Influence of Radiology Report Format on Reading Time and Comprehension

A radiology report is the official record documenting the contribution of a radiologist to a patient's care. The use of structured reports and a common lexicon will help referring physicians better understand the contents of reports. These same features in electronic health records will enable radiologists to mine reports for utilization management information as well as form the basis for clinical investigations.

Although imaging technologies have undergone dramatic evolution over the past century, radiology reporting has remained largely static, in both content and structure. Existing free-text (prose) reports have been criticized for a number of inherent deficiencies, including inconsistencies in content, structure, organization, and nomenclature. A number of new initiatives and technologies now present the radiology community with the unique opportunity to fundamentally change the radiology report from free to structured text. These new developments include a standardized nomenclature (RadLex), automated information technologies (picture archiving and communications systems and electronic medical records), and automated data tracking and analysis software (natural-language processing). Despite the increasing availability of these tools and technologies for revolutionizing reporting, clinical, psychologic, legal, and economic challenges have collectively limited structured reporting to mammography. These challenges are most evident in the current environment of heightened expectations for improved quality, timeliness, and communication, along with increasing stress, fatigue, and malpractice concerns. In conclusion, the authors present an alternative to traditional reporting that attempts to address some of these diverse challenges while incorporating the aforementioned initiatives and technologic developments. This approach uses a graphical symbol language that is directly mapped to a standardized lexicon (RadLex) and is automatically converted into a structured hierarchical text report, which can then be much more easily searched and analyzed.

To determine hospital consultants' preferences for the format and content of radiology reports. Ninety-nine questionnaires were sent to consultant staff with responsibility for requesting ultrasound examinations. The participants were invited to rank a variety of hypothetical reports in order of preference. They were also asked whether they felt other commonly included features of a radiology report were of value. Rank data were analysed by the Friedman statistic, Fisher's multiple comparisons least significant difference test, and the Kemeny-Young method. Forty-nine responses were received. There was a preference for more detailed reports that included a clinical comment by the radiologist, for both normal and abnormal results (p<0.05). Reports presented in tables were preferred. The combination of a detailed tabular report with a radiologist's comment was the most popular single structure, preferred by 43% of respondents for normal reports and 51% for abnormal reports. Detailed reports with a radiologists' comment are preferred to briefer reports, even for normal examinations. Tabular reports are preferred to prose, with the combination of a detailed report presented in a tabular format accompanied by a radiologist's comment being the most preferred style.