Rofo 2019; 191(01): 33-39
DOI: 10.1055/a-0636-3851
Review
© Georg Thieme Verlag KG Stuttgart · New York

Structured Reporting in Clinical Routine

Artikel in mehreren Sprachen: English | deutsch
Daniel Pinto dos Santos
1   Department of Radiology, University Hospital Cologne, Germany
,
Johann-Martin Hempel
2   Department of Neuroradiology, University Hospital Tübingen, Germany
,
Peter Mildenberger
3   Department of Radiology, University Medical Center Mainz, Germany
,
Roman Klöckner
3   Department of Radiology, University Medical Center Mainz, Germany
,
Thorsten Persigehl
1   Department of Radiology, University Hospital Cologne, Germany
› Institutsangaben
Weitere Informationen

Correspondence

Dr. Daniel Pinto dos Santos
Institut für Diagnostische und Interventionelle Radiologie, Uniklinik Köln
Kerpener Str. 62
50937 Köln
Germany   
Telefon: ++ 49/1 52/56 84 68 22   

Publikationsverlauf

06. Dezember 2017

04. Mai 2018

Publikationsdatum:
13. August 2018 (online)

 

Abstract

Background The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.

Method In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.

Results The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.

Conclusion Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.

Key Points:

  • Structured reports have numerous advantages over conventional narrative reports.

  • The German Radiological Society is developing consensus-based and quality assured report templates.

  • Report templates are provided at www.befundung.drg.de under a free license.

  • Vendors are now encouraged to provide solutions for the implementation of structured reporting.

Citation Format

  • Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 – 39


#

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

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).

Zoom Image
Fig. 1a 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

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]).

Zoom Image
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).
Zoom Image
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.


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Die Autoren geben an, dass kein Interessenkonflikt besteht.

