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Commentary |
1 Both authors: Department of Radiology, Veterans Affairs Maryland Healthcare System, 10 N Greene St., Baltimore, MD 21201.
Received November 4, 2005; accepted after revision May 12, 2006.
B. Reiner is founder of GestureRad, which receives funding support from
Fuji Medical Systems, USA.
OBJECTIVE. Despite extraordinary advances in imaging and information technologies, the form and content of radiology reporting has changed little in the discipline's more than 100-year history. In this commentary, we outline the challenges that have confronted innovations such as speech recognition and structured reporting and call for a radical rethinking of the reporting process. By combining new applications with the expanding power of radiology and hospital information systems, the attention of the radiologist—and his or her referring colleagues—could be more focused on the image and its meaning.
CONCLUSION. One promising result of such a change in focus could be improved and more reliable communication, already an area of heightened concern in the imaging community. Moreover, such a shift away from the printed word to image-centered content could lead to benefits in shared image viewing; more streamlined and timely reporting; data mining of aggregate results; and image archives, and, ultimately, enhancement of the consultative value of the radiologist's contribution to patient care and treatment.
Keywords: communication • digital images • PACS • radiology practice • radiology reporting
Traditional prose (free-text) reports are the major and sometimes only means of communication between radiologists and referring clinicians [1]. The importance of the radiology report is amplified in the filmless practice environment, where radiologist-clinician consultations have been reduced dramatically with the widespread adoption of PACS, which provide ubiquitous access to images and reports throughout the enterprise [2]. This transition from analog to digital has led to a growth in the use of teleradiology and, in many cases, to the elimination of geographical barriers to the practice of radiology— events that have served, in some cases, to protect the traditional "turf" of the reporting radiologist. The result, however, has been a decline in direct in-person consultations at a time when the perceived value of reports has never been more important to radiologists' survival, both in an economic sense and in the more far-reaching effort to maintain the status of the diagnostic imaging specialist as a pivotal participant in patient care. Despite the clear importance of the imaging report and despite radiologists' daily work in a field defined by rapid progression of new techniques and innovative digital tools, most radiologists continue to create reports in a manner strikingly similar to that of their predecessors practicing 100 years ago [3].
The inherent limitations and inefficiencies of traditional free-text reporting are well documented [1, 4-6]. Members of the referring clinician community cite poor report content and organization as the greatest problems with radiology reporting [1]. In addition, the current reporting process is subject to multiple sources of failure and frustration, including the errors and delays associated with dictation, transcription, and delivery.
These challenges are frustrating and are compounded by the medicolegal risks associated with radiology reporting. Improper and poor communication is cited as one of the principal causes of radiology lawsuits [7-9]. One study revealed that breakdowns in communication were found to be causative factors in up to 80% of malpractice lawsuits [10]. This is a relatively recent phenomenon within radiology. Before the mid-1980s and the widespread introduction of screening mammography, lawsuits related to communication lapses between radiologists and clinicians were quite rare [11]. Since that time, the American College of Radiology (ACR) has issued communication standards emphasizing the importance of radiologist-referring physician communication for "urgent or significant unexpected findings" [12-14].
We (the collective radiology community) have not done a good job in addressing our reporting and communication shortfalls. We should aggressively look to technology and innovation for assistance in bringing these processes into the 21st century. One way to leverage technologic advancement to both improve and verify communication of emergent radiologic findings is through the introduction of more sophisticated communication and, specifically, results reporting programs within PACS or radiology information systems [15]. Improved communication and reporting software could offer the radiologist the ability to electronically transmit key imaging data in real time, with the ability to create a digital audit trail of receipt of the report by the referring clinician. This communication can take a number of forms, including text messages, e-mails requiring acknowledgment, annotated images, "sticky notes," or ".wav" files. A successful system would include the capability to automatically page or call the referring clinician of record and to record and archive the electronic two-way communication.
Although the digital revolution has transformed the processes of image acquisition, processing, storage, distribution, display, and interpretation, reporting has been largely ignored. Some gains have been realized by digital dictation and speech recognition systems, but these have focused primarily on cost savings and report timeliness. Many radiologists have resisted the transition to speech recognition out of concerns about reduced productivity and disruptions in workflow, but others report that the proactive use of templates and macros can ameliorate these concerns [16]. However, despite widespread availability and an ability to dramatically improve report timeliness, speech recognition has not significantly changed overall report content, structure, or input method (speech) used in the reporting process. The end product for both digital dictation and speech recognition remains largely the same in form and content, and both form and content have been criticized by the larger community for disorganization, ambiguity, and inconsistency.
In recent years, a few academic institutions have attempted to address these shortcomings through the adoption of computer-generated itemized reporting, a process that is usually referred to as structured reporting [17, 18]. Although structured reporting offers the theoretic benefits of improving consistency and organization, it has seen limited use within the radiology community. A number of factors may contribute to its slow adoption, including concerns over computer literacy, steep learning curves, lack of standards, and inertia. Simply stated, transitioning from free-text to structured reporting requires radiologists to undergo a proactive and deliberate process that runs counter to the one they have been accustomed to throughout their working lives.
