The Same Page
Radiologists discuss the future of the profession's most fundamental product — the radiology report.
"It's like the children's game Operation, only for doctors." That's how David J. Vining, MD, professor of diagnostic radiology at the University of Texas MD Anderson Cancer Center in Houston, characterizes a new radiology reporting technology he has developed.
"Radiologists capture key images while dictating their findings," continues Vining, "and the software labels the images with coded information and renders a picture of the patient, adding images of the findings to the relevant anatomical sites. That way, radiologists can better visualize radiologic findings and relate them to the patient's overall health." This multimedia structured reporting system, called ViSion, is more image-centric than the typical text-based report.
Vining's creative approach is just one example of how radiologists are working to hone the value of the radiology report to referring physicians. For decades, imaging specialists have delivered their final reports in narrative form. This format, still in use today, gives radiologists wide latitude in describing their observations. However, referring clinicians often find it difficult to wade through paragraphs of text to find critical results that must be acted upon expeditiously.
To remedy this perceived shortcoming, in recent years there has been a movement within organized radiology to shift to a more well-defined, structured method of reporting. While easier for referring clinicians to interpret, structured reporting presents its own set of challenges to some radiologists in the form of slowed-down workflows and terminology that does not always fit clinical findings. Given the limitations of both approaches, what will the radiology report of the future look like?
The Picture of Health
Similar to Vining's more visual approach to reporting, radiologists at NYU Langone Medical Center in New York City have begun embedding rich media into some of their reports. Initiated within the past two years, the use of multimedia reports is helping to improve communication with referring clinicians and to emphasize the significance of radiology in patient care, as outlined in ACR's Imaging 3.0TM campaign, says Michael P. Recht, MD, Louis Marx Professor of Radiology and chair of the department of radiology at NYU Langone Medical Center.
"The initiative is the definition of Imaging 3.0," explains Recht. "It creates value for both referring physicians and patients. For the first time, clinicians and patients don't have to translate what the radiologist says in a report — images are automatically linked to prose, with key findings annotated and marked on the images." Since every department at NYU Langone uses an enterprise-wide electronic medical record (EMR) system to view radiology reports, Recht and his colleagues worked with the IT department to embed the multimedia elements in a report that is viewable within the EMR. Additionally, they are working to make the reports available to physicians outside of the hospital through a web portal.
NYU Langone's radiologists hired an outside vendor to develop the functionality of multimedia reports after considering the inefficiency of writing lesion measurements in lines of prose. "Nobody who deals with numbers and measurements would ever accept that as a way to present figures," Recht explains. "If you look at other fields that deal with numbers, such as the financial sector, they use tables and charts." So radiologists at NYU Langone requested that the multimedia reports include tables that track both new and old lesion measurements in addition to allowing radiologists to embed images. They have also added image annotations and are considering other enhancements, like video of exams such as ultrasounds. "We want a report that really shows referring physicians what we do and, more importantly, delivers the findings in a way that is much more user friendly," Recht says.
Andrew B. Rosenkrantz, MD, associate professor in the department of radiology at NYU Langone Medical Center, notes that for the multimedia reports to be effective, they had to be integrated into radiologists' existing workflow. To that end, radiologists partnered with the hospital's radiology information technology team and an outside vendor to develop a tool that automatically creates the multimedia report from the radiologist's standard report. "It can scan our standard report and identify the image references and just embed the images automatically," Rosenkrantz explains. "Then for the lesion table, we have macros to insert tags, and we construct the table from those tags."
NYU Langone's radiologists have created thousands of multimedia reports already, but not every case requires one. The radiologists determine whether a multimedia report is warranted; typically such a report will not be issued for a normal scan, Recht says. For cases that do warrant such multimedia, the media elements allow referring physicians to see exactly what the radiologists are highlighting in the written report. "When we see a lesion in the liver, it is very obvious to us. But when referring physicians try to look at the images, they often don't know exactly what we're talking about," Recht says. "With the multimedia reports, they don't have to guess what we're referring to. It allows them to get much more value from our imaging reports and develop better management plans for patients."
Although the format of radiology reports plays a significant role in the speed with which findings are communicated to referring physicians, it is not the only factor. ACR's Actionable Reporting Work Group, which was formed to address the potential role IT can play in communicating imaging findings, has identified three areas of actionable findings: findings that require communication and a clinical decision within minutes, hours, or days.1
Knowing which findings fit into these categories should be a top priority for any practice or department, says Lincoln L. Berland, MD, FACR, professor emeritus and vice chair for quality improvement and patient safety in the department of radiology at the University of Alabama at Birmingham and a member of the ACR Actionable Reporting Work Group. "There needs to be a local policy about what the referring physicians at a given hospital consider the most critical findings. Then radiologists must reliably communicate these critical results."
"Beyond communicating results, it is also important for radiologists to know that the referring physician has received the report, understood it, and appropriately acted upon it."
–Paul A. Larson, MD, FACR
This type of tiered system is important for a number of reasons, chief among them ensuring that radiologists do not unnecessarily disrupt referring physicians' workflow, explains Paul A. Larson, MD, FACR, radiologist with Radiology Associates of the Fox Valley in Neenah, Wis., who was chair of the ACR Actionable Reporting Work Group. "If a patient has suffered an acute stroke, there needs to be prompt communication, probably consisting of a phone call," observes Larson. However, if a patient has, say, acute appendicitis, the referring physician doesn't need to know this within a few minutes, but should be informed within an hour or so. In other words, notes Larson, "The radiologist should still contact the clinician as soon as possible — maybe by sending a page after signing off on the report — but the radiologist doesn't want to interrupt the clinician in the middle of something more important."
In the future, however, it will not be enough just to convey results in a clear manner to the right provider at the right time, notes Larson. "Beyond communicating results, it is also important for radiologists to know that the referring physician has received the report, understood it, and appropriately acted upon it," says Larson. This takes reporting one step further, creating an infrastructure around the report such that, depending on the nature of the findings, referring physicians would be pinged via text message or email if they have not at least acknowledged receipt of a report within a given time frame.
As Yogi Berra famously quipped, "It's hard to make predictions — especially about the future." No one quite knows what radiology reports will be like ten years from now. One thing, however, is certain: the technology must facilitate a linear route of communication that keeps both radiologists and referring physicians on the same page. Only then will reports realize their full potential to help patients receive the highest quality care possible.
LEARN MORE AT ACR 2015
This year's open microphone session will include a discussion of opportunities and challenges in improving information quality. Bring your questions and comments about reporting, communication, decision making, and patient care to the session on Monday.
By Chris Hobson, Imaging 3.0 content manager, with Jenny Jones, freelance writer for the ACR Bulletin
1. Larson PA, Berland LL, Griffith B, Kahn CE, Liebscher LA. Actionable findings and the role of IT support: report of the ACR Actionable Reporting Work Group. JACR 2014;11(6):552–58.