  • References

  • 1 Clinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988; 169: 825-826
  • 2 Hall FM. Language of the radiology report: primer for residents and wayward radiologists. American Journal of Roentgenology 2000; 175: 1239-1242
  • 3 Ridley LJ. Guide to the radiology report. Australasian Radiology. Blackwell Science Pty 2002; 46: 366-369
  • 4 Bosmans JML, Weyler JJ, De Schepper AM. et al. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 2011; 259: 184-195
  • 5 Johnson AJ, Chen MYM, Zapadka ME. et al. Radiology Report Clarity: A Cohort Study of Structured Reporting Compared With Conventional Dictation. JACR 2010; 7: 501-506
  • 6 Schwartz LH, Panicek DM, Berk AR. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology 2011; 260: 174-181
  • 7 Bosmans JML, Weyler JJ, Parizel PM. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. European Journal of Radiology 2009; 72: 354-358
  • 8 Dunnick NR, Langlotz CP. The radiology report of the future: a summary of the 2007 Intersociety Conference. 2008: 626-629
  • 9 Rubin DL. Creating and curating a terminology for radiology: ontology modeling and analysis. J Digit Imaging 2008; 21: 355-362
  • 10 Morgan TA, Helibrun ME, Kahn Jr CE. Reporting Initiative of the Radiological Society of North America: Progress and New Directions. Radiology 2014; 273: 642-645
  • 11 RSNA. [Internet]. rsna.org. [cited 2014 Aug 14]. Available from: Radiology Reporting Initiative. https://www.rsna.org/Reporting_Initiative.aspx
  • 12 IHE Radiology Technical Committee. IHE Radiology Technical Framework Supplement Management of Radiology Report Templates (MRRT). 2017: 1-51
  • 13 Kahn CE, Genereaux B, Langlotz CP. Conversion of Radiology Reporting Templates to the MRRT Standard. J Digit Imaging 2015; 28: 528-536
  • 14 Kahn CE. Incorporating intelligence into structured radiology reports. Law MY, Cook TS. , editors. SPIE Medical Imaging. 9039. SPIE; 2014: 90390M-90390M–6
  • 15 Towbin AJ, Hawkins CM. Use of a Web-Based Calculator and a Structured Report Generator to Improve Efficiency, Accuracy, and Consistency of Radiology Reporting. J Digit Imaging 2017; 147: 333-335
  • 16 European Society of Radiology (ESR). Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights Imaging 2011; 2: 93-96
  • 17 Kahn Jr CE, Langlotz CP, Burnside ES. et al. Toward Best Practices in Radiology Reporting. Radiology 2009; 252: 852-856
  • 18 Douglas PS, Hendel RC, Cummings JE. et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. Journal of the American College of Cardiology 2009; 53: 76-90
  • 19 Flusberg M, Ganeles J, Ekinci T. et al. Impact of a Structured Report Template on the Quality of CT and MRI Reports for Hepatocellular Carcinoma Diagnosis. Journal of the American College of Radiology 2017; 14: 1206-1211
  • 20 Sahni VA, Silveira PC, Sainani NI. et al. Impact of a Structured Report Template on the Quality of MRI Reports for Rectal Cancer Staging. American journal of roentgenology 2015; 205: 584-588
  • 21 Nörenberg D, Sommer WH, Thasler W. et al. Structured Reporting of Rectal Magnetic Resonance Imaging in Suspected Primary Rectal Cancer: Potential Benefits for Surgical Planning and Interdisciplinary Communication. Invest Radiol 2017; 52: 232-239
  • 22 Brook OR, Brook A, Vollmer CM. et al. Structured Reporting of Multiphasic CT for Pancreatic Cancer: Potential Effect on Staging and Surgical Planning. Radiology 2015; 274: 464-472
  • 23 Marcovici PA, Taylor GA. Journal Club: Structured radiology reports are more complete and more effective than unstructured reports. American journal of roentgenology 2014; 203: 1265-1271
  • 24 Wildman-Tobriner B, Allen BC, Bashir MR. et al. Structured reporting of CT enterography for inflammatory bowel disease: effect on key feature reporting, accuracy across training levels, and subjective assessment of disease by referring physicians. Abdom Radiol (NY) 2017; 1: 2
  • 25 Gassenmaier S, Armbruster M, Haasters F. et al. Structured reporting of MRI of the shoulder – improvement of report quality?. Eur Radiol 2017; 3: 35
  • 26 Sabel BO, Plum JL, Kneidinger N. et al. Structured reporting of CT examinations in acute pulmonary embolism. J Cardiovasc Comput Tomogr 2017; 11: 188-195
  • 27 Dickerson E, Davenport MS, Syed F. et al. Effect of Template Reporting of Brain MRIs for Multiple Sclerosis on Report Thoroughness and Neurologist-Rated Quality: Results of a Prospective Quality Improvement Project. J Am Coll Radiol 2017; 14: 371-379
  • 28 Goldberg-Stein S, Gutman D, Kaplun O. et al. Autopopulation of Intravenous Contrast Type and Dose in Structured Report Templates Decreases Report Addenda. J Am Coll Radiol 2017; 14: 659-661
  • 29 Lee MC, Chuang KS, Hsu TC. et al. Enhancement of Structured Reporting – an Integration Reporting Module with Radiation Dose Collection Supporting. J Med Syst 2016; 40: 852
  • 30 Faggioni L, Coppola F, Ferrari R. et al. Usage of structured reporting in radiological practice: results from an Italian online survey. Eur Radiol 2017; 27: 1934-1943
  • 31 Balleyguier C, Ayadi S, Van Nguyen K. et al. BIRADS classification in mammography. European Journal of Radiology 2007; 61: 192-194
  • 32 Segrelles JD, Medina R, Blanquer I. et al. Increasing the Efficiency on Producing Radiology Reports for Breast Cancer Diagnosis by Means of Structured Reports. A Comparative Study. Methods Inf Med 2017; 56: 248-260
  • 33 Goebel J, Hoischen J, Gramsch C. et al. Tumor response assessment: comparison between unstructured free text reporting in routine clinical workflow and computer-aided evaluation based on RECIST 1.1 criteria. J Cancer Res Clin Oncol 2017; 22: 779
  • 34 Larson DB, Towbin AJ, Pryor RM. et al. Improving Consistency in Radiology Reporting through the Use of Department-wide Standardized Structured Reporting. Radiology 2013; 267: 240-250
  • 35 Goldberg-Stein S, Walter WR, Amis ES. et al. Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach. Curr Probl Diagn Radiol 2017; 46: 295-299
  • 36 Pinto dos Santos D, Klos G, Kloeckner R. et al. Development of an IHE MRRT-compliant open-source web-based reporting platform. Eur Radiol 2017; 27: 424-430
  • 37 Bosmans JML, Neri E, Ratib O. et al. Structured reporting: a fusion reactor hungry for fuel. Insights Imaging 2015; 6: 129-132
  • 38 Ganeshan D, Duong PAT, Probyn L. et al. Structured Reporting in Radiology. Academic Radiology 2018; 25: 66-73
  • 39 Johnson AJ, Chen MYM, Swan JS. et al. Cohort study of structured reporting compared with conventional dictation. Radiology 2009; 253: 74-80
  • 40 Hanna TN, Shekhani H, Maddu K. et al. Structured report compliance: effect on audio dictation time, report length, and total radiologist study time. Emerg Radiol 2016; 23: 449-453
  • 41 Pons E, Braun LMM, Hunink MGM. et al. Natural Language Processing in Radiology: A Systematic Review. Radiology 2016; 279: 329-343
  • 42 Margolies LR, Pandey G, Horowitz ER. et al. Breast Imaging in the Era of Big Data: Structured Reporting and Data Mining. American journal of roentgenology 2016; 206: 259-264
  • 43 Durack JC. The value proposition of structured reporting in interventional radiology. American journal of roentgenology 2014; 203: 734-738
  • 44 Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol 2008; 39: 359-367

