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SN Comprehensive Clinical Medicine

, Volume 1, Issue 6, pp 397–407 | Cite as

Structured Radiology Reporting: Addressing the Communication Quality Gap

  • Julian DobranowskiEmail author
  • Wieland Sommer
Imaging
Part of the following topical collections:
  1. Topical Collection on Imaging

Abstract

Ineffective communication in healthcare contributes to patient morbidity and mortality. Understanding why failures in communication occur requires an understanding of how healthcare professionals communicate and models explaining the communication process. Radiologists communicate most commonly using the radiology report. Worldwide it is estimated that billions of radiological examinations are performed annually. The quality of each radiology report can contribute to patient care either in a positive manner leading to better outcomes or can be a source of medical error. Recent articles highlight quality gaps in radiology reports related not only to accuracy but also to clarity and completeness. We review and highlight the gaps related to the quality of radiology reports and discuss strategies to improve effective communication.

Keywords

Radiology Effective communication Structured reporting Patient-centered radiology Quality 

Introduction

Medical errors are the third most common cause of death in the USA [1]. It is estimated that between 251,454 and 400,000 hospital patients die from preventable medical errors each year [2]. The need to focus on patient safety in healthcare is essential in preventing these deaths, and this was brought to light in 1999 with the Institute of Medicine’s (IOM) sentinel report, To Err is Human: Building a Safer Health System [3]. The report reveals a paradox. A system designed to meet individual healthcare needs with promises of “primum non nocere” is also the source of considerable morbidity and mortality related to medical errors.

Recent safety and error prevention studies [4, 5, 6] show that ineffective communication among healthcare professionals is a leading cause of these medical errors. This supports findings by the Joint Commission that identified communication failures as the root cause in more than 70% of sentinel events between 1995 and 2003 [7].

Radiology is not immune to communication failures [8, 9] and is at high risk for causing communication errors due to the immense and growing number of reports generated by radiologists every day. The written radiology report is the most common method of communication between radiologists and their stakeholders. In an effort to improve communication, radiology has focused on the timeliness of reporting critical and significant findings [10, 11]. However, a timely report does not address errors in transcription and interpretation of acute and non-acute findings that may prevent imminent and future harm.

Guidelines published on the quality of radiological reports highlight the need for radiologists to answer the clinical question [11, 12, 13, 14]. Stakeholders expect a report with information that will enable clinical decision-making. Despite the availability of guidelines and stakeholder expectations, variation persists in the detail and delivery of radiological reports [15, 16], and recent studies show gaps in medical imaging report completeness [17, 18, 19]. To address these gaps, radiologists must understand why they exist and radiologists must change how they are using the report as a communication tool. These gaps are decreasing the value of radiology.

This review will highlight gaps related to the quality of radiology reports. It will focus on completeness and discuss the use of structured reporting as an enabler to help narrow the gaps.

What Is Communication?

The English term “communication” has evolved from two Latin words [20], communis and communicare. The noun communis means common, communality, or sharing. The verb communicare means to make something common or to share.

Merriam-Webster’s Dictionary [21] defines communication as a process by which information is exchanged by individuals through a common system of symbols, signs, or behavior.

Communication is the process of transmitting information and common understanding from one person to another [22]. Communication is the use of words to exchange information.

The Communication Process

Many models have been developed to help understand the communication process [23].

Communication in radiology occurs in various ways, at various levels, and between various stakeholders. Limiting the discussion on communication in radiology to the written report than an appropriate model to help understand the communication process would be the “linear model of communication.” This “linear” model was described in 1948 by Shannon and Weaver [24] specifically to improve technical communication but later found broader application in the field of communication.

The model envisions communication as a one-way linear process. The common elements of every communication are the sender and the receiver. In this model, the sender encodes and transmits the message while the receiver receives and decodes the information. Factors which affect the communication process are called “noise.”

In healthcare, the “linear” model is valuable because it helps identify where communication errors can occur [25]. The model presents communication in a simple, linear fashion but the model has limitations when applied into practice. One of the criticisms of the Shannon and Weaver theory is the lack of feedback. The sender does not know if the receiver received the message or whether the received message was understood. To address these limitations, the model has been expanded over the years and new models have been proposed that address some of the limitations of this model [26].

