Reporting is communication

In very generic terms, radiology provides two essential services: imaging studies and reports. The centerpiece of a radiologist’s communication is the radiology report. It is an encapsulation of a consultation including the question posed, the clinical information provided at the time of service, the type of imaging test performed, a detailed recounting of the imaging findings, and a summary or impression that ties the relevance of the findings to the clinical problem and a communication. The report is also a medicolegal document: it codifies the type of service provided, the clinical query the service is attempting to answer, the success or limitations of the provided service, the findings identified, and the conclusions derived based on the findings. In addition to its clinical function, the report can be used for billing, accreditation, quality improvement, research, and teaching, and can serve as a means to communicate with the patient.

Although there have been phenomenal technologic advances in the generation and transmission of the written word through digital dictation and the Internet, the content and format of radiology reporting has changed very little since the first medical radiograph was produced. In most instances, a radiology report is prose text that capitulates a list of imaging findings with a summation that addresses these findings in the context of a given clinical problem. For many years, radiology reports were handwritten documents. Carbon paper allowed for generation of multiple copies of the handwritten report at the time the study was interpreted such that a copy of the report could be included in the patients’ film records and in the patient chart. Delivery of reports (and films) to referring physicians used conventional courier methods that sometimes took days or weeks to arrive. The advent of the analog dictation system allowed radiologists to focus more of their attention on the images (rather than the report) by simultaneously speaking while studying the actual images. The adaptation of this technology helped to increase throughput and improved the overall appearance of the transcriptionist typed report. Additional technologies, such as the ubiquitous facsimile machine and copy machine, adopted into clinical practices improved the dissemination of information, speed of delivery, and consistency of the delivered product. Speech recognition (SR) technology has enabled real-time transcription of radiology reports, and Internet technologies now provide instantaneous communication and delivery of reports and critical findings. Although the layout of radiology reports has changed little since the profession began, the changing structure and governance of medicine suggest that radiology reporting requires a makeover.

Although tremendous strides have been made in the technology used to generate and disseminate the radiology report, the content and prose method of reporting has remained essentially unchanged for more than 100 years. It is still the primary method of communication between radiologist and clinician. The report can be created and delivered more efficiently, yet the message it contains still varies considerably in style and clarity. One of the earliest observers of the vagaries of radiology reporting was a nineteenth century radiologist named Preston Hickey who also served as one of the first editors of the American Journal of Roentgenology . Hickey was a proponent of proper radiology reporting skills and he advocated for the need of a standardized approach to radiograph reporting as early as 1899. He introduced the term “radiograph” as a substitute for roentgenogram, and he was the first to describe the process of radiographic “interpretation,” which he defined as creating a differential diagnosis from radiographic findings that might lead to a conclusion based on probabilities similar to a pathologic report. Even at that time when the specialty was in its infancy, Hickey observed that the styles of reporting of the day were so ambiguous such that it was impossible to formulate a diagnosis or even relate the findings to the clinical problem. Hickey was a strong advocate for the use of a standardized report (similar to pathology) and urged the consistent use of standardized nomenclature in reporting. He was particularly disappointed by the general lack of requirements to teach trainees the skills to describe and characterize abnormalities. His devotion to this concept led to his recommendation that candidacy for membership to the American Roentgen Ray Society be predicated on review of 100 example reports submitted with a candidate’s application. A candidate’s membership could be denied based on the quality of their reports. A contemporary of Hickey, Charles Enfield, wrote of the importance of conveying meaning to the reported findings and the essential need to express opinion or conclusion as to the significance of the findings.

The insights of Hickey and Enfield into the value of the quality of radiology reports are no less relevant today than they were a century ago. These individuals recognized that the added value of the radiologist was in his or her skill to assemble a cogent, concise, and unambiguous description of relevant findings that addressed the given clinical problem. This required a careful choice of terminology, good organization, and brevity whenever possible. A critical component of the report was the synthesis of the findings to formulate a conclusion or summary that takes into account the clinical status of the patient and the unanswered question being addressed in the report.

What are the features of a complete radiology report?

