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

Abstract

Background To evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years. Methods We analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology. Results As of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes. Conclusions The increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR. Key points Structured reporting usage increased markedly since its implementation at our institution in 2016. Mean usage for the ten most popular structured reporting templates was 77% in 2022. Both radiologists and referring physicians preferred structured reports over free-text reports. Our data shows that structured reporting can be successfully implemented. We strongly encourage others to implement structured reporting at their institutions.

Structured reporting for efficient epidemiological and in-hospital prevalence analysis of pulmonary embolisms

“…High usage rates could be shown in our hospital for most structured reporting templates (e. g., polytrauma CT 97 %, prostate MRI 92 %, and urolithiasis CT 91 % in the year 2022). In contrast, the usage rate of the PE template (58 % in 2022) since implementation of the template in the 2018 (18 %) was relatively lower but has increased steadily [10]. Finally, SR is not equally suited for all examination types and its use at our hospital is not mandatory.…”

“…In 2016, a web-based SR platform compatible with Integrating the Health Enterprise Management of Radiology Report Templates (IHE MRRT) was developed and implemented for use in the clinical routine in our hospital [17]. Since then, numerous templates for various types of examinations in the ultrasound, CT, and MRI modalities have been able to be developed and implemented [10]. The reporting template for CT angiography to rule out pulmonary embolism was implemented in the clinical routine in the third quarter of 2018.…”

“…This could also be explicitly proven for PE CT examinations [9]. Both clinical referring physicians and radiologists prefer structured reports compared to free-text reports [10].…”

“…However, SR has not yet been able to become established in the clinical routine in spite of the numerous advantages. Usage is low in most radiology departments [10]. This is probably due to difficulties that can occur when implementing SR.…”

A novel reporting workflow for automated integration of artificial intelligence results into structured radiology reports

“…At our department, an IHE-MRRT-compliant web-based SR platform, which is fully connected to the radiology information system, was first introduced into clinical routine in 2016 [ 23 ]. Since then, reporting templates for various examination types in different imaging modalities have been developed and established in the workflow [ 24 ].…”