RSNA: Structured reporting could save the day for surgeons (Part 4 of 4)

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Radiologists looking to build better relationships with surgeons should develop standardized reports based on surgeon’s needs, according to the What the Referring Physician Needs to Know session presented Nov. 28 at the 96th annual scientific meeting of the Radiological Society of North America (RSNA).

Health Imaging News shared referring physicians’ wish lists in a four-part series during RSNA week. Part 4 details surgeons’ needs.

Moderated by Mary C. Mahoney, MD, director of breast imaging at University of Cincinnati in Ohio, the four-part session queried a variety of physicians to help radiologists better understand how to meet their needs. Mahoney asked the four physicians to respond to five questions:

  • What information do you like to see in radiology reports?
  • How do you want important results communicated to you?
  • Would you like radiologists to speak to patients about clinical findings (or lack thereof) on an imaging exam?
  • How do you figure out the correct imaging exam?
  • Do you know about American College of Radiology (ACR) Appropriateness Criteria?

The ideal radiology report: A surgeon’s perspective

If radiology reports are done properly, surgeons don’t have to communicate that much with radiologists, offered Kevin P. Bethke, MD, assistant professor of clinical surgery, Northwestern University Feinberg School of Medicine in Chicago. Bethke pointed out that a ream’s worth of surgical reports equates to nearly a ream of paper. Thus, he outlined his ideal report.

A good radiology report is clear, concise and complete, he said. A standardized document builds diagnostic confidence. Bethke explained that structure reporting is key to standardization. “Templates can address the specific needs of various stakeholders.” Such stakeholder reports can store customized requirements for various clinicians.

He suggested that radiologists ask surgeons what they want on report templates. The basics are simple: anatomic detail, annotations and recommendations for future imaging of the clinical problem and incidental findings. For example, a breast surgeon requires a short patient history, answers to specific anatomical questions, a concise description of the biopsy procedure and further recommendations based on a review of images.

“[This approach] will save time for radiologists in long run and make surgeons happy,” he claimed.

Bethke identified current problems in reporting methods. “Free text is variable and may not answer the needs of the stakeholder, which makes outcomes research and analysis very time-consuming and expensive.” Errors are not uncommon, while transcription is expensive.

The surgeon also acknowledges the role of structured reporting in a larger context, pegging structured reporting as a platform for evidence-based medicine by enabling a standardized report database. He cautioned, however, that to provide real value to end users, the system should accentuate workflow and be integrated into existing information systems.

Although Bethke envisions structured reporting as a means to efficient communication, he reinforced the value of radiologists. Radiologists are an integral member of the clinical team, he said, and surgeons need their conference input as well as openness and availability to communication with patients and the surgical team.

While communication basics are a beginning, the surgeon dubbed structured reporting ‘necessary’.