Correspondence

Dr. Daniel Pinto dos Santos
Institut für Diagnostische und Interventionelle Radiologie, Uniklinik Köln
Kerpener Str. 62
50937 Köln
Germany   
Telefon: ++ 49/1 52/56 84 68 22   

  • References

  • 1 Clinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988; 169: 825-826
  • 2 Hall FM. Language of the radiology report: primer for residents and wayward radiologists. American Journal of Roentgenology 2000; 175: 1239-1242
  • 3 Ridley LJ. Guide to the radiology report. Australasian Radiology. Blackwell Science Pty 2002; 46: 366-369
  • 4 Bosmans JML, Weyler JJ, De Schepper AM. et al. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 2011; 259: 184-195
  • 5 Johnson AJ, Chen MYM, Zapadka ME. et al. Radiology Report Clarity: A Cohort Study of Structured Reporting Compared With Conventional Dictation. JACR 2010; 7: 501-506
  • 6 Schwartz LH, Panicek DM, Berk AR. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology 2011; 260: 174-181
  • 7 Bosmans JML, Weyler JJ, Parizel PM. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. European Journal of Radiology 2009; 72: 354-358
  • 8 Dunnick NR, Langlotz CP. The radiology report of the future: a summary of the 2007 Intersociety Conference. 2008: 626-629
  • 9 Rubin DL. Creating and curating a terminology for radiology: ontology modeling and analysis. J Digit Imaging 2008; 21: 355-362
  • 10 Morgan TA, Helibrun ME, Kahn Jr CE. Reporting Initiative of the Radiological Society of North America: Progress and New Directions. Radiology 2014; 273: 642-645
  • 11 RSNA. [Internet]. rsna.org. [cited 2014 Aug 14]. Available from: Radiology Reporting Initiative. https://www.rsna.org/Reporting_Initiative.aspx
  • 12 IHE Radiology Technical Committee. IHE Radiology Technical Framework Supplement Management of Radiology Report Templates (MRRT). 2017: 1-51
  • 13 Kahn CE, Genereaux B, Langlotz CP. Conversion of Radiology Reporting Templates to the MRRT Standard. J Digit Imaging 2015; 28: 528-536
  • 14 Kahn CE. Incorporating intelligence into structured radiology reports. Law MY, Cook TS. , editors. SPIE Medical Imaging. 9039. SPIE; 2014: 90390M-90390M–6
  • 15 Towbin AJ, Hawkins CM. Use of a Web-Based Calculator and a Structured Report Generator to Improve Efficiency, Accuracy, and Consistency of Radiology Reporting. J Digit Imaging 2017; 147: 333-335
  • 16 European Society of Radiology (ESR). Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights Imaging 2011; 2: 93-96
  • 17 Kahn Jr CE, Langlotz CP, Burnside ES. et al. Toward Best Practices in Radiology Reporting. Radiology 2009; 252: 852-856
  • 18 Douglas PS, Hendel RC, Cummings JE. et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. Journal of the American College of Cardiology 2009; 53: 76-90
  • 19 Flusberg M, Ganeles J, Ekinci T. et al. Impact of a Structured Report Template on the Quality of CT and MRI Reports for Hepatocellular Carcinoma Diagnosis. Journal of the American College of Radiology 2017; 14: 1206-1211
  • 20 Sahni VA, Silveira PC, Sainani NI. et al. Impact of a Structured Report Template on the Quality of MRI Reports for Rectal Cancer Staging. American journal of roentgenology 2015; 205: 584-588
  • 21 Nörenberg D, Sommer WH, Thasler W. et al. Structured Reporting of Rectal Magnetic Resonance Imaging in Suspected Primary Rectal Cancer: Potential Benefits for Surgical Planning and Interdisciplinary Communication. Invest Radiol 2017; 52: 232-239
  • 22 Brook OR, Brook A, Vollmer CM. et al. Structured Reporting of Multiphasic CT for Pancreatic Cancer: Potential Effect on Staging and Surgical Planning. Radiology 2015; 274: 464-472
  • 23 Marcovici PA, Taylor GA. Journal Club: Structured radiology reports are more complete and more effective than unstructured reports. American journal of roentgenology 2014; 203: 1265-1271
  • 24 Wildman-Tobriner B, Allen BC, Bashir MR. et al. Structured reporting of CT enterography for inflammatory bowel disease: effect on key feature reporting, accuracy across training levels, and subjective assessment of disease by referring physicians. Abdom Radiol (NY) 2017; 1: 2
  • 25 Gassenmaier S, Armbruster M, Haasters F. et al. Structured reporting of MRI of the shoulder – improvement of report quality?. Eur Radiol 2017; 3: 35
  • 26 Sabel BO, Plum JL, Kneidinger N. et al. Structured reporting of CT examinations in acute pulmonary embolism. J Cardiovasc Comput Tomogr 2017; 11: 188-195