The written radiology report is the linear transmission of information from the radiologist (sender) to the stakeholder (receiver). According to this model, the radiologist reviews the acquired images and encodes the information extracted from the images by using words. A message is created. The radiology report is the end product of the encoding. The message can now be transmitted. The radiology report is sent via fax, email, or EMR.

The stakeholder receives the message and decodes the message into information that can be used to influence clinical decision-making. The communication process is complete once the receiver accepts the information, interprets it, and understands the message (Fig. 1).
Fig. 1

Linear model of communication related to radiology

What Is Effective Communication and Ineffective Communication

Effective communication extends the concept of communication to require that transmitted content is received and understood by the stakeholder in the way it was intended.

The benefits of effective communication in healthcare [6, 27, 28, 29] have been described as follows:
  • Improved medical outcomes

  • Reduced medical errors and malpractice

  • Improved patient and physician satisfaction

  • Improved patient safety

An important goal of effective communication in radiology and healthcare in general is to enable the receiver of the information to make clinical decisions that impact patient outcomes [25].

Treatment options for various cancers are based predominantly on the stage of the cancer [30]. For stage 1, non-small cell lung cancer surgery may be the only treatment required. Stage 3 cancer may require radiation therapy, chemotherapy, and/or surgery. The information derived from a staging CT scan is critical for proper staging. Effective communication would occur when the radiology report provides all the information needed by the oncologist to choose the appropriate treatment regime.

Effective communication begins with encoding, or the skill of relaying a message in a clear, direct way that allows the receiver to correctly decode your message. To properly encode requires understanding the needs of the receiver. Decoding, another essential component of effective communication, requires the receiver to ensure that the message is fully understood.

Ineffective communication can occur when there is a faulty message [31]. The message sent does not carry the information needed by the receiver. Ineffective communication also occurs when there is a faulty understanding of the message. This can happen when the information sent in the message is missing, is unclear, or is misinterpreted by the receiver. The interpretation of the message made by the receiver is different to the intended message sent by the source. The meaning of the message is lost.

In radiology, ineffective communication can occur for a variety of reasons (noise) [32, 33]. Errors can be made during the encoding of the message, for example, typographical errors or missed words. It can also be more subtle, if, for example, the summary of the report does not focus on the important findings. A report with missing information can lead to errors during decoding if the stakeholders reach conclusions through inference. The stakeholder may assume that a certain anatomical structure that was not mentioned in the report is normal. Inference does not take into consideration that the radiologist may not have examined the structure or may have forgotten to include the positive findings related to the structure in the report.

In a radiology-centered environment, the focus of communication is on the sender, the radiologist. The radiologist has control. The message sent is what the radiologist decides to communicate.

In a patient-centered system, the focus of communication is on the receiver, the patient either directly or through the referring physician or other healthcare providers. The referring physician has control and must ensure that the sender understands what information is needed and why.

Communication in healthcare and radiology can be explained with a communication matrix (Table 1) [34]. In the ideal clinical scenario, the sender will provide 100% of the information needed by the receiver.
Table 1

The communication matrix and the information needs of the receiver

Receiver

Sender

 

Info provided

Info not provided

 

Info needed

100%

0%

Info not needed

0%

0%

Effective communication in radiology occurs when the radiologist encodes the report with information needed by the receiver (Table 2). The receiver decodes the information exactly as the radiologist intended, and the receiver can use the information to inform clinical decision-making.
Table 2

The communication matrix in radiology and the information needs of the referring physician

Receiver (referring physician)

Sender (radiologist)

 

Info provided

Info not provided

 

Info needed

100%

0%

Info not needed

0%

0%

Who Are the Stakeholders—Who Are Radiologists Communicating with?

The linear model of communication describes communication between one sender and one receiver. In healthcare systems, communication is complex [8], and it is becoming increasingly less common for the communication to be limited to only one sender and one receiver. Patients are frequently requesting and becoming important direct receivers of information.

