foreseeable future. Even though initial IT solutions for the implementation of
structured reporting are available, there continues to be a lack of commercial products
allowing efficient and simple use of the free report templates developed by the professional
societies in the daily routine in radiology. Moreover, radiologists need to be willing
to fundamentally change personal work practices in the reporting process. Furthermore,
the concern regarding an increase in the time required for reporting is not without
cause. Some studies on the topic indicate that radiologists feel that the use of report
templates is restrictive and time-consuming [38]
[39]. However, other studies were able to show that the use of corresponding templates
for traumatological examination reporting did not have a significant effect on the
time needed to create a report [40]. Particularly in situations in which a high percentage of normal findings are to
be expected, report templates with corresponding default values result in a relevant
time savings [34].
Outlook and potential
There is a vast amount of clinically relevant information in radiology reports but
it is extremely difficult or even impossible to automatically extract this information
from free-text reports. It would be theoretically conceivable to analyze reports with
Natural Language Processing (NLP) and to then further process the information contained
in the report. However, in addition to computational linguistic challenges, the problem
that certain data is only contained in some reports is often encountered [41]. Structured reporting using corresponding templates could simplify data analysis
due to the use of a primary computer-compatible format. It would also ensure that
the same data is included in all reports.
Initial approaches to make information contained in reports usable or statistically
analyzable have already been described for interventional radiology and areas in which
standardized reporting systems, such as BI-RADS, are used [42]
[43]. Therefore, databases could be filled during clinical use with structured and usually
complete data, the analysis of which could be relevant for quality assurance as well
as various research areas. As a result of the central role of radiology in almost
all clinical pathways, it would be possible to analyze the prevalence and incidence
of various pathologies as well as the disease course. This data could be analyzed
on an anonymized nationwide basis, thereby helping to answer questions that could
otherwise only be answered in larger studies.
Structured reporting with integration of data from other sources such as lab and pathology
would open up even more interesting possibilities. Initial attempts to create structured
reports in pathology have already been made in Norway [44]. If databases could be linked to such structured reports, the radiological assessment
of a tumor could be automatically compared to the surgical specimen, for example,
or interventional radiologists could receive automatic notification regarding CT-guided
biopsies. However, the required interoperable interfaces and structured data recording
in hospital information systems have not yet been sufficiently technically implemented.
Structured reporting could prove to be a key to further progress with respect to other
current topics such as machine learning and artificial intelligence. Unstructured
reports with inconsistencies are not suitable as a reliable collection of annotations,
while a structured report could provide reliable and machine-readable annotations
for all fields contained in the report template.
Conclusion
The radiology report is a central medium in the communication of findings with referring
clinicians. The conventional narrative form has various limitations with respect to
the quality of radiology reports and interdisciplinary communication that can be avoided
by structured reporting using corresponding report templates.
The German Radiological Society therefore launched an initiative with the goal of
providing free consensus-based and quality-assured German report templates in a manufacturer-independent
format.
Software manufacturers now need to support this approach and provide flexible interoperable
solutions in their IT systems.
