Setting the Standard
In today's value-driven health care environment, standardized language in structured reports allows for improved patient care.
No news is good news. That has often been radiologists' refrain when sending imaging reports to referring physicians. Radiologists frequently use language that is either overly verbose or too imprecise, making it hard for referring physicians to pinpoint actionable findings.
Trouble is, while this approach may give the radiologist more narrative freedom, it causes delays down the health care chain as referring clinicians struggle to understand what the imager was trying to convey. Referring physicians, in turn, rarely have the time or a sufficient understanding of the radiological findings to ask the radiologist to use more standard language. And so it goes.
Bucking this trend, some radiologists have opened their eyes to the quality and patient care implications of using standardized language. Lexicons specific to different body parts, such as the ACR Breast Imaging Reporting and Data System (BI-RADS®) for breast imaging, have been documented to improve upon the decades-old practice of using a wide variety of terms in a narrative report. This standard lexicon terminology may be used in a narrative report or in a more structured template.
An Organizing Principle
Since the differences between lexicons — or standardized language — and structured reports are often misunderstood, perhaps a definition of each, and how they can potentially interact with each other, is in order:
Lexicons or standard terminology. According to Priscilla Butler, MS, FACR, senior director of medical physics and special projects at ACR, "the lexicon is the language that is used in relation to a certain clinical need or interpretation that has been approved by a group of expert committees." In other words, lexicons reduce the ambiguity of radiology report content by limiting the language that can be used in a report, making it easier for referring physicians to understand the findings.
Although reports that utilize standardized language do not have to possess a template structure, they do incorporate standard words and phrases drawn from a radiology lexicon. "This ensures that when many people use the same terms, the terms mean the same thing and everyone knows exactly what the content means," explains Mythreyi Chatfield, PhD, senior director of data registries at ACR.
Structured reports. According to a study titled "Cohort Study of Structured Reporting Compared with Conventional Dictation," structured reports are those "with standardized format and phrases, with an accepted lexicon of terms." These are templates with defined and consistent formatting that incorporate drop-down menus with specific options, allowing health care providers to quickly pinpoint relevant and actionable findings.
Standardizing the language for reporting holds several advantages over less consistent terminology. According to the authors of a recent article in Radiology, lexicons "offer a more quantitative approach to quality control, are more uniform and user friendly for clinicians reading the reports, and, hopefully, reduce errors by interpreting radiologists." Although several radiology-specific lexicons exist, the first successful example was the BI-RADS lexicon.
Spurred by assertions made by the American Medical Association and others that "mammography reports too often contained unintelligible descriptions and ambiguous recommendations,"3 ACR's leadership called together a committee under the ACR Task Force on Breast Cancer to develop a system to standardize mammography terminology and reporting. This resulted in the development of BI-RADS. First published in 1992, the system contains several components, including a lexicon of descriptors, a recommended reporting structure (including final assessment categories with accompanying management recommendations), and a framework for data collection and auditing.
The success of BI-RADS paved the way for the creation of other systems based on anatomic regions, including the Liver Imaging Reporting and Data System (LI-RADS™), which has been in use for a few years; the Prostate Imaging Reporting and Data System (PI-RADS™); the Head Injury Imaging Reporting and Data System (HII-RADS), which is under development; and an as-yet-unnamed lexicon based on the lung. In addition, RSNA has developed RadLex, an ontology that contains a comprehensive list of radiology terms and classifies relationships between terms in an effort to enable accurate ordering and description of images and anatomy. One major goal of all of these systems is to reduce variation in language and cut down on reporting errors.
Although these systems apply rigorous terminology and structure to reports, they do not preclude radiologists from employing narrative writing techniques. Radiologists use BI-RADS and LI-RADS terms in reports that may not follow a structured template. "The committees working on LI-RADS and PI-RADS intend to provide suggested report templates for users to accompany the lexicon, but the templates allow for narrative sections. The narrative will capture content not completely accounted for in the template," notes Chatfield. The reason for including a narrative reporting dimension, she says, is to give clinicians the ability to report on findings that are "outside of the cookbook," or that do not appear on the template. In addition, notes Jeffrey C. Weinreb, MD, FACR, professor of diagnostic radiology at Yale School of Medicine and director of MRI at Yale New Haven Hospital, cases in which a radiologist feels the findings cannot be encapsulated by standardized language should be seen as opportunities to talk directly to the referring clinicians.
