For all its high-tech gadgets, tools, prompts, aids and reminders, the modern radiology report really isn’t all that different from the first of its kind, rendered as a longhand note.
“The X ray shows plainly that there is no stone of an appreciable size in the kidney,” reported Dr. William Morton of the New York Post-Graduate Medical School and Hospital to Dr. Leopold Stieglitz, a Park Avenue physician, in 1896. “I only got the negative today and could not therefore report earlier. The picture is not so strong as I would like, but it is strong enough to differentiate the parts.”
There you had it—workflow problems, along with a bit of a hedge, all the way back in the 19th century. With the handwritten note projected before the audience, Curtis P. Langlotz, MD, PhD, professor of radiology and biomedical informatics at Stanford, wryly noted: “Some things never change.”
The occasion was the California Radiology Society’s 2015 annual meeting and leadership summit in early October. Langlotz highlighted the historic moment by way of introducing select material from his recently published book, The Radiology Report: A Guide to Thoughtful Communication for Radiologists and Other Medical Professionals.
“Why are our reports so similar to those very early ones? Because it actually is very convenient for radiologists to pick up a microphone and describe what they see,” he said. “But other forces are starting to counterbalance and drive changes into the radiology report.”
Those forces include not only referring physicians fed up with inconsistent nomenclature but also payors and practice managers demanding details like radiation dose, the Joint Commission requiring notifications of critical results, CMS assessing incentives (or penalties) for quality—and, increasingly, patients expecting full and meaningful transparency in every aspect of their care.
Stressing the timeless importance of standardization across various aspects of the radiology report, Langlotz pivoted from the past to the present and then on to the future. He walked attendees through several steps that radiologists—especially those currently using speech recognition systems and doing predominantly narrative reporting—can take to make sure tomorrow’s reports are better than today’s.
1. Adopt and implement standard templates.
Langlotz displayed a standardized template designed by his Stanford colleague David Larson, MD, Langlotz said one of the template’s key attributes is its accountability to a formal governance structure.
“You want to have the leadership on board,” Langlotz said, adding that Larson’s governance called for forming a committee to set rules, create a style guide with checklist and audit for adherence.
“He made it easy to do the right thing,” Langlotz said. “Once these templates were decided upon, they came up automatically as a default setting in our reporting system. You could change them if you wanted to, but it was easy to work with what came up first. We actually had very good adherence.”
For those who have run into snags coming up with templates, or gaining buy-in on them, Langlotz suggested turning to RSNA’s RadReport.org. There, an open template library facilitates open uploading as well as downloading of templates, while the Report Template Library functions as an authoritative “voice from on high” guide. It’s multilingual and its templates have been viewed or downloaded more than 2.3 million times.
2. Create phrase lists with trigger words.
Langlotz described a reporting tool that brings up a set of sentences when certain words are dictated. “As I am reporting, I am heavily using the fast-forward and rewind buttons to jump between fields, and I’m using these words to have certain phrases come in automatically,” he explained.
Emphasizing the need to include standard macros for regulatory and billing compliance, he pointed to “presence attestation for a procedure” as an example, noting that it’s required by many payors.
As notification of critical results is required by the Joint Commission, creating phrase lists with trigger words “makes it very easy for you to audit your reports when you are done,” Langlotz said. “Then you use this standard template to detect whether there has been a notification. Thus, you can get a dashboard in real time to show how many of the critical results have a documented notification. You can go back and make sure that you addend those reports to make sure that someone is aware of those critical results.”