Similarly, it is rare in radiology for the interpretive report to represent a message only between the radiologist and a single stakeholder. The report of an ER x-ray for a limb fracture will be sent to the ordering ER doctor but may be viewed by the orthopedic surgeon and the primary care physician. The report may also be viewed by the patient.

Communication of radiology reports on oncological examinations is even more complex. The radiological report of a lung cancer staging examination CT ordered by the thoracic surgeon may well end up being reviewed by over 16 stakeholders (Fig. 2) [34]. Each of the stakeholders requires specific information from the report. If all of the important information is present in the report, appropriate clinical decisions regarding the patient can be made by all stakeholders. If the information is lacking, then there are significant opportunities for errors to occur.
Fig. 2

Various stakeholders requiring the lung cancer staging radiology report

Quality and Communication—Why Is There a Communication Gap?

Quality in healthcare has various definitions. The Institute of Medicine (IOM) defines quality of care [35] as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. The Agency for Healthcare Research and Quality (AHRQ) defines quality healthcare [36] as “doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results.”

Quality can also be defined through quality elements. The IOM [35] has determined that medical care for patients should incorporate the following six elements: safe, timely, effective, efficient, equitable, and patient-centered. Additional quality elements [37] include the following: integrated, accessible, responsive, and appropriate.

A good quality report is an essential driver of patient care. As presented earlier, a poor quality report can have a significant negative impact on patient outcomes. The radiological report has an impact on all quality dimensions but especially on appropriateness, efficiency, safety, and patient-centered care.

The RAND/UCLA healthcare utilization studies have defined appropriateness of any medical intervention [38]. The indication to perform a medical procedure is appropriate when the expected health benefit (i.e., increased life expectancy, relief of pain, reduction in anxiety, and improved functional capacity) exceeds the expected negative consequences (i.e., mortality, morbidity, anxiety of anticipating the procedure, and pain produced by the procedure) by a sufficiently wide margin that the procedure is worth doing.

Research studies provide guidance on how a radiological examination should be performed and what information needs to be extracted (quality reporting elements (QREs)) from the study to make the study valuable. These quality reporting elements have a significant impact on appropriateness.

Ideally, a test is ordered using appropriateness guidelines. If the radiologist extracts and effectively and accurately communicates all quality reporting elements, then the test has true value.

The same test may be ordered appropriately, but if the radiologist reporting the test does not include all of the quality reporting elements, then the examination will be by default inappropriate because it will not provide the information needed to drive clinical decision-making.

Various studies have identified lack of information (QREs) in radiological reports [17, 18, 19, 39, 40].

Radiologists’ cancer staging examination reports, for example, for pancreatic [39] and rectal [40] cancer require quality reporting elements to be included to allow the referring physicians to decide on correct treatment methods.

In the ideal situation, 100% of the needed quality reporting elements will be provided by the radiologist in the report. The examples of pancreatic and rectal cancer highlight the extent of missing information (Table 3 and Table 4).
Table 3

Communication matrix and pancreatic cancer staging [39]

Receiver (referring physician)

Sender (radiologist)

 

Info/QRE provided

Info/QRE not provided

 

Location of primary tumor

93.9

6.1

Size of primary tumor

69.8

30.2

Nature of local spread of primary tumor beyond the pancreas

44.4

55.6

Table 4

Communication matrix and rectal cancer staging [40]

Receiver (referring physician)

Sender (radiologist)

 

Info/QRE provided

Info/QRE not provided

 

Rectal localization

76.9

23.1

Tumor length

63.5

37.5

Extramural venous invasion

7.7

92.3

Lack of information in radiology reports is not restricted to cancer imaging. Similar problems with lack of information have been identified, for example, in lumbar spine imaging [41], multiple sclerosis MRI [42], and cervical spine CT [43].

Why Is there a Communication Problem?

The expectations of the various stakeholders regarding completeness and quality of radiology reports are not being met for a variety of reasons including the following:
  1. 1.

    Evidence transfer gap

     
  2. 2.

    Insufficient clinical information

     
  3. 3.

    Lack of feedback

     

Ad 1) The evidence-based practice model as described by McMaster University [44] is composed of five steps: ask, search, appraise, apply, and evaluate.