A more important and fundamental difficulty is posed by structured reporting. The creation of a structured report separates the interpretation and reporting process into two distinct and separate steps that are commingled in the more conventional reporting process. In completing the structured report, the radiologist is tasked with compartmentalizing these overlapping intellectual pursuits in a manner that may be perceived as unconventional, inefficient, and counterintuitive. Most radiologists tend to operate in a continuous-flow mode in which images are reviewed, interpreted, and reported in a single, all-inclusive process. By partitioning these individual steps, some radiologists may sense a loss of continuity in the overall thought process and may be reluctant to learn a new reporting paradigm.
Reporting as we know it also suffers from a central disconnect that has effectively separated medical images and interpretive reports into two distinct data sets. A referring clinician reviewing a chest radiograph sees the image and makes certain observations and conclusions from the data contained there. He or she then reviews the text report and attempts to conceptually merge the imaging (picture) findings with the report (text) findings. In the somewhat free-form process of associating these separate data sources, communication errors may occur regarding the specific findings and their clinical relevance. This unlinking of image and report findings can come at either end of the reporting chain. The radiologist may be ambiguous in describing anatomy or pathology or in choice of terminology when creating the report. At the same time, the referring clinician may mistakenly focus on an entirely different perceived area of abnormality from the one on which the radiology report focuses. The result is that the perception of the picture findings and the word findings do not always match, and the interpretation of the two is often left to the eyes of the beholder.
Problems with report terminology are equally troubling, with a number of studies indicating tremendous inconsistencies and variations in the vocabulary used to describe comparable findings [19, 20]. For reports describing a common pathologic entity such as pneumonia, for example, a number of synonymous terms may be used, including infiltrate, pneumonitis, and consolidation, to name a few. Other terms may be used to describe this same finding, including air-space disease, groundglass attenuation, and poorly defined density. Although used to describe the same radiologic finding, these latter descriptive terms can lend a degree of reviewer uncertainty as to the underlying cause and its clinical significance.
Until a standardized lexicon is developed that incorporates concepts such as anatomy, pathology, technique, and morphology, reporting will remain subject to variabilities so great that comparisons of reports are often impossible between radiologists and institutions. Attempts are currently under way to develop such a standardized lexicon, the most noteworthy of which is the Radiological Society of North America's RadLex initiative [21].
Taking Radiology Reporting to the Next Level
Is there a viable solution to the problems facing radiology reporting that takes into account the needs of all interested parties? The solution, in our opinion, is relatively simple in concept. Five main pointers represent our collective vision of the direction in which radiology reporting should change. First, existing text reports must be transformed into computer-generated structured reports that offer the advantages of similar organization, structure, and terminology. By doing so, referring clinicians will be able to fully comprehend the findings in unambiguous terms, with a clear and reproducible understanding (and corresponding quantitative measures) of the clinical significance of these findings.
Second, radiology reporting should make these structured reports sufficiently flexible and be customizable by the interpreting radiologist to allow additional observations and comments that go outside of the defined framework of the report.
Third, radiologists must be reeducated in the overall interpretation process using PACS, with an emphasis on maintaining continuity (and synergy) in the individual steps of image display, perception, navigation, interpretation, and reporting. The ideal approach would be to allow the radiologist to maintain 100% of eye (and brain) contact on the imaging data set, without distractions from ancillary devices such as a keyboard, mouse, or microphone. For cross-sectional imaging studies (e.g., CT, MRI) with multiple sequences and large numbers of individual images, alternative navigational strategies and input devices must be developed that allow this approach. The possible technologies for this include a variety of controllers that have been developed for videotape gamers and for graphics design specialists, such as speech commands and an electronic stylus on a touch screen. The decoupling of image navigation and reporting from the steps of image display, processing, and interpretation clearly has a deleterious effect on radiologist productivity and workflow and, in all likelihood, also negatively affects cognition and data assimilation. By focusing the radiologist's attention on the image, this problem could be remedied.
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The fifth, and perhaps most important direction in which radiology reporting should change, relates to the concept that supporting imaging data with text reports may eventually become obsolete and unnecessary. If a radiologist can identify key images and annotate these with pertinent findings highlighted, the traditional text report may no longer be necessary (Figs. 1 and 2). Say, for example, that we develop a codified set of icons and symbols to map to the standardized lexicon that provides the annotation for pertinent findings on the image. A radiologist could draw the universal symbols for cardiomegaly, pulmonary edema, and pleural effusion directly over the areas in question in the chest radiographic image. These symbols could then become the equivalent of the text report, assuming the reviewer understands and can decode the symbols being used. At the same time, a structured report could be simultaneously and automatically computer generated (along with the marked-up image) by using handwriting recognition software for translation of the symbols into structured text. The reviewer acquires the necessary information by simply turning on the symbol overlay (or, alternatively, reviewing the same information on the structured report). Note that even the most comprehensive symbol-based reporting would work in tandem with—but not re- place—some form of additional structured reporting. Symbol-based reporting, for example, would be more difficult in complex, cross-sectional cases. But by symbol-marking only abnormal findings and then using a speech recognition-based system to generate a report, most such studies could still be interpreted effectively.
