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Toward “Best Practices” in Radiology Reporting

Toward “Best Practices” in Radiology Reporting. Charles E. Kahn, Jr., MD, MS Medical College of Wisconsin Milwaukee, Wisconsin. Interpreting physician. Referring physician. Technologist. Imaging device. Interpreting physician. Referring physician. Decision support. CAD.

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Toward “Best Practices” in Radiology Reporting

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

  2. Interpreting physician Referring physician

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

  4. Interpreting physician Referring physician Data mining Administrator

  5. 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

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

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

  8. Report Components

  9. Report Components

  10. Report Components

  11. Report Components

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

  13. 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

  14. General Physician View DOE, Jane 123-456 Report

  15. Specialist View DOE, Jane 123-456 Report

  16. Patient View DOE, Jane 123-456 Report

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

  18. Body Trauma CT Chest Thoracic Aorta Lungs Lungs Abdomen Solid organs Modular Reporting Template Library Aortic Aneurysm Body Trauma CT Body Trauma CT Renal Mass Renal Mass Extremity Fracture Pancreatitis Gallbladder Disease

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

  20. Quality Metrics • Quality of examination • Technical limitations • Complications • Radiologist interpretation • Completeness of report • Discrepancy from preliminary interpretation • Errors in interpretation • Appropriateness • Match to appropriateness criteria • Outcomes information

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

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

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

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

  25. Any questions? kahn@mcw.edu

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