While radiology in general is good in the ask, search, and appraise steps, challenges occur in the apply and evaluate steps. Clinical trials are performed to show the value of imaging in a particular clinical situation. The results are published/presented and incorporated into clinical practice. An example is the CT in staging of pancreatic cancer. In a controlled research environment, information from the examination is extracted by radiologists in a structured format following set protocols so that the information can be analyzed. The results are published and radiologists incorporate the use of CT in pancreatic cancer staging into clinical practice. What is lacking is the incorporation of the structured details of the interpretive process that was used in the study. This is leading to a disconnection between test evaluation and clinical practice creating an evidence transfer gap.

Ad 2) A second reason for radiology reports lacking information may be ineffective communication on the part of the referring physician and lack of clinical information on the examination requisition [45].

We can apply the communication matrix to the needs of the radiologist (Table 5). In an ideal situation, the referring physician would provide all information that the radiologist needs to decide on what the appropriate examination is and also what clinical questions need to be answered. Completeness may be a reflection of the information provided on the requisition. For example, a requisition with the only clinical information given is “lymphoma” is inadequate. To provide an informed report, the radiologist needs to know if the examination is for staging or restaging. It is important to have all relevant information related to previous surgeries or other therapies.
Table 5

The communication matrix in radiology and the information needs of the radiologist

Receiver (referring physician)

Sender (radiologist)

 

Info needed

Info not needed

 

Info provided

100%

0%

Info not provided

0%

0%

Ad 3) As previously discussed, one of the drawbacks of the “linear” communication model is lack of feedback. Feedback is essential in improving quality. The feedback intervention theory (FIT) [46] speaks of the importance of feedback in driving change. Feedback in radiology occurs between radiologists and referring doctors either on a one-to-one basis or more collectively through rounds, such as multidisciplinary tumor boards. The feedback that occurs is variable and inconsistent.

Peer review is a process that provides feedback between radiologists, and the focus of peer review in radiology has been on error detection and timeliness of communication [47, 48]. Peer review as used currently does not directly address the issue of report completeness.

To address the needs of the various stakeholders requires feedback from each of the stakeholders.

Structured Reporting and Its Role in Improving Effective Communication

Interprofessional communication [49] occurs when health providers and various stakeholders communicate with each other. In radiology, interprofessional communication is the first step to effective communication. This requires that radiologists listen to the stakeholders and embed their needs into the radiological report. Each stakeholder brings knowledge to the table. Using common language, respecting each other, and understanding expectations and limitations will allow radiologists to respond to the specific needs. This is an ongoing process that requires ongoing dialog and staying up to date. To improve the quality of radiology reports requires the use of new tools developed through multistakeholder engagement.

Over the last years, “structured reporting” has evolved as a possible solution to narrowing the communication quality gap in medicine [50]. The creation of structured reports starts with structured communication and can also include common language, lexicon, and evidence-based requirements for a complete report [34, 51].

Structured reporting can have an important role in the integration of feedback into communication in radiology. Using a multistakeholder model and allowing feedback from various stakeholders would insure that the information needed to allow clinical decision-making would be embedded in the structured reporting template during the creation of the template. This approach has been implemented by Cancer Care Ontario [52].

Structured reporting is a priority for many radiological societies, including the European Society of Radiology [53], the Radiological Society of North America [54], and other organizations such as Cancer Care Ontario [52].

Defining Structured Reporting

An increasing number of scientific articles are published [55] every year on the topic of structured reporting (Fig. 3) in various healthcare disciplines including pathology, cardiology, surgery, and radiology. Oncologic imaging is one of the main focuses of these publications, but in radiology, nearly all fields are covered including cardiovascular imaging [56], interventional radiology [57], and musculoskeletal imaging [58].
Fig. 3

Number of publications by year for PubMed search “structured reporting”

