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Toward “Best Practices” in Radiology Reporting
Charles E. Kahn, Jr., MD, MS Medical College of Wisconsin Milwaukee, Wisconsin
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Interpreting physician
Referring physician Interpreting physician
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Interpreting physician
Technologist Imaging device Referring physician Interpreting physician CAD Decision support
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Interpreting physician
Administrator Referring physician Interpreting physician Data mining
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RSNA Reporting Committee
Reporting Workshop Special report Radiology Health Policy Statement Cardiovascular Imaging SR Joint statement of ACC, ACR, RSNA, others Reporting Templates Critical results reporting Clinical example
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RSNA Reporting Workshop
June 2008 50+ participants Radiologists Medical physicists Imaging informatics specialists Referring physicians Cardiology Oncology Surgical pathology
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Report Components Administrative information Patient identification
Clinical history Imaging technique Comparison Observations Summary or Impression Signature Consensus Statement
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Report Components Administrative information
Imaging facility Referring provider Date of service Time of service Patient identification Name Identifier (e.g., MRN or SSN) Date of birth Gender Clinical history Medical history Risk factors Allergies, if relevant Reason for exam (medical necessity)
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Report Components Time of image acquisition Imaging device
Imaging technique Time of image acquisition Imaging device Image acquisition parameters Device settings Patient positioning Interventions Contrast materials / meds Radiation dose
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Report Components Comparison Date and type of previous exams reviewed, if applicable Observations Narrative description or itemization of findings Measurements Image annotations Key images
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Report Components Key observations Recommendations
Summary or Impression Key observations Recommendations Signature Electronic signature Date and time Each responsible provider Attestation statement
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Critical Results Finding Level of criticality Person notified
“Red” “Orange” “Yellow” Person notified Date and time of notification
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Report Views “Object-oriented” reporting
One report Many views Tailor presentation to reader’s needs General practitioners Specialists Radiologists Patients DOE, Jane Report
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General Physician View
DOE, Jane Report
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Specialist View DOE, Jane Report
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Patient View DOE, Jane Report
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Modular Reporting Based on the needs of the user
Reports elements dynamically... highlighted de-emphasized combined
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Modular Reporting Body Trauma CT Chest Abdomen Template Library
Thoracic Aorta Lungs Body Trauma CT Chest Abdomen Solid organs Template Library Aortic Aneurysm Body Trauma CT Body Trauma CT Renal Mass Renal Mass Extremity Fracture Pancreatitis Gallbladder Disease
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Operational Considerations
Patient throughput Report turn-around time Documentation of service Billing Regulatory compliance Quality assurance / improvement
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Quality Metrics Quality of examination Radiologist interpretation
Technical limitations Complications Radiologist interpretation Completeness of report Discrepancy from preliminary interpretation Errors in interpretation Appropriateness Match to appropriateness criteria Outcomes information
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Technical Considerations
Reporting templates “Template for templates” Extensible Markup Language (XML)
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Information Interchange
International standards DICOM Structured Reporting HL7 Clinical Document Architecture (CDA) XML Web Services
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Consistent Language Universally recognized vocabularies SNOMED-CT
Systematized Nomenclature of Medicine Clinical Terms RadLex RSNA’s radiology lexicon
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User / Developer Partnership
Integrating the Healthcare Enterprise Forum of healthcare professionals and industry to improve information sharing Coordinates use of established standards (DICOM, HL7)
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Any questions?
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