Now that patients want to play a more hands-on role in their own healthcare, the quality of radiology reports has never been more important. In a new analysis published in the American Journal of Roentgenology, the authors highlighted current reporting standards and emerging best practices with special emphasis placed on patient-centric concepts in radiology reporting.
“The quality of the report serves as a manifestation of the radiologist’s contribution to patient care,” wrote lead author Marina I. Mityul, Mallinckrodt Institute of Radiology at the Washington School of Medicine in St. Louis, and colleagues. “Recently there is increasing interest in radiology reporting practices as radiologists seek to add value and make radiology more patient-centered.”
To provide more value to patients, radiologists should consider these 3 things when creating radiology reports:
1. Report language should be clear and concise to avoid confusion and anxiety to the referring physician and the patient, respectively. Using concrete analysis (percentages, unified lexicon of radiologic terms, etc.) could minimize the chances of ambiguity when reading the report.
A survey of primary care physicians revealed that after diagnostic accuracy, the single most important component of the radiology report is “clarity of language.” And another survey of patients found that “unclear or technical language” was the biggest problem identified in radiology reports.
“It is important for the radiologist to recognize that merely identifying and describing the findings using arbitrary language may not fully satisfy the report purpose,” the authors wrote. “It is incumbent on the radiologist to consider how to make his or her report more useful and intelligible to the readers by reducing unnecessary verbiage, avoiding potentially unclear abbreviations in the report, and emphasizing the most salient findings and recommendations.”
2. Radiologists should research and review both free-text reporting and structured formatting which have their advantages and drawbacks and choose the appropriate format deemed fit for that particular scenario.
Free text reporting has generally been the industry standard. The unrestricted format allows the radiologist to be selective in what they choose to add to the report and is generally more efficient. Structured formatting is also an option as it improves readability, reduces omissions of pertinent information and improves the visibility of critical findings.
A drawback of free text reporting is that variability in both the language and form may result in miscommunication between the author and reader. Also, pertinent information could be unknowingly understated in the report.
The major drawback of structured reporting primarily impacts radiologists. The author uses templates and checkboxes to populate the findings, but this affects workflow. The radiologist must pay additional visual attention to the report, which takes away from the study images. This could interfere with interpretation.
3. When delivering results, radiologists must make themselves available to both referring physicians and patients.
Communicating test results via online portals is becoming commonplace and promotes information sharing and patient participation, though traditionally a radiologist has little to no active role communicating results. However, radiologist visibility is critical to patient care. The authors suggested embedding contact information for the radiologist by telephone or electronic messaging in the report as it will give the patient personal access to the radiologist should the patient have questions regarding the report.