There is variation in the definition of structured reporting in these articles. Definitions range from a simple given set of subheadings all the way to synoptic reporting with discrete fields and fully analyzable data based on radiological ontologies. In view of this variation in definitions and building on the three-tier/level system of structured reporting previously published [59], a new six-level spectrum for structured reporting (Fig. 4) has been proposed [34]. Each level has clear distinguishing characteristics. This approach to defining structured reporting is helpful in understanding the current status of reporting and in planning for the future. In general, the reproducibility, the completeness, and the quality of report data for analyses increase as the level of structure in the report increases.
Fig. 4

Six levels of structured reporting [34]

Whereas these levels are shown as separate in Fig. 4, this concept displays a continuum of increasing structure in radiological reports. In clinical practice, some aspects of a report might be reported at structure level 6, i.e., PI-RADS [60] score for a prostate lesion; other aspects are reported as structure level 2. Even in synoptic reporting, structure level 6, free text remains an important option for each report, e.g., for the conclusion which takes into account previous examinations and other sources of information which are not covered in the findings section.

Although predefined specific headings and report elements for certain pathologies (e.g., pancreatic cancer) will result in more complete reports, it remains difficult to analyze the data from free text. If report data is needed for data mining or to create annotated datasets for machine learning algorithms, the most effective way to obtain the data is by synoptic reporting and discrete fields (level 6).

There are different initiatives by radiological societies which can be used for structured reporting. The American College of Radiology launched the “ACR Assist” program [61] in 2015. The core clinical components included:
  1. 1.

    Structured classification and reporting taxonomies in the form of the ACR “RADS” such as PI-RADS [60], LI-RADS [62], Lung-RADS [63], Ti-RADS [64], Bi-RADS [65], and Hi-RADS [66]

     
  2. 2.

    Care pathways/algorithms such as those found in the “Incidentiloma” white papers [67]

     
  3. 3.

    Classification and communication needs for actionable findings

     

The RADREPORT initiative [68] is a well-known initiative by the Radiological Society of North America which provides an extensive reporting library. The reports however vary significantly in levels of complexity.

Challenges for the Implementation of Structured Reporting

Arguments have been made that structured reporting takes more time and decreases radiologist efficiency [69, 70, 71, 72, 73]. It needs to be carefully evaluated which exactly takes longer. When you evaluate the typical reporting setting in a radiology department with a radiologist with 20 years of training in free-text reporting, every change in workflow will result in an initial loss of time. This issue is not about the effectiveness or efficiency of a new method or reporting system but rather a question of change management [74]. When electronic PACS was introduced into radiology departments, there was a similar argument that PACS will decrease efficiency and increase reporting time [75]: Whereas previously a chest CT had 25 printed images with PACS, this number increased to several hundred images. Although this change certainly took time in the beginning, today nobody doubts that the system of electronic archiving of images increases the efficiency of the radiologist workflow [76].

This initially requires time to change a workflow but the resulting efficiency on the long term needs to be taken into account when talking about the introduction of structured reporting. A lot of the time you spend as a radiologist during your daily routine is answering questions due to ambiguous or incomplete reports. For the ever-increasing amount of tumor boards radiologists are facing, incomplete cancer reports cause a serious problem and the radiologist in the tumor board often needs to perform a second read due to missing information. Further examples where innovative systems using structured reporting would increase the effectiveness could be follow-up studies which show no or only minor changes to the previous examination. In systems using synoptic reporting (level 6), these reports could be completely automated from the previous report.

A recent survey about the introduction of synoptic reporting in cancer pathology in different countries evaluated this question [77]. The authors’ state: “Even though SR appears to be more time-consuming in the beginning, implementation actually resulted in a significant reduction time spent on the production of the report by pathologists.” Therefore, it is also likely for radiology that the introduction of synoptic reporting will also be time-efficient on the long term.

Opportunities of Structured Reporting

Structured reporting can lead to an increase in quality of reports, higher reproducibility and standardization, increased productivity of the department, better satisfaction of referring physicians, fewer inquiries on report content, and a huge number of data from the possibility to analyze the report content [17, 18, 43, 78, 79]. The latter has further consequences for better exploitation of routine data for the gain of new knowledge in the medical field. Exploiting routine data is one of the aims of digitalization in medicine; however, this will require high data quality, reproducibility, and a format that can be analyzed.