  • 27 Dickerson E, Davenport MS, Syed F. et al. Effect of Template Reporting of Brain MRIs for Multiple Sclerosis on Report Thoroughness and Neurologist-Rated Quality: Results of a Prospective Quality Improvement Project. J Am Coll Radiol 2017; 14: 371-379
  • 28 Goldberg-Stein S, Gutman D, Kaplun O. et al. Autopopulation of Intravenous Contrast Type and Dose in Structured Report Templates Decreases Report Addenda. J Am Coll Radiol 2017; 14: 659-661
  • 29 Lee MC, Chuang KS, Hsu TC. et al. Enhancement of Structured Reporting – an Integration Reporting Module with Radiation Dose Collection Supporting. J Med Syst 2016; 40: 852
  • 30 Faggioni L, Coppola F, Ferrari R. et al. Usage of structured reporting in radiological practice: results from an Italian online survey. Eur Radiol 2017; 27: 1934-1943
  • 31 Balleyguier C, Ayadi S, Van Nguyen K. et al. BIRADS classification in mammography. European Journal of Radiology 2007; 61: 192-194
  • 32 Segrelles JD, Medina R, Blanquer I. et al. Increasing the Efficiency on Producing Radiology Reports for Breast Cancer Diagnosis by Means of Structured Reports. A Comparative Study. Methods Inf Med 2017; 56: 248-260
  • 33 Goebel J, Hoischen J, Gramsch C. et al. Tumor response assessment: comparison between unstructured free text reporting in routine clinical workflow and computer-aided evaluation based on RECIST 1.1 criteria. J Cancer Res Clin Oncol 2017; 22: 779
  • 34 Larson DB, Towbin AJ, Pryor RM. et al. Improving Consistency in Radiology Reporting through the Use of Department-wide Standardized Structured Reporting. Radiology 2013; 267: 240-250
  • 35 Goldberg-Stein S, Walter WR, Amis ES. et al. Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach. Curr Probl Diagn Radiol 2017; 46: 295-299
  • 36 Pinto dos Santos D, Klos G, Kloeckner R. et al. Development of an IHE MRRT-compliant open-source web-based reporting platform. Eur Radiol 2017; 27: 424-430
  • 37 Bosmans JML, Neri E, Ratib O. et al. Structured reporting: a fusion reactor hungry for fuel. Insights Imaging 2015; 6: 129-132
  • 38 Ganeshan D, Duong PAT, Probyn L. et al. Structured Reporting in Radiology. Academic Radiology 2018; 25: 66-73
  • 39 Johnson AJ, Chen MYM, Swan JS. et al. Cohort study of structured reporting compared with conventional dictation. Radiology 2009; 253: 74-80
  • 40 Hanna TN, Shekhani H, Maddu K. et al. Structured report compliance: effect on audio dictation time, report length, and total radiologist study time. Emerg Radiol 2016; 23: 449-453
  • 41 Pons E, Braun LMM, Hunink MGM. et al. Natural Language Processing in Radiology: A Systematic Review. Radiology 2016; 279: 329-343
  • 42 Margolies LR, Pandey G, Horowitz ER. et al. Breast Imaging in the Era of Big Data: Structured Reporting and Data Mining. American journal of roentgenology 2016; 206: 259-264
  • 43 Durack JC. The value proposition of structured reporting in interventional radiology. American journal of roentgenology 2014; 203: 734-738
  • 44 Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol 2008; 39: 359-367

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Fig. 1a 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.
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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).
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Fig. 3 Process of development, publication and continued updating of the report templates.
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Abb. 1a RIS-basierte Befundung nach BI-RADS, hier i-Solutions (i-Solutions Health GmbH, Mannheim). b Befundung onkologischer Fragestellungen mit Hilfen zu TNM und Tumor-Response, hier mint-Lesion (Mint Medical GmbH, Dossenheim). c Strukturierte Befundung mit Smart Radiology (Smart Reporting GmbH, München). d Generische Befundungsplattform für strukturierte Befundung (www.mrre.org), hier integriert in i-Solutions (i-Solutions Health GmbH, Mannheim in Kooperation mit DFC-Systems GmbH, München).
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Abb. 2 Beispiel einer IHE-MRRT-konformen Befundvorlage, hier zur MRT bei Rektumkarzinom (Ähnliche finden sich unter http://www.befundung.drg.de).
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Abb. 3 Prozess der Erarbeitung, Veröffentlichung und kontinuierlichen Aktualisierung der Befundvorlagen.