Structured Reporting: Unique way to improve quality & productivity

For many years, structured reporting has been a goal in radiology to enhance report quality ¹. However, clinical practice results have been inconsistent, with varying opinions on structured reporting’s impact on productivity and quality.

TLDR: This article shares my experiences with structured reporting implementations. I use 'levels' of structured reporting to demonstrate why some are disappointed with the quality and productivity after implementation. I provide ways to guarantee improved quality and productivity in a structured reporting implementation.

The European Society of Radiology statement paper indicates radiologist Preston Hickey initially observed that variability in language and style prevented radiological reports from being used for further analysis ²[Link]. Today, surveys identify key reasons for adopting structured reporting, as shown below ¹[Link]. Although radiologists have mixed opinions on structured reporting, clinicians overwhelmingly choose structured reports for readability ⁴[Link].

• Standardizing reporting styles (51%)
• Improving billing accuracy (36%)
• Reducing errors (35%)
• Enhancing resident education (34%)
• Streamlining reporting systems (25%)

Different Structured Reporting Levels

Martijn Nobel usefully characterized structured reporting into Level 1 as Structured Layout and Level 2 as Structured Layout with Structured Content⁵[Link]. I expand Nobel’s characterization into four levels, as it provides insight into best practices and actionable data to improve efficiency and quality.  

• Level 0. Free text
• Level 1. Standardized Layout 
• Level 2. Standardized Layout and Structured Content
• Level 3. Standardized, Structured and Automated

Level 0 – Free Text Structured Reporting

Free text report templates are the original or conventional report templates. They continue to be used everywhere for rare or complex cases where less structure is a feature. Illustration 1 is an example of a Free Text Powerscribe template.

Level 1 – Standardized Layout Structured Reporting

A standardized layout ensures all essential elements are included. Early adopters and most (33%) adopted standardized layouts in radiology reporting¹. 

A primary motivation for a standardized approach is to maximize reimbursement. For instance, a complete abdominal ultrasound exam mandates eight elements: liver, gallbladder, bile ducts, kidneys, pancreas, spleen, inferior vena cava, and aorta.  The incomplete report is re-coded as a limited abdominal examination if any of the eight elements are missing.  Reclassifying exams as limited is not uncommon, as estimates range from 9.3 to 20.2%, with a revenue loss of 2.5-5.5%⁷ [Link].  In one study, incomplete abdominal ultrasound reports dropped from 3.1% to 0.6% after implementing some form of structured reporting⁷. 

Many standardized layouts also prepopulate with ‘normal’ findings to reduce report generation effort.  
While standardized layouts enhance consistency, they can introduce rigidity and inefficiency, especially for experienced radiologists ¹.

Level 2 – Standardized Layout AND Structured Content Structured Reports

Level 2 builds upon the standardized layout by incorporating structured content and organizing clinical information beyond organ-specific details⁵. Depending on the reporting tool (Powerscribe, M*Modal, etc.), dropdown menus, pick lists, and point-and-click supplement speech recognition to facilitate the insertion of routine, structured content.  

Level 2 implementations are less common due to IT dependencies, especially for non-technologically savvy radiologists with little free time.  

One particular use of structured content is to assist in implementing clinical decision support systems such as TI-RADS or LI-RADS. These systems standardized data and content further through clear definitions, specific terms, grading systems, or points. However, everyone who has tried an implementation can attest to the significant shortcomings of common reporting tools such as Powerscribe.   

Similar to Level 1, efficiency and rigidity can be challenges for those experienced in radiology reporting. Interestingly, structured content was occasionally associated with less accurate reports when inappropriate ‘normal’ template text was not deleted or modified. 

Level 3 – Standardized, Structured, and Automated Structured Reports

Level 3, Automation, builds upon the standardized template and structured content to prefill Findings and some Impressions to create a draft report.  Automation is in addition to macros and picklists in Level 2. In academic settings, residents or fellows often serve as manual ‘automation’ tools to create draft reports 😭.

However, dedicated software has emerged to automate the creation of draft reports. 
I use the ultrasound modality as an example, but the example applies to other modalities. An opportunity with Ultrasound exists because sonographers scan patients and often fill out worksheets. With the right tools, taking relevant information from sonographer measurements and worksheets creates an opportunity to automate the report. A sonographer provides the same ‘automation’ as the resident or fellow. With the right tools, the sonographer requires minimal effort compared to traditional methods. 

Measurement only solutions

Many sites implemented ‘partially automated’ solutions. These sites use applications from Modlink or Laurel Bridge to transfer measurements to the reporting program. My previous blog research and data collection found that 50% of fields in report templates are ‘qualitative’ versus quantitative (measurement) information¹¹. Qualitative information is everything from echogenicity to the existence of gallstones and Murphy’s sign. One point of the blog was that a measurement-only solution does not reach the productivity and quality of Level 3 implementation since it only addresses one-half of the fields in a template.  

