Navigation Links
Structured reporting software creates less complete and accurate radiology reports than free text

WINSTON-SALEM, N.C. As many software companies work to create programs that will give uniform structure to the way radiological test results are reported, a new study by researchers at Wake Forest University School of Medicine shows that such a system does not improve, but rather decreases the completeness and accuracy of the reports.

The study, published recently in Radiology, compared the accuracy and completeness of reporting test results in a free text, narrative format versus using standardized words and phrases from a pull-down menu (structured reporting).

"This research is our attempt to evaluate a new technology that is a pretty hot topic in medicine right now and has been for a few years," said Annette J. Johnson, M.D., M.S., an associate professor of radiology and lead investigator on the study. "Since radiology began, we have been creating our reports in a free text, narrative format. The rationale behind efforts to change this format is that all of the reports that we create could potentially be a very useful data base for clinical care and research if they were standardized."

Standardization would mean that key content could be accessed through automated means, by computer systems, rather than requiring a human being to read the report and manually sift through narrative comments to try to find and categorize key content, Johnson said.

"This type of standardization is a very appealing idea, but we did not have data regarding what effect structured systems like this might have on individual report quality until now," she added. "It turns out that a structured reporting system actually decreases the accuracy and especially the completeness of reports, which is the opposite of what we expected."

This study provides the only known data about the proposed program's effect on the quality of radiological reports, Johnson said.

Currently, she explained, a physician might send a patient who is experiencing weakness in his arm, for example, for a head computed tomography (CT) scan to rule out concerns about a stroke. A radiologist then reads the CT scan and reports what she sees.

"I might say, 'There's no evidence of hemorrhage,' or any other variety of wording to convey that idea. I could say, 'no bleeding' or 'no hematoma' or 'no hyperdensity,' all of which mean the same thing," Johnson said. "In a structured system, I would choose from a list of standardized phrases with certain specific terms available in a dropdown menu, such as 'No presence of acute stroke.' Standardization seems simple, but it's not always easy or what we commonly do in medicine. The theory is that structured reporting would make the reports intrinsically better because we'd all be using the same ideas recorded in the same verbiage instead of using numerous different ways to say 'blood.' Right now, several people reading a scan may all agree that they see the same thing, but each individual will say it in a different way."

For the study, the researchers tested such a structured reporting system on two groups of residents. Each individual in both groups was given the same set of 25 brain magnetic resonance imaging (MRI) scans along with a video of a staff physician's interpretation of the MRI scans, and was asked to report the interpretation using the free text narrative they were familiar with using. Four months later, the same set of MRIs was given separately to each individual again. Half of the residents were asked to report their observations in the free text narrative form as they had the first time. The other half were asked to create their reports using the structured reporting software, which listed standardized sentences and phrases describing different findings to choose from.

"We thought that the structured reporting group would make better reports," Johnson said. "However, the reports created using structured reporting software were actually substantially less complete and a little less accurate compared to the reports made by the same residents in free text four months earlier and with the other group of residents who used free text both times."

The company that made the specific structured reporting software used for the study is no longer in existence, Johnson said, but there are still many more software companies very focused on creating these programs and finding ways to structure reports. These companies, and the physicians who choose to use structured reporting systems, should strongly consider how the software is going to affect the quality of real patient records, and all software should be specifically tested for quality effects before being implemented, she said.


Contact: Jessica Guenzel
Wake Forest University Baptist Medical Center

Related medicine news :

1. DATATRAK Announces Restructured Senior Management Team
2. DCL Extends Structured Product Labeling (SPL) Services to Meet New FDA Requirements; Support Now Offered for CDER, CBER, CDRH, CVM and ONP Products
3. Structured Cabling Solutions Provider ICC Announces Rewards Program for Installers and Contractors
4. New Analysis Underscores Legality of Physician Ranking and Public Reporting Systems When Used by Health Insurers to Improve Health Care Quality
5. Substantial costs and underreporting of dengue fever, concerns about blood supply face US
6. Alarming MRSA Infection Rates Underscore Need for Public Reporting of Hospital-Acquired Infections
7. Consumers, Health Care Purchasers Applaud Agreement On Physician Performance Reporting
8. Womens Health Leader Lauds Agreement on Physician Performance Reporting in New York State
9. New Global Health Video Footage Available Rights-Free on
10. Health care opinion leaders support public reporting of health care quality, prices
11. Vermont Requires Reporting of NQF Serious Reportable Events
Post Your Comments:
(Date:11/27/2015)... ... , ... A team of Swiss doctors has released a report on mesothelioma ... posted the findings on the website. Click here to read the details now. ... patients who were treated with chemotherapy followed by EPP surgery. Among the 106 patients ...
(Date:11/27/2015)... , ... November 27, 2015 , ... Lizzie’s Lice Pickers ... company is offering customers 10% off of their purchase of lice treatment product. In ... full price. According to a company spokesperson. “Finding lice is a sure way to ...
(Date:11/27/2015)... ... ... No.1 Herpes-only dating community in the world, revealed that over 50% of its members are ... people under the age of 50 – or 67% of the population - are infected ... HSV-1 infection . , "The data shocks us highly!" said Michelle Li, Co-Founder of ...
(Date:11/27/2015)... ... ... A simply groundbreaking television series, "Voices in America", which is hosted by Hollywood legend, ... that are presently affecting Americans. Dedicated to providing the world with a wide variety ... consumers focus on, one episode at a time. , In the latest installment ...
(Date:11/27/2015)... ... 2015 , ... CBD College is proud to announce that on ... accreditation to its Diagnostic Medical Sonography program. CBD College is honored to join this ... colleges and universities in the state of California make the cut. CBD College is ...
Breaking Medicine News(10 mins):
(Date:11/25/2015)... , Nov. 25, 2015  Amgen (NASDAQ: AMGN ... Application (BLA) with the United States ... 501, a biosimilar candidate to Humira ® (adalimumab). ... application submitted to the FDA and represents Amgen,s first ... Sean E. Harper , M.D., executive vice president of ...
(Date:11/25/2015)... , Nov. 25, 2015 AAIPharma ... planned investment of at least $15.8  Million to ... Wilmington, NC . The expansion will ... to meet the growing demands of the pharmaceutical ... site expansion will provide up to 40,000 ...
(Date:11/25/2015)... N.Y. , Nov. 25, 2015  Henry Schein, ... and services to office-based dental, medical and animal health ... (GNYDM) Meeting the Henry Schein ConnectDental® Pavilion , ... broadest array of open solutions designed to help any ... Click here for a schedule of experts ...
Breaking Medicine Technology: