Structured radiology reporting provides a strong foundation for radiology quality assurance, peer review.
Radiology Quality Assurance
Radiology quality assurance programs often focus on auditing performance in the wake of tragic mistakes. While this approach can help radiologists identify what went wrong in particular cases, it is difficult to turn incident-based reviews into holistic reform.
Continuous quality assurance requires a culture of comprehensive reporting, supported by tools that help prevent radiology errors and improve communication across care teams.
Radiology Synoptic Reporting
Synoptic reporting uses standardized checklists to provide structure to clinical documentation—with minimal mouse clicks and immediate error checking.
Synoptic reporting for radiology applies digitized versions of RSNA clinical templates to achieve consistent content and streamlined workflow. Rather than dictating narrative reports, radiologists use configurable templates to capture interoperable data, eliminating transcription costs and increasing report quality.
Structured radiology reports are more complete, contributing to greater diagnostic accuracy [1,2]. Research also finds that radiologists prefer the synoptic reporting workflow and care teams prefer the structured format of synoptic radiology reports [3–5]. When radiology reports are easier to interpret, the value of radiologists’ work is clear.
But to effectively distribute structured radiology reports, care teams need to implement clinical software with various interface options, including backwards compatibility to interface with PACS that expect text input.
Radiology Reporting Software for Continuous Quality Assurance, Radiologist Peer Review
To build a culture of continuous quality assurance, radiologists need tools that both streamline workflow and ensure comprehensive reporting.
Radiology reporting software should balance consistency and configurablility. RSNA templates should be configurable for local terminology, clinical research or specialized cases. Data fields should be interoperable, using standardized codes like ICD-10 to improve communication with referring physicians, hospital billing departments and regional cancer registries.
Quality assurance also means improving communication among radiologists.
Radiology peer review is optimized when data is consistent throughout electronic medical documentation. The consistency of synoptic reporting makes data easily comparable, ensuring that peer reviews are comprehensive and streamlined. Moreover, the speed of synoptic reporting ensures radiologist peer review can take place within hours, without the costly delays of dictation and transcription.
- Marcovici PA, Taylor GA. Structured radiology reports are more complete and more effective than unstructured reports. American Journal of Roentgenology. 2014 Dec;203(6):1265–71.
- Lin E, Powell DK, Kagetsu NJ. Efficacy of a checklist-style structured radiology reporting template in reducing resident misses on cervical spine computed tomography examination. Journal of Digital Imaging. 2014 Oct;27(5):588–93.
- Schwartz, LH. Panicek, DM, Berk AR, Li Y, Hricak H. Improving communication of diagnostic radiology findings through structured reporting. Radiology. 2011 Jul;260(1);174–81.
- Larson DB, Towbin AJ, Pryor RM, Donnelly LF. Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology. 2013 Apr;267(1):240–250.
- Sistrom CL, Honeyman-Buck J. Free text versus structured format: information transfer efficiency of radiology reports. American Journal of Roentgenology. 2005 Sep;185(3):804–12.