AI, DEXA, CT and other Modalities

Although automation is most commonly implemented with Ultrasound, the second most often used modality is DEXA. DEXA is a simpler implementation since there are no worksheets for qualitative information. Automation is also possible in 3D labs, where technicians perform segmentation and measurement tasks. Coronary calcium scoring is a sample opportunity that comes to mind.  

There has been a steady increase in artificial intelligence applications that perform image analysis to create report content. These AI tools are often limited to a specific clinical application and research settings. Regardless, AI tools can be combined with software that automates the drafting of all reports in an imaging department – such software is Imorgon Medical. 

Imorgon Solution

Imorgon can improve every healthcare organization’s clinical practice reporting process to Level 3. It overcomes the auto-text and picklist limitations of existing reporting packages.  Imorgon eliminates the dictation of measurements and most qualitative data. Features enabling this include:

• Integrated Clinical Decision Support calculators eliminating web lookups
• Automatic retrieval of prior measurements and radiological reports 
• Drawings with automatic measurements
• Calculators for volumes and interval differences
• Enhanced pick lists with enhanced conditional text generation
• Integrated logic to prevent contradictions or highlight exceptions

Imorgon also ensures the successful implementation of reporting automation through:

• Enforcement of best practices through webforms/worksheets
• Measurement data mapping with guaranteed data transfer
• Template development assistance 
• 24×7 support

Imorgon tools will generate a completed draft radiological report. Imorgon is able to improve the quality and productivity missing in structured reporting today.

Conclusions for Improving Structured Reporting

Imorgon has the experience to implement and support any initiatives.  If your facility uses free text, a standardized layout, or even basic measurement transfer software, Imorgon will improve your workflow and quality of care. 

If you want a free consultation to discuss your unique clinical practice and challenges, please reach out to me. 

Andy Milkowski CEO

I am proud to have made a meaningful impact on many lives by improving the utility of diagnostic ultrasound worldwide. For over 20 years, I have been part of the diagnostic ultrasound community in various corporate roles, including leadership roles in sales, product management, and research.  Working with both committed clinicians and extremely talented scientists, we have brought new capabilities to ultrasound.  We have enabled ultrasound to provide more information and across a large habitus of patients to Radiologists – allowing for a diagnosis without follow-up exams using contrast agents or radiation.  I have been thankful for my early training and education in statistics and engineering, which has allowed me to see the ‘signal from the noise.’  

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References

1. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. Acad Radiol. 2015 Feb;22(2):226-33. doi: 10.1016/j.acra.2014.08.014. Epub 2014 Oct 23. PMID: 25442793. ↩︎
2. European Society of Radiology (ESR). ESR paper on structured reporting in radiology-update 2023. Insights Imaging. 2023 Nov 23;14(1):199. doi: 10.1186/s13244-023-01560-0. PMID: 37995019; PMCID: PMC10667169. ↩︎
3. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. Acad Radiol. 2015 Feb;22(2):226-33. doi: 10.1016/j.acra.2014.08.014. Epub 2014 Oct 23. PMID: 25442793. ↩︎
4. The Radiology Report as Seen by Radiologists and Referring Clinicians: Results of the COVER and ROVER Surveys Jan M. L. Bosmans, Joost J. Weyler, Arthur M. De Schepper, and Paul M. Parizel
   Radiology 2011 259:1, 184-195 ↩︎
5. Nobel, J.M., Kok, E.M. & Robben, S.G.F. Redefining the structure of structured reporting in radiology. Insights Imaging 11, 10 (2020). https://doi.org/10.1186/s13244-019-0831-6 ↩︎
6. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. Acad Radiol. 2015 Feb;22(2):226-33. doi: 10.1016/j.acra.2014.08.014. Epub 2014 Oct 23. PMID: 25442793. ↩︎
7. Pysarenko K, Recht M, Kim D. Structured Reporting: A Tool to Improve Reimbursement. J Am Coll Radiol. 2017 May;14(5):662-664. doi: 10.1016/j.jacr.2016.10.016. Epub 2016 Dec 24. PMID: 28027857. ↩︎
8. Pysarenko K, Recht M, Kim D. Structured Reporting: A Tool to Improve Reimbursement. J Am Coll Radiol. 2017 May;14(5):662-664. doi: 10.1016/j.jacr.2016.10.016. Epub 2016 Dec 24. PMID: 28027857. ↩︎
9. Powell DK, Silberzweig JE. State of structured reporting in radiology, a survey. Acad Radiol. 2015 Feb;22(2):226-33. doi: 10.1016/j.acra.2014.08.014. Epub 2014 Oct 23. PMID: 25442793. ↩︎
10. Nobel, J.M., Kok, E.M. & Robben, S.G.F. Redefining the structure of structured reporting in radiology. Insights Imaging 11, 10 (2020). https://doi.org/10.1186/s13244-019-0831-6 ↩︎
11. Surprising Improved Productivity with Ultrasound Worksheets (imorgon.net) ↩︎