Also, the role of machine learning will generate many new algorithms which partly automate aspects of the reading of images. However, good data quality and annotated datasets are a necessity for training of these algorithms. In order to integrate findings from automated segmentation into clinical routine, synoptic reporting will be the most likely way due to the database in the back end of synoptic reports. Further trends like the combination of radiology and pathology reports will also require a synoptic data format to provide interoperability.

The megatrend of digitalization is likely to completely change medicine and the everyday work of physicians. Data quality is a necessity for these developments, and there will be many innovations in this field which will provide optimized workflow, partly or fully automated steps of current routine, and resulting efficiency in the provision of best medical care. This will certainly be a driving force for the implementation of quality standards in radiology reporting and will aim towards synoptic reporting. However, there will also be other driving forces for the implementation and these will especially consist of governance structure.

Future Outlook—Governance and Its Role in the Implementation of Structured Reporting

The successful implementations of synoptic reporting in pathology stress the importance of governance structures in a province- or country-wide implementation. In Ontario, Canada, synoptic reporting has been rolled out between 2004 and 2012 by Cancer Care Ontario [80], which mandated this change in reporting. By the end of this period, 92% of pathology departments used the highest level of structured reporting.

Whereas a central mandate seems the easiest way for such a change management, these governance structures with the right to mandate do not exist in other healthcare systems. Further driving forces of implementing change could be reimbursement for radiologists based on report quality and standards. The question who has the right to mandate in different healthcare systems remains largely unanswered. However, the large radiological societies may serve as the driving forces and consider providing governance. The use of quality structured reports may be a consideration for future accreditation of radiology programs.

In contrast to a centralized mandate for structured reporting, the alternative would be a bottom-up approach by individual radiologists who decide to implement this in their clinical workflow. However, there are several prerequisites both for a central mandate and for the bottom-up approach to be feasible:
  1. 1.

    Templates and updated medical content: Whereas there are very good examples for classifications and templates already available by large societies, it still remains only a small fraction of radiology routine, which could be covered by these templates. Also, the effort to keep all templates updated will be enormous and needs organizational structures, high costs, and large amounts of workforce. The American Pathology Society has recently taken the ownership of the templates for pathology and will take the responsibility for creation, distribution, and updating the medical content. Rules need to be established on the creation of templates that will insure effective communication.

     
  2. 2.

    Software solutions for successful implementation: Considering the cost pressure for radiologists, it is important to leverage effectiveness. Every system for structured reporting which will take more time than the current free-text reporting will be a major obstacle and will face strong resistance to utilization. A complete integration of structured reporting into the workflow will be the only chance for broad implementation. The selection of the right template, the navigation within the templates, the amounts of additional clicks, and the interoperability of export formats need to be considered prerequisites for a successful implementation. Full integration of speech recognition is also essential since even in the most advanced synoptic reporting template, there will be a need for free text.

     

Conclusion

In radiology, despite decades of incredible technical advancements and innovation, the radiological report remained largely unchanged. There is general consensus and recognition for the need of optimizing the quality of radiological reports and improving communication. Despite many challenges, there have been significant advancements in structured reporting in radiology during recent years. Further improvement in effective communication will require a multistakeholder approach and the establishment of an appropriate governance structure.

Take-home Points

  1. 1.

    Ineffective communication in healthcare contributes to patient morbidity and mortality

     
  2. 2.

    Effective communication in radiology requires an understanding of the information required by radiologists and by the various stakeholders

     
  3. 3.

    Structured radiology reports that employ templates developed in a collaborative model with all relevant stakeholders may improve patient care

     

Notes

Compliance with Ethical Standards

Conflict of Interest

Julian Dobranowski declares to have no conflicts of interest. Wieland Sommer declares that he is the founder of “Smart Reporting,” a company for structured reporting.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Radiology, Faculty of Health SciencesMcMaster UniversityHamiltonCanada
  2. 2.Medical ImagingNiagara Health SystemSt. CatharinesCanada
  3. 3.Cancer Imaging ProgramCancer Care OntarioTorontoCanada
  4. 4.Smart Reporting GmbHMunichGermany

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