Developing a comprehensive understanding of effective reporting and communication is predicated on having a broad understanding of who uses the report and how they use it. Radiology now serves many “customers” including the patient. The radiology report is a multifunctional document that provides information at several levels: it provides essential details about the provided service and it can be an invaluable reference in the billing process. As radiologists, we think of the report as documentation of the presence, absence, progression, or remission of a disease or the description of a therapeutic procedure. There is no single “consumer” of the radiology report: users include the ordering provider; other specialists; trainees and health professionals; and other radiologists (who may refer to the report at a later time or interpret additional modalities). In the modern era of the personalized health record, the patient has also become an important consumer of medical reports. Primary care physicians are dependent on the content of the radiology report, whereas specialists (eg, neurosurgeons, neurologists, or orthopedic surgeons) depend on review of the imaging studies themselves and use the report as a reference. Clinicians have less time to review radiology reports, particular ones that are overly wordy or complex. The radiologist needs to be cognizant that in many instances only a portion of the report (typically the impression or summary) is actually read; therefore, particular care must be taken in crafting the summary or conclusion of any report. As face-to-face contact between referring physicians and radiologists has waned with dissemination of enterprise imaging distribution systems, the quality of the written report has taken on even greater importance and the obligation to improve the product is more relevant today than it was in the past.

A well-crafted report should be structured to maximize value to the consumer of that information. In most cases that is the ordering physician. However, attitudes among radiologists as to what constitutes a quality report are variable. All reports have three cardinal features: (1) content, (2) structure, and (3) style. Compromises in any of these features can produce substantial changes to the quality of the report and can have detrimental effects on communication with the clinician and customer satisfaction. Clinician surveys of radiology report quality are often cited as justification for a fresh approach to report generation, although many of these studies suffer from bias inherent to the limited characteristics polled in each survey. One of these surveys examined the relationship between report complexity and perceived report clarity by clinicians. A software program was used to objectively rate a report for inherent grammatical complexity in a collection of more than 10,000 thousand reports and then to compare whether these indices related to perceived clarity and comprehension of the report by clinicians. Not surprisingly, the authors found that the indices were higher for more intricate studies. Readability indices varied by radiologist for similar studies likely reflecting stylistic and linguistic differences. Interestingly, complex reports with higher indices (ie, long, complex sentences) were perceived as less clear by the clinicians and conveyed less diagnostic certainty than shorter and more concise reports. The authors suggested that complex reports may be perceived as unreliable or associated with obfuscation and that elements of uncertainty should be expressed directly.

Several published editorial and opinion pages are devoted to the appropriate structure and style of the radiology report. Much of what has been established for correct reporting is based on preference surveys from clinicians. Although there is a general lack of evidence regarding effectiveness of reporting guidelines and much of what has been written is based on anecdote and opinion, one can conclude that a report should follow a logical structure and reach a conclusion similar to a scientific paper or abstract ( Box 1 ). A proper report is accurate, concise, clear, and pertinent in style. Clinicians also have a preference for structured reports over pure unstructured free-text report. The American College of Radiology (ACR) handbook for residents recommends that the prototypical radiology report be divided into six main sections: (1) examination, (2) history and indication, (3) technique, (4) comparison, (5) findings, and (6) impression. It has been suggested that a good radiology report allows the referring physician to generate a mental picture of the abnormalities identified; it suggests a probability of specific diagnosis and the next appropriate steps for management. Therefore, it is imperative that the report should always be geared to address the needs of the referring clinician. It should clearly describe the study or procedure, the pertinent findings, a differential diagnosis ranked by order of likelihood, and recommendations for additional evaluation if indicated. The report should address any specific question (eg, “no demyelinating lesions” in an instance where “rule out demyelinating disease” is specified).

Reporting style is important because if used incorrectly it can adversely affect the clarity of the report. For this reason, a report should not be overly technical or wordy. Coakley and colleagues recommend adhering to three main stylistic guidelines of (1) brevity, (2) clarity, and (3) pertinence. Armas advocated the six-Cs of correct radiology reporting: (1) clarity, (2) correctness, (3) confidence, (4) concision, (5) completeness, and (6) consistency ( Box 2 ). There are numerous editorials and opinion papers on best practices for radiology reporting offer stylistic “do’s and don’t’s” for crafting good dictation style ( Box 3 , Table 1 ). Two additional nonstylistic (“C”) qualities were proposed by Reiner and colleagues (communication and consultation), both of which have become the mantra for radiology quality and safety.

