vRad Structured Reporting: Keeping Eyes on Images

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 - Ben Strong, MD
Benjamin W. Strong, MD (ABR, ABIM), Chief Medical Officer, vRad

When it comes to dictating radiology reports to produce consistently presented diagnostic evaluations, Benjamin W. Strong, MD (ABR, ABIM), is bullish on two tools: (1) customized speech-to-text software, and (2) flexible diagnostic checklists. In fact, to vRad’s chief medical officer, the evolutionary integration of those two workflow aids—which he has been using himself and refining for vRad’s 500-plus radiologists over the past 10 years— is structured reporting.

For starters, Dr. Strong, something of a structured reporting evangelist, urges all new vRad radiologists to read Atul Gawande’s The Checklist Manifesto. “The more rigorously you adhere to a checklist, the better able your mind is to step outside the list’s elements and evaluate them in relation to one another,” Dr. Strong explains. “The process actually frees the mind for more thorough and professional evaluation while guaranteeing that no simple step along the process is skipped.”

As for voice recognition, he’s pleased to see how widely the profession of radiology has adopted the technology. Unfortunately, though, that’s not the end of that story. “I’m never shocked,” he says with unchecked disappointment in his voice, “to see that so many practices are not using it to its best advantage.” Which is to say they’re mostly using mass-marketed speech-to-text software “as is,” straight off the shelf.

It would seem Dr. Strong has earned the right to be disappointed. During the past 10 years, he has spearheaded the creation of vRad’s custom-built voice recognition system. It now houses a massive library of macros—two- and three-word phrases that trigger the software to fill in a standardized report template based on the 3,000 most frequently uttered sentences in radiology. It has built-in redundancies so that similar words, such as, say, small and mild or renal and kidney, are interchangeable. It uses red type to flag “off-macro” and unusual words and phrases, as well as those that tend to vex referring physicians, for easy review prior to report singing.

And his partners, vRad’s software engineers, have otherwise ironed out vexing voice-recognition usage wrinkles that, in the past, tempted reading radiologists to shift their eyes from the diagnostic images on which they’re reporting in order to check the text screen for accuracy. Encouraging radiologists to remain laser-focused on images throughout the dictation period is the primary purpose of speech-to-text tools. A good solution builds radiologists’ confidence in the tool’s ability to get every word right. Second-rate software has the opposite effect, creating wariness and, with it, compromised mental focus.

Saying everything by saying nothing

Dr. Strong points out that vRad’s take on structured reporting is a direct outgrowth of the practice’s overall approach to streamlining workflow. Structured reports follow a pre-formatted template to automatically condense and standardize radiologists’ dictations, enabling referring physicians to quickly review exam results, triage patients and take action.

“In fact, we refer to our structured reporting simply as ‘the workflow,’ and it’s highly synchronized with our radiology order-management system,” he explains.

Meanwhile, the macros allow the system to take information about a study from multiple sources—DICOM header, technologist’s entry—and automatically populate the header with such information as contrast administration, 3-D reconstructions or coronal and sagittal reformats. In the past, vRad’s radiologists had to repeatedly chant, mantra-like, sentences such as CT scan of the abdomen and pelvis was performed from the diaphragm to the pubic symphysis with 5 mL cuts with administration of intravenous contrast and oral contrast and coronal and sagittal reformats were provided.

“You know what we say now to populate our header information? Nothing!” says Dr. Strong. “What we say at the beginning of every study, in order to set up the template, is absolutely nothing. All of that standard wording is automatically pulled into the system, and as it is purely objective—not interpretive—there is no reason not to do so.”

Allowing that there are times when the macros need to be substantially modified, he says that, around 10% of the time, he does look at the dictation screen. “On occasion, I will insert a measurement, insert a little anatomic specificity. And every now and then, I’ll encounter some heinous tumor for which I just don’t have all the preconfigured sentences,