Four simple strategies can improve the value of radiologist reports, according to an article published in the Journal of the American College of Radiology.
Assistant Professor Arun Krishnaraj, MD, and fourth year resident Suraj Kabadi, MD, both of the University of Virginia Department of Radiology and Medical Imaging, conducted a review of nearly 400 over-reads, finding that 12.4 percent had clinically significant changes—prompting their blueprint for reducing that error rate in radiology reports.
Healthcare in the U.S. has been trending towards value-based care for a decade in response to the highest expenditures when measured as a proportion of GDP. The Affordable Care Act kicked the transition into high gear, emphasizing outcome-based care and tying reimbursement to quality measures.
These changes prompted specialties to reconsider how they provide value to patients. The American College of Radiology, responded by creating a framework to measure value, called Imaging 3.0. For radiologists, tracking value begins the moment an imaging exam is ordered through the delivery of a radiology report—but there are few examples of how to apply value-based strategies in everyday care, according to the authors.
“Without a thorough understanding of the meaning of value for radiology reporting, this aspect of a radiologist’s work is difficult to improve and is often heterogeneous,” they wrote. “Typical reports, in the eyes of our referring colleagues and, ultimately, the patient, may fail to add significant value.”
Krishnaraj and Kabadi reviewed over-reads on 400 consecutive studies in order to identify how patients’ treatment plans are changed in the face of a discrepancy. After finding that more than 45 of the reports had clinically significant changes, they classified 64 percent of those reports as perceptual errors (abnormality undetected) and 36 percent as cognitive errors (incorrect diagnosis of the abnormality).
The authors compared the original interpretations to the over-reads, revealing error patterns that informed their recommendations for improving the radiology reports—with the overarching goal of mitigating error.
1. Synthesizing varied anatomic findings into a cohesive disease process
Too many reports can be boiled down to simple anatomical descriptions, reducing the role radiologists play in the diagnostic process. Radiologists are trained to evaluate images piece by piece, often resulting in a dry list of findings that the reader then attempts to synthesize.
“I would argue that this synthesis, for an stute radiologist, should occur in real-time while making the findings so that it can guide your search pattern (such as portal vein thrombosis, fluid collections, etc.),” said Kabadi. “For example, once an abnormality that looks like pancreatitis is visualized, attention should be paid to common complications associated with pancreatitis as the radiologist goes through their search pattern.”
It’s important for a radiologist to approach each study as a disease process, rather than scrutinizing the images for disparate abnormalities, only incorporating them together at the end, according to Kabadi.
2. Integration of relevant electronic health record data (aka Dig into the patient’s chart)
Including background information—such as laboratory values, operative notes and pathology reports—can provide invaluable context to a radiologist. The advent of EMR makes the inclusion of additional data easier than ever, although the authors caution readers from over-emphasizing the significance of clinical history.
“Clinical histories and physical exams are themselves not fool proof, and are often confounded by the patient's account of their own symptoms, subjective evaluations of pain on physical exams, etc.,” said Kabadi. “So for example, clinical indication may say 'Left lower quadrant pain, concern for diverticulitis' on an abdomen/pelvis CT. Immediately, the radiologist is focused specifically on looking for diverticulitis, and as such, may miss a small left kidney stone or, in a female, left ovarian pathology.”
3. Use of structured reporting (aka Structured reporting is better for everyone)
A structured report makes interpreting a radiologist’s findings more organized and predictable, in addition to giving radiologists a checklist that can guide the search for abnormalities, forcing them to look at every part of the study. In addition, structured reports have been shown to give referring physicians an increase in satisfaction ratings, according to the authors.
“I believe every radiologist should use a structured report, but not necessarily a universal structured report because we all look at images in different search patterns,” said Kabadi. “I think it is more important that each radiologist should have their own unique structured report that is tailored to how they look at the study, so that this search pattern is ensured to be followed regardless of interruptions.”
4. Forming actionable impressions (aka Make your impression an impression)
Delivering an actionable report is a major part of the Imaging Value Chain, as defined in Imaging 3.0. Steering the referring physician toward a clear course of action should be the end goal, but many impressions did not produce an actionable conclusion, according to the authors.
“Unlike any other specialty, everything a radiologist says is permanently documented on a piece of paper, and so it is very important what we say, and how we say it,” said Kabadi. “Radiologists have different approaches to how they tackle this. When it comes down to it, some unfortunately 'do not stick their necks out' at all to give their professional opinion, but would rather hedge, likely for liability reasons.”
Instead of reporting that a finding “may represent X or Y, correlate clinically,” Kabadi believes that a more effective impression would read, “This is favored to represent X. Y is considered less likely, but remains in the differential.” This points the referring physician in a direction, rather than putting the onus on the provider to “clinically correlate."
“Hedging in this manner (in an effort to avoid litigation) is ironically the most common reason why physicians get sued, because it leads to delays in diagnosis, as demonstrated in prior studies,” said Kabadi.