A critical quality of effective radiology reporting today is “timeliness.” An interpretation that is delivered after a critical management decision has been made has no inherent value. In this modern healthcare era of cost containment, with emphasis on reductions in length of stay with concurrent improvements in quality and safety, staying competitive and relevant mandates that radiology must deliver a quality product in a time frame that maximizes impact on patient care. Technology has had the largest positive impact in expediting report delivery with the advent of SR, integrated picture archive and communications systems (PACS), radiology information systems (RIS), speech solutions, and dissemination of electronic medical records.

Report timeliness has been augmented with the advent of SR technology. Although not as ubiquitous as soft copy PACS, there has been continued and steady growth of SR installations in practices of all sizes. The advantages include rapid generation of a nicely formatted product, immediate verification of the content, near instantaneous delivery by facsimile machine or e-mail, and virtual elimination of transcription costs. The principle disadvantages of SR include requisite typing skills, frequent SR errors, and the loss of radiologist efficiency inherent to self-correction of these errors. The frequency of SR errors is not insignificant. One study that assessed errors in breast imaging reports found that SR error rates were typically eight times the rate higher than conventional transcription, independent of experience or academic rank.

Although there are a myriad of quality measures in any radiology practice, two metrics that are heavily scrutinized are report turnaround time (period between examination completion and finalized dictation) and report quality. Although report turnaround is perhaps easier to measure, report quality has no defined metrics associated with it. As such, report quality is frequently tied to error rates. Radiologic errors are often divided into observational (perceptual) and cognitive (interpretative). Errors in radiology reporting are not uncommon with estimates averaging around 30% overall but with a range of 26% to 90% in some series. Lehr and colleagues found that errors rates were similar across modalities and that there was no relationship between frequency of errors and radiologist experience or time spent interpreting radiographs. Reducing medicolegal risk can be accomplished by addressing reporting error rates. Although perceptual errors can be reduced through additional training or double-readings, the cause of interpretive errors can be multifactorial and not necessarily directly tied to inadequate knowledge. Lack of access to appropriate prior studies or reports and relevant clinical information may also inadvertently contribute to reporting errors. These factors can be addressed with some of the newer technologic solutions that augment integration of relevant clinical information to the radiologists’ desktop at the time of interpretation.

What are the features of a complete radiology report?

Developing a comprehensive understanding of effective reporting and communication is predicated on having a broad understanding of who uses the report and how they use it. Radiology now serves many “customers” including the patient. The radiology report is a multifunctional document that provides information at several levels: it provides essential details about the provided service and it can be an invaluable reference in the billing process. As radiologists, we think of the report as documentation of the presence, absence, progression, or remission of a disease or the description of a therapeutic procedure. There is no single “consumer” of the radiology report: users include the ordering provider; other specialists; trainees and health professionals; and other radiologists (who may refer to the report at a later time or interpret additional modalities). In the modern era of the personalized health record, the patient has also become an important consumer of medical reports. Primary care physicians are dependent on the content of the radiology report, whereas specialists (eg, neurosurgeons, neurologists, or orthopedic surgeons) depend on review of the imaging studies themselves and use the report as a reference. Clinicians have less time to review radiology reports, particular ones that are overly wordy or complex. The radiologist needs to be cognizant that in many instances only a portion of the report (typically the impression or summary) is actually read; therefore, particular care must be taken in crafting the summary or conclusion of any report. As face-to-face contact between referring physicians and radiologists has waned with dissemination of enterprise imaging distribution systems, the quality of the written report has taken on even greater importance and the obligation to improve the product is more relevant today than it was in the past.

A well-crafted report should be structured to maximize value to the consumer of that information. In most cases that is the ordering physician. However, attitudes among radiologists as to what constitutes a quality report are variable. All reports have three cardinal features: (1) content, (2) structure, and (3) style. Compromises in any of these features can produce substantial changes to the quality of the report and can have detrimental effects on communication with the clinician and customer satisfaction. Clinician surveys of radiology report quality are often cited as justification for a fresh approach to report generation, although many of these studies suffer from bias inherent to the limited characteristics polled in each survey. One of these surveys examined the relationship between report complexity and perceived report clarity by clinicians. A software program was used to objectively rate a report for inherent grammatical complexity in a collection of more than 10,000 thousand reports and then to compare whether these indices related to perceived clarity and comprehension of the report by clinicians. Not surprisingly, the authors found that the indices were higher for more intricate studies. Readability indices varied by radiologist for similar studies likely reflecting stylistic and linguistic differences. Interestingly, complex reports with higher indices (ie, long, complex sentences) were perceived as less clear by the clinicians and conveyed less diagnostic certainty than shorter and more concise reports. The authors suggested that complex reports may be perceived as unreliable or associated with obfuscation and that elements of uncertainty should be expressed directly.