Streamlining the Process
Establishing a clear line of communication between radiologists and referring physicians by using a standardized approach is crucial to quality patient care, says Weinreb. He notes that referring clinicians do not have time to sift through narrative reports that are devoid of standardized language to find actionable information. During his work on LI-RADS, he was often surprised by how many different terms were used to describe the same finding. "When we were working on LI-RADS, we highlighted a finding on liver MRI and CT scans. I then went through the published literature and found 15 different terms for the same finding. That can't be good," says Weinreb. "Even in my own department, for this one finding, it's been hard to get everyone to use one or two terms instead of six or seven." With the advent of BI-RADS, explains Debra L. Monticciolo, MD, FACR, chair of ACR's Commission on Quality and Safety, "The lexicon coaxed radiologists away from using terms that were not included — terms that are not necessarily helpful to clinicians. It makes our reports more consistent for clinicians, a real plus in practice."
This regard for referring clinicians' needs should be a driving concern for radiologists, says Gary H. Danton, MD, PhD, chief of imaging informatics in the Department of Radiology at the University of Miami Miller School of Medicine. "During an internal quality study of clinicians and house staff, we found that when presented with the option of receiving narrative versus structured reports, clinicians overwhelmingly preferred structured reports," he says.
That type of clear communication benefits not just referring physicians but radiologist colleagues as well. "If a patient comes in and needs an additional workup, we now know what the other radiologist's intentions were," says Monticciolo. Weinreb agrees: "Radiologists forget that one of the biggest consumers of these reports are other radiologists, whether they be colleagues or radiologists at another practice." He asserts that when interpreting follow-up exams, working from reports with a structured format, "as opposed to having to decipher what a narrative report says," reduces the time it takes to locate relevant findings, as well as the chances he'll misinterpret the findings.
Apart from helping both referring clinicians and fellow radiologists better understand findings, standardized terminology and reports are also valuable when it comes to reporting on quality measures. Given that radiologists have increasingly been asked to demonstrate how their work adds value to the health care industry instead of causing a financial drag, many of the lexicon-based data systems in structured templates make quality analytics, and thus reporting, easier. Monticciolo, whose department participates in programs like the Physician Quality Reporting System, meaningful use, and the National Mammography Database, thinks that the incentives to participate in these programs will only increase. But, she says, "it's hard to get accurate metrics if you can't mine data," which is much more difficult in a narrative report.
Just as quality assurance programs can help attract business to a practice, so too can allowing patients more access to their own health data. As Weinreb explains, "Patients are increasingly demanding and getting access to their medical records and reports. In order for them to comprehend a radiology report, though, it has to be translated into language a patient can decipher. BI-RADS was groundbreaking for this." Indeed, the Mammography Quality Standards Act requires facilities to provide patients with "lay letters," composed in language patients can easily understand, soon after their appointment. Mammography reporting systems — most of which are BI-RADS licensees and use BI-RADS terminology — automatically generate these lay letters, allowing patients to become full participants in their own health care.
Radiologists increase their viability when they can provide patients and referring physicians alike with clear, straightforward reports. Although narrative reports afford radiologists creative freedom to describe findings exactly as they see fit, that freedom comes at a price. Referring clinicians often find it difficult to wade through densely written text to find actionable elements within a report, decreasing efficiency and possibly affecting the speed with which a patient is provided proper care. As radiologists determine how to reposition themselves at the center of patient care, using standardized language in structured reports can make them an invaluable addition to the health care team.
3. Burnside ES, et al. “The ACR BI-RADS® Experience: Learning from History.” JACR 2009; 6(12):851–60.
By Chris Hobson