Is it possible to convert a large radiology department to using structured reports rather than free dictation, while at the same time winning the support of radiologists? Yes, it is. Cincinnati Children's Hospital explained how its effort succeeded in a presentation at the recent RSNA 2011 meeting.
Over the course of 18 months, Cincinnati Children's radiology department implemented a program in which more than 90% of reports prepared by its 39 radiologists, 10 fellows, and a varying number of residents used a structured report template. The only reports that haven't and won't be templated are for exams that are performed fewer than 50 times a year in the department.
Rebecca Pryor, the department's administrative radiation compliance and education specialist, and pediatric radiologist Dr. David B. Larson, medical director of radiology quality and improvement, attributed the success of report template adoption to these critically important factors: collegial respect and consensus-building from start to finish, detailed planning, realistic goals, dedication to the project, and hard work.
In the fall of 2009, as part of a hospital-wide objective to improve consistency in treatment and operations, the radiology department decided to adopt the use of structured report templates. Department members felt that benefits of the move would include improved understanding of radiology reports by referring physicians due to standardized terminology and language, reduced risk of overlooked grammatical and transcription errors in signed reports, and improved ease of dictation.
The radiology department formed a working group consisting of radiologists, department leaders, and administrative staff. It was very important to have all members of the department participate in creating the reports so that they would reflect the voice of the department, Pryor said. Over the next two or three months, this working group met several times, but it became apparent that a dedicated core group would be needed to make the project a reality.
The core group consisted of four individuals: Larson; Pryor; Dr. Alex Towbin, medical director of radiology informatics; and an administrative assistant. A "secondary" core group that was active at the start of the project included one representative from each radiology division.
The first activity was to identify, define, and standardize the format of the elements of a radiology report. After agreeing upon an overall format, the core group developed guidelines on how each radiology section could create its own templates. Initial assignments were given to the point person for each division.
"By March 2010, 12 existing report templates had been established," Larson said. "These corresponded to 45.7% of the department's studies by volume."
By June, the department had implemented a system-wide format for all reports, whether or not a standard report template had been created. When radiologists opened an exam to dictate, the formatted template would pop up to be completed.
The general format included five sections: clinical history, comparison, procedure comments, findings, and impression. The parameters for the content of each structured report included a description of normal findings most commonly desired by clinicians, and pertinent negatives referring to the most common and/or important clinical questions.
The report templates also included fill-in fields for the most common abnormal diagnoses, and they required either minimal data entry or none at all to be able to remove statements from a normal exam. The format also had to be easy to change to support the reporting of abnormal examinations.
Once a draft report template had been created, it was submitted to an executive committee within the structured reporting work group for editing and standardization of phraseology. For example, Pryor said, reporting a "left" something and then a "right" something became consistent. Another example is whether radiologists using the report should describe one kidney at a time, or both kidneys in one paragraph.
Reports were also edited to use language that is commonly understood by radiologists and clinicians. Grammar, punctuation, and misspelling errors were corrected. Noncontributory language, such as "is seen" and "no definite," was minimized. The core group also checked that each draft report included all elements required for reimbursement.
Edited reports were distributed in batches to the department faculty for review and comment. "It was easier to get our colleagues to respond to the need to review a batch of draft reports, rather than bombard them with one report after another," Larson explained. Batches also helped reviewers visualize them as part of a larger collection.
The core group and the relevant department representative were responsible for reviewing all recommended changes and answering all questions. After reports were revised, they would then be circulated in batches to everyone who might dictate or be directly affected by the template and its contents. Comments, suggestions, and questions were addressed, and if more changes were made, the report would circulate again.
"We tried to have as few surprises as possible," Larson said. "I think the extra time we put in up front to get as much participation as possible really paid off. People trusted the system and had a reasonably good feeling about the project."
Larson and Pryor both emphasized the need to work hard to achieve consensus with everyone involved in using the templates. There is very little published evidence about what to include in a report and the best way to structure it, they pointed out. The core group and section leads had looked at the RSNA's library of "best practice" templates, but because these were prepared for adult patients, they were not as useful from the perspective of a pediatric hospital.
As each structured report was adopted, it was entered into the department's speech recognition dictation system (RadWhere, Nuance Communications), tied to a specific RIS exam code. The department's speech recognition system is able to use the RIS exam code to automatically launch the exam-specific report as the dictation is opened.
Achievements
By March 2011, 178 exam-specific report templates had been implemented. These corresponded to 90.1% of the studies by volume. By November 2011, 95% of all studies by volume had templates, and the remaining 5% represented exams that are performed fewer than 50 times a year.
Cincinnati Children's radiologists use the template for dictation of normal exams 93% of the time, Pryor said.
"There may be good reasons to deviate from the exact template," Larson said. "We also encourage radiologists to specifically answer a question that an ordering physician has asked, and this may necessitate some minor modifications to template language."
In June 2010, the department started auditing for compliance. Hospital executives had suggested that compliance be matched with a small financial incentive. The bar was set high to receive the incentive, and it was an everyone-or-no-one deal, Larson said.
"It was in our own best interests, as well as those of the department, to know who was deviating from the templates and, more importantly, to find out why," Larson said.
The core team analyzed the deviations to determine if they were consistent. In some instances, reports were modified because the "deviation" language proved to be better. While it would have been better to have dealt with these recommendations during the template development process, they were handled in good humor. When radiologists were deviating too frequently without cause, they were told that they'd have to conform "for the good of the department." This didn't happen too often, Larson noted.
The report templates have been embraced by most radiologists as helping to improve the consistency of messages and the overall professionalism of the department. The presenters also think that template adoption has improved productivity and the ability to sign off on a completed report more rapidly, but they have not measured this as these were secondary goals.
What came as a surprise was that many of the referring physicians who received the new, templated reports did not notice the changes. While this was to be expected for the clinical specialists such as orthopedic surgeons and emergency physicians whom the core group involved at the outset of report development, the group expected it would get more unsolicited feedback. A few physicians have commented on the ease of finding information, especially with longer reports and those using advanced imaging modalities. And some, when asked, have said that they've seen fewer oddball reports, or that the new reports look more professional.
Recommendations for others
The most important step, according to Larson and Pryor, is to do whatever it takes to achieve consensus by everyone a report template affects. In addition to working with every radiologist, the core team talked with referring physicians about what they wanted to see in a report and how they wanted it presented.
They also suggested the following actions:
- Set ground rules and a process and adhere to them. The process for modification should be fair, and don't deviate from it.
- Once a precedent is established, it should be followed. For example, if one section wants to report a right kidney and then a left kidney in a template, but a decision has already been made to report a left hip and then a right one, collectively determine if left-right or right-left is more appropriate for the majority, and then stick with it.
- Avoid the temptation of allowing individual templates.
- Offer a financial incentive to the group for achieving realistic goals over a timeline.
- Emphasize that the reason structured report templates are being adopted is to provide better communication.