This electronic coupling of images and interpretive data also could provide an efficient and reliable means for electronic consultation and improved communication using existing technology. A radiologist reviewing a brain MR image, for example, might observe an abnormality in the brainstem and be uncertain of its cause. By capturing and annotating the key image (with a question mark, perhaps), the radiologist could electronically transmit the image to a selected colleague and, within a few minutes, receive the image back with the consultation made through the established symbol language.
This same consultation capability could be used by clinicians who want to confer with the interpreting radiologist. The referring clinician might observe a nodular density superimposed over the first rib that was not marked on the image/report. The clinician could mark the area with a question mark. The radiologist receiving the query, in turn, would mark the area in question with the symbol for calcification, denoting costochondral calcification as the source of the nodular density. Although the radiologist would have the ability to consult with text (in written or spoken form), such consultation would be largely unnecessary, and the entire consultation would be streamlined through electronic transmission of annotated images using a standardized gesture/symbol language. As we have noted in a previous publication [2], the all-automatic reporting and notification environment does carry with it the risk of increasing radiologist isolation by reducing the amount of time spent in direct collegial consultation. This has been a concern since the introduction of the first digital imaging system and the ability to send both images and reports anywhere within the medical enterprise. Electronic communication of findings and collegial communication are not, however, mutually exclusive. Radiology practices need to assess new outreach methods (rounds, cases of the day, scheduled visits) that enhance the quality of professional relationships to spotlight innovations and beneficial imaging techniques.
Limitations and Challenges
Although a system like the one proposed might be relatively easy to implement within a single, hospital-based radiology practice, the incorporation of such image-oriented reporting into a multienterprise health care system or private practice outpatient environment could prove more challenging. Such a system would almost certainly require secure but easily accessible network connections with all potential referring physicians—a daunting proposition that could increase associated costs in hardware, software, training, and support personnel. However, a working model of secure, Web services-based reporting with access to referring physicians has already been successfully integrated in several practices, including that at Massachusetts General Hospital and Brigham and Women's Hospital in Boston. An increasing number of vendors offer hosted Web-based systems, such as Veriphy by Vocada, that track, archive, and verify responses to e-mails, voice communications, faxes, and text messaging. These communication systems will become a routine part of hospital and outpatient electronic medical record systems within the next few years. Even now, the cost of such systems is dropping rapidly to become cost-effective when compared with the expenses associated with maintaining a full-time employee to communicate findings and document receipt of notification.
The security of protected patient information in such an all-electronic, image-based system (as with all Internet-facilitated health care interchanges) will almost certainly cause some potential users of new reporting technology to take a wait-and-see approach. However, a well-implemented digital communications environment can actually be much more secure than the current paper-based analog system. No element of the proposed reporting system would be more vulnerable than other types of transmitted patient information when adequately protected by virtual private networks, secure socket connections, and user authentication procedures, which are already in common use.
Perhaps the greatest challenge to the adoption of a uniform reporting system that relies heavily on images is the lack of uniform electronic standards for transmitting and viewing images. One could not expect all referring physicians within an area to be viewing imaging results on the same displays from the same vendors. Indeed, the flexible reporting environment of the future should make it possible for results to be viewed on a number of types of displays, from standard radiology workstations to personal digital assistants (PDAs) to cell phones. The importance of establishing electronic standards for display and reconstruction, as already initiated by DICOM and other groups, will be vital to this and other efforts to streamline the communication of imaging results quickly and effectively.
The implementation of a new method for reporting and communicating findings in radiology will also require that the referring physician community understand, endorse, and support the proposed changes. In an ideal world, the transition to a new reporting system would be transparent for the referring physician—essentially the same but improved in content and accessibility. However, as with all new technologies, such implementation is likely to be evolutionary rather than revolutionary, and some period of adaptation, adjustment, and associated buy-in will be needed.
Conclusion
Using existing wireless technologies (e.g., PDA or tablet PC) within the filmless medical enterprise, physicians using a system such as the one we have outlined could potentially interpret, report, and communicate via images alone. They would, in effect, be freed of the text report, which has to some extent become the albatross of radiology. The report itself would be no less important, but its delivery would be more direct, its contents less ambiguous, and the attendant possibilities for research applications and improvements almost limitless. The solution may sound overly simplistic, but the technology and ingenuity required for its execution are not far off. All that is required is a little creative thinking, progressive engineering, and a deliberate focus on images instead of words.
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