Several published editorial and opinion pages are devoted to the appropriate structure and style of the radiology report. Much of what has been established for correct reporting is based on preference surveys from clinicians. Although there is a general lack of evidence regarding effectiveness of reporting guidelines and much of what has been written is based on anecdote and opinion, one can conclude that a report should follow a logical structure and reach a conclusion similar to a scientific paper or abstract ( Box 1 ). A proper report is accurate, concise, clear, and pertinent in style. Clinicians also have a preference for structured reports over pure unstructured free-text report. The American College of Radiology (ACR) handbook for residents recommends that the prototypical radiology report be divided into six main sections: (1) examination, (2) history and indication, (3) technique, (4) comparison, (5) findings, and (6) impression. It has been suggested that a good radiology report allows the referring physician to generate a mental picture of the abnormalities identified; it suggests a probability of specific diagnosis and the next appropriate steps for management. Therefore, it is imperative that the report should always be geared to address the needs of the referring clinician. It should clearly describe the study or procedure, the pertinent findings, a differential diagnosis ranked by order of likelihood, and recommendations for additional evaluation if indicated. The report should address any specific question (eg, “no demyelinating lesions” in an instance where “rule out demyelinating disease” is specified).

Reporting style is important because if used incorrectly it can adversely affect the clarity of the report. For this reason, a report should not be overly technical or wordy. Coakley and colleagues recommend adhering to three main stylistic guidelines of (1) brevity, (2) clarity, and (3) pertinence. Armas advocated the six-Cs of correct radiology reporting: (1) clarity, (2) correctness, (3) confidence, (4) concision, (5) completeness, and (6) consistency ( Box 2 ). There are numerous editorials and opinion papers on best practices for radiology reporting offer stylistic “do’s and don’t’s” for crafting good dictation style ( Box 3 , Table 1 ). Two additional nonstylistic (“C”) qualities were proposed by Reiner and colleagues (communication and consultation), both of which have become the mantra for radiology quality and safety.

A critical quality of effective radiology reporting today is “timeliness.” An interpretation that is delivered after a critical management decision has been made has no inherent value. In this modern healthcare era of cost containment, with emphasis on reductions in length of stay with concurrent improvements in quality and safety, staying competitive and relevant mandates that radiology must deliver a quality product in a time frame that maximizes impact on patient care. Technology has had the largest positive impact in expediting report delivery with the advent of SR, integrated picture archive and communications systems (PACS), radiology information systems (RIS), speech solutions, and dissemination of electronic medical records.

Report timeliness has been augmented with the advent of SR technology. Although not as ubiquitous as soft copy PACS, there has been continued and steady growth of SR installations in practices of all sizes. The advantages include rapid generation of a nicely formatted product, immediate verification of the content, near instantaneous delivery by facsimile machine or e-mail, and virtual elimination of transcription costs. The principle disadvantages of SR include requisite typing skills, frequent SR errors, and the loss of radiologist efficiency inherent to self-correction of these errors. The frequency of SR errors is not insignificant. One study that assessed errors in breast imaging reports found that SR error rates were typically eight times the rate higher than conventional transcription, independent of experience or academic rank.

Although there are a myriad of quality measures in any radiology practice, two metrics that are heavily scrutinized are report turnaround time (period between examination completion and finalized dictation) and report quality. Although report turnaround is perhaps easier to measure, report quality has no defined metrics associated with it. As such, report quality is frequently tied to error rates. Radiologic errors are often divided into observational (perceptual) and cognitive (interpretative). Errors in radiology reporting are not uncommon with estimates averaging around 30% overall but with a range of 26% to 90% in some series. Lehr and colleagues found that errors rates were similar across modalities and that there was no relationship between frequency of errors and radiologist experience or time spent interpreting radiographs. Reducing medicolegal risk can be accomplished by addressing reporting error rates. Although perceptual errors can be reduced through additional training or double-readings, the cause of interpretive errors can be multifactorial and not necessarily directly tied to inadequate knowledge. Lack of access to appropriate prior studies or reports and relevant clinical information may also inadvertently contribute to reporting errors. These factors can be addressed with some of the newer technologic solutions that augment integration of relevant clinical information to the radiologists’ desktop at the time of interpretation.