The radiology report is the heart of what radiologists do and the value they hold to referrers and patients. Despite this essential role, radiologists put millions of dollars in reimbursement at risk each year, as well as open themselves up for potential embarrassment, by allowing errors to slip into their reporting or forgetting key pieces. Now, practices are looking to technology and structured templates to dot every i, cross every t and optimize every report.
Reporting errors can undermine otherwise diagnostically sound interpretations by omitting or muddling important facts. Errors of laterality—for example, when an x-ray of the right hand has a report that mistakenly says left hand—can erode confidence from referrers and patients.
“The patients might be thinking, ‘Did he even look at the right study? Did he even look at my x-ray and not somebody else’s x-ray?,’” says Woojin Kim, MD, assistant professor of radiology at the Hospital of the University of Pennsylvania (UPenn) in Philadelphia. He adds that misstating patient age or sex is the error that seems to upset patients the most, judging from the calls he received during a stint as interim chief of the Division of Musculoskeletal Imaging.
Update from the RSNA Reporting Committee
Two RSNA structured reporting projects are aiming to provide a boost to reporting quality early in 2014. The first is the development of an Integrating the Healthcare Enterprise (IHE) profile for the Management of Radiology Report Templates. This standard technical format for radiology report templates provides capabilities such as menus, tables and fields that can be automatically pre-filled with information from other systems.
“It saves radiologists time when ultrasound measurements, IV contrast dose, or radiation exposure already appear in the report when it is opened,” says Curtis P. Langlotz, MD, PhD, of the department of radiology at the University of Pennsylvania in Philadelphia. Vendor adoption of the standard is expected in the coming year, he adds.
RSNA also is developing a report template exchange that radiologists can use to share their favorite templates with one another online. A prototype of the exchange can be viewed at exchange.radreport.org.
Kim makes the analogy that a report is akin to an online dating profile. You can graduate from an Ivy League school, but look fairly dumb if your profile is riddled with typographical and grammatical errors, and likewise, a report with mistakes doesn’t convey professionalism or expertise.
Failing to properly document key items can cost more than embarassment, it can cut into reimbursement. Radiologists may forget to note the administration of intravenous contrast or correctly describe the number of radiographic views. In cases where a complete abdominal ultrasound is ordered, all relevant structures must be included in the report even if findings are normal or a body part was obscured or is missing. These mistakes can lead to errors of overcoding or undercoding.
So how common are reporting errors? A few studies shed light on the topic. A study of laterality errors from the department of radiology at Massachusetts General Hospital in Boston looked at more than a million radiology reports produced over the course of a year and demonstrated that while such errors were present in just 0.00008 percent of cases, this still translated to dozens of laterality errors and was higher than self-reported estimates (Am J Roent 2009;192:W239-W244). Another study, from the University of Michigan Health System in Ann Arbor, took a broader view and looked at all significant report errors when using automatic speech recognition technology, including wrong-word substitution and nonsense phrases, and found that more than 20 percent of the reports evaluated contained potentially confusing errors (J Am Coll Radiol 2008;5:1196-99).
Another study involving nearly 13 million abdominal ultrasound reports from 37 practices revealed incomplete physician documentation in 9.3 to 20.2 percent of cases (J Am Coll Radiol 2012;9:403-8). Of the exams titled complete, only 87.4 percent actually fulfilled complete CPT criteria, and 60.6 percent of exam titles were clearly erroneous or too ambiguous to code. The bottom line, according to the authors, is that incomplete physician documentation in the reports they analyzed resulted in a professional loss of income of 2.5 to 5.5 percent.
To err is human, to fix errors gets technical
An awareness of the type and frequency