Toward “Best Practices” in Radiology Reporting Charles E. Kahn, Jr., MD, MS Medical College of Wisconsin Milwaukee, Wisconsin

Interpreting physician Referring physician Interpreting physician

Interpreting physician Technologist Imaging device Referring physician Interpreting physician CAD Decision support

Interpreting physician Administrator Referring physician Interpreting physician Data mining

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

RSNA Reporting Workshop June 2008 50+ participants Radiologists Medical physicists Imaging informatics specialists Referring physicians Cardiology Oncology Surgical pathology

Report Components Administrative information Patient identification Clinical history Imaging technique Comparison Observations Summary or Impression Signature Consensus Statement

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)

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

Report Components  Comparison Date and type of previous exams reviewed, if applicable  Observations Narrative description or itemization of findings Measurements Image annotations Key images

Report Components   Key observations Recommendations Summary or Impression Key observations Recommendations  Signature Electronic signature Date and time Each responsible provider Attestation statement

Critical Results Finding Level of criticality Person notified “Red” “Orange” “Yellow” Person notified Date and time of notification

Report Views “Object-oriented” reporting One report Many views Tailor presentation to reader’s needs General practitioners Specialists Radiologists Patients DOE, Jane 123-456 Report

General Physician View DOE, Jane 123-456 Report

Specialist View DOE, Jane 123-456 Report

Patient View DOE, Jane 123-456 Report

Modular Reporting Based on the needs of the user Reports elements dynamically... highlighted de-emphasized combined

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

Operational Considerations Patient throughput Report turn-around time Documentation of service Billing Regulatory compliance Quality assurance / improvement

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

Technical Considerations Reporting templates “Template for templates” Extensible Markup Language (XML)

Information Interchange International standards DICOM Structured Reporting HL7 Clinical Document Architecture (CDA) XML Web Services

Consistent Language Universally recognized vocabularies SNOMED-CT Systematized Nomenclature of Medicine Clinical Terms RadLex RSNA’s radiology lexicon

User / Developer Partnership Integrating the Healthcare Enterprise Forum of healthcare professionals and industry to improve information sharing Coordinates use of established standards (DICOM, HL7)

Any questions? kahn@mcw.edu