Structured report templates are growing in popularity, but creating those templates and implementing them in a health system requires a significant amount of time and effort. After leading such an effort at their own system, a group of specialists wrote about the experience in a new analysis published in the American Journal of Roentgenology.
The authors noted that they started the process by building organ system-based report templates for abdominal and pelvic CT and MRI examinations. These organ system-based templates “provide a consistent format and content for more routing examination indications.” They then moved to disease-specific report templates, which “provide important information for referring physician specialists to determine management.” The organ system-based reports came first, the authors explained, because results from those reports are then used when radiologists complete disease-specific reports.
The team also had to determine how, and when, to use default text in their report templates. There are outside factors to consider, they explained, including the preferences of the individuals who will be reading the report.
“Although some authors advocate for using ‘normal’ as the default text, this has the disadvantage of looking somewhat lazy and is not preferred by patients or referring physicians,” wrote author Brian R. Herts, MD, Cleveland Clinic, and colleagues. “Referring physicians and patients prefer more specific reassurances that the radiologist excluded certain pathologic conditions. There is also the problem of determining what constitutes normal for any specific organ.”
To tackle this step, the authors used a review-of-systems (ROS) approach, which uses “pertinent negative and common positive findings” to determine the template’s default text options. Pick-list text fields were also added when applicable, providing consistency while also allowing radiologists a small amount of flexibility.
“For example, for the adrenal gland findings, some prefer ‘no nodules’ and others ‘no masses,’” the authors wrote. “Both options can be made available for use in a pick list.”
The team also wanted to address default text, which can be used in report templates so frequently that radiologists accidentally leave default text in a report that does not apply to that specific patient. Their solution was to never use default text in a field “that is not an overwhelmingly probable description of that organ’s pertinent negative finding.”
Herts and colleagues concluded that their approach will “allow a higher degree of consistency across templates and facilitate their use.”
“Creating organ system- and disease-specific templates in conjunction with referring physicians makes the reporting structure familiar to all users,” they wrote.