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

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 actua
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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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