Guidelines Regarding §16 of the German Transplantation Act – Initial Experiences with Structured Reporting

Abstract

Purpose To transfer the report sheet from the guidelines regarding the German Transplantation Act to a standards-compliant report template and to evaluate it in the clinical routine. Materials and Methods The template was developed using the freely available software brackets.io. It was implemented in the clinical routine using a reporting platform developed in-house. Interfaces to the department RIS and PACS allowed for integration into the usual reporting workflow. The evaluation period was 70 days. Results Developing the template for implementation of the guidelines was possible without any difficulties. The content of the report sheet provided in the guidelines was transferred one to one. Additionally, a text field was included to allow for further remarks. In the period under review, 7 radiologists performed 44 evaluations in line with § 16 of the German Transplantation Act. Users of the template, referring physicians and the employees of the transplantation office reported a high degree of satisfaction. Conclusion Implementing report sheets that are required by law (e. g. in the guidelines regarding § 16 of the German Transplantation Act) in the clinical routine electronically is easy and achieves a high degree of acceptance. The standard supported by the German Radiological Society (IHE – "Management of radiology report templates") allows for a quick response to the growing demand for structured and standardized reporting. Key Points Citation Format

Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

“…The liver transplant evaluation template was the first to be established, in Q2 2016. For this template, we successfully implemented electronic report sheets that are required by German law for organ transplantation in clinical routine [23].…”

LI-RADS in the year 2020 – Are you already using it or still considering?

“…Im Gegensatz dazu ist LI-RADS in den aktuellen deutschen und europäischen Leitlinien noch nicht integriert. Obwohl auch im deutschsprachigen Raum organübergreifend ein klarer Trend zur strukturierten Befundung und Normierung der Terminologie erkennbar ist [12][13][14], erscheint die tatsächliche Anwendung genau dieser noch relativ zurückhaltend. Zusätzlich problematisch für die Akzeptanz im klinischen Alltag ist gegenwärtig die noch häufig wechselnde inhaltliche Versionierung von LI-RADS und hieraus resultierende Unsicherheit unter Radiologen, aber auch bei den klinischen Partnern in der Inneren Medizin, Hepatologie und Chirurgie.…”

“…In contrast, LI-RADS is not yet integrated into the current German and European guidelines. Although there is a clear trend towards structured reporting and standardization of terminology across all organs in the German-speaking world [12][13][14], the actual application still appears to be relatively limited. An additional problem for the acceptance of LI-RADS in the clinical routine is the still frequently changing versioning of LI-RADS and the resulting uncertainty among radiologists, but also among clinical partners in internal medicine, hepatology and surgery.…”