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Reports have long been a bugaboo for radiologists. It is one thing to do good work; it is quite another to get the word out to referring physicians on what great things you have done and what important findings have thereby been disclosed. It seems quite simple—just send a report to the referring physician.
Well, yes—but. First, there is getting the films together with the request and the patient's film jacket; then there is the actual review and interpretation of the examination and dictation of the report by the radiologist. Next comes the transcription of the report, the return of the report to the radiologist responsible for review and correction, if necessary, followed by retyping and a second review and signature of approval, and, finally, transmission of the report to the appropriate doctor's office or doctors' offices or, alternatively, to the appropriate nurses' station in the hospital for inclusion in the patient's medical record. Time is consumed in each of these steps.
And unless you practice in a private radiology office, many of these required functions are out of your control and are not always performed in a timely fashion. Hospital administrators may be reluctant to put sufficient monies into a system to ensure the prompt transcription and transmission of reports. After all, administrators see little return on investment from such expenditures. And when the problem of delays in the receipt of radiology reports is brought to administrators' attention, they often overlook inefficiencies in their film-file management and reporting systems and readily attribute reporting delays to "our" radiologists who, it has been said, are known to be lax in dictating and signing their reports.
Then, of course, radiologists have the further concern of getting someone to review, seriously consider, and take appropriate action based on that which is reported.
All in all, not always an efficient or effective process!
Radiologists have little trouble in dealing with studies done for clinicians who make it a habit to come to the radiology department to review their patients' studies with a radiologist. But, unfortunately, such referring physicians are a distinct minority. Radiologists are also comfortable with calling and discussing the case directly with the patient's physician or leaving a message with his or her office staff, knowing the staff is likely to assume responsibility for seeing that the physician gets the message. Such phone contact is fine in emergent and urgent situations but is obviously impractical for the more routine day-to-day practice.
On the other hand, leaving a message with a clerk at the nursing station of an impatient medical or surgical nursing unit is another matter. You just can't be confident that the message will get into the medical record or to the physician involved. And with shortened hospital stays, reports on many studies may not be transcribed until after the patient has left the hospital. These reports can accumulate in boxes in the hospital medical records department and may never be field in the patients' medical records.
I am convinced that the way out of this reporting morass lies in the digital world. We should be able to circumvent these problems with paper-less electronic reports. Once digitized reports are, in effect, levitated, they can be easily distributed to wherever they may be required. There are those who would trumpet voice recognition technology as the way out of our reporting dilemma, but I see this as only an intermediate step in our journey to reporting nirvana.
Digital radiography is being adopted by more and more practices. Digital radiographs are viewed on a monitor, which comes with an attached keyboard. All that need be done is to wed the digital radiograph with the report. Report macros—standard report formats for various imaging studies—can be prepared and individualized to suit each radiologist, much like the standard reports that are now used by some practices. Radiologists could then use the keyboard to modify the macro as required and immediately approve the report by electronic signature. The report is done, the examination is completed, and the results are immediately available. No further review is required and considerable time is saved. An electronic report is then available on the monitor when and wherever the images are viewed by whoever is viewing them. As soon as the reports are approved, the report is available to be read online or e-mailed or faxed by clerical personnel or report dispatchers to medical or surgical units and various doctors' offices, wherever the reports may be required.
From personal experience I can say that you don't have to be a great typist to accomplish this task. Using such macros, the editors in the AJR editorial office type correspondence to authors concerning manuscripts handled by the AJR. Younger radiologists are facile with computers and the use of keyboards, so typing would not pose a problem for them. It is the older radiologists who might balk, but I'm sure they could adapt. Getting rid of the hassle associated with reporting and ensuring the immediate availability of reports is a laudable goal and worth the effort required.
Now if you are looking for help in developing standard reports and macros, turn to the article by Sandeep S. Naik, Anthony Handibge, and Stephanie R. Wilson [1], who have thoroughly assessed the style and content of radiology reports. You will find their work of great help in improving your present reports as well as preparing you and your associates for the happy prospect of trouble-free, worry-free information transfer in our radiology reporting future.
References
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This article has been cited by other articles:
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  L. Berlin Replacing traditional text radiology reports with image-centric reports: a shift from epiphany to enigma? Am. J. Roentgenol., November 1, 2006; 187(5): 1156 - 1159. [Full Text] [PDF]
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 C. P. Langlotz Automatic Structuring of Radiology Reports: Harbinger of a Second Information Revolution in Radiology Radiology, July 1, 2002; 224(1): 5 - 7. [Full Text]
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L. Berlin Relying on the Radiologist Am. J. Roentgenol., July 1, 2002; 179(1): 43 - 46. [Full Text] [PDF]
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