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Structured reporting software creates less complete and accurate radiology reports than free text
Date:11/16/2009

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
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Contact: Jessica Guenzel
jguenzel@wfubmc.edu
336-716-3487
Wake Forest University Baptist Medical Center
Source:Eurekalert

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