Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of
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SYSTEMS-LEVEL QUALITY IMPROVEMENT
Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings Allard W. Olthof 1,2
&
Anne L. M. Leusveld 1 & Jan Cees de Groot 3 & Petra M. C. Callenbach 4 & Peter M. A. van Ooijen 2,5
Received: 14 May 2020 / Accepted: 15 July 2020 # The Author(s) 2020
Abstract Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term postimplementation study compared with the short-term results. The two most often occurring categories of critical findings are “infection / inflammation” and “oncology”, corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings. Keywords Quality improvement . Radiology . Medical informatics . Communication
Introduction This article is part of the Topical Collection on Systems-Level Quality Improvement * Allard W. Olthof [email protected] 1
Department of Radiology, Treant Health Care Group, Dr. G.H. Amshoffweg 1, Hoogeveen, The Netherlands
2
Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands
3
Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, The Netherlands
4
Research Bureau, Treant Health Care Group, Dr. G.H. Amshoffweg 1, Hoogeveen, The Netherlands
5
University Medical Center Groningen, Data Science Center in Health (DASH), Machine Learning Lab, University of Groningen, Zielstraweg 2, Groningen, The Netherlands
Structured reporting is a proven concept in radiology [1]. It contributes to an improved inter-reader agreement [2], improved communication [3], guideline compliance [4] and improved economic efficiency [5].
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