Abstract
BACKGROUND AND PURPOSE
Structured reporting has many advantages over conventional narrative reporting and has been advocated for standard usage by radiologic societies and literature. Traditional structured reports though are often not tailored to the appropriate clinical situation, are generic, and can be overly constraining. Contextual reporting is an alternative method of structured reporting that is specifically related to the disease or examination indication. Herein, we create a library of 50 contextual structured reports for neuroradiologists and emphasize their clinical value over noncontextual structured reporting. These templates are located in the On-line Appendix, and a downloadable PowerScribe 360 file may be accessed at https://drive.google.com/open?id=1AlPUmfAXPzjkMFcHf7vGKF4Q-vIdpflT.
MATERIALS AND METHODS
The contextual templates were created in a systematic process that spanned >1 year, which is similar to processes in other institutions.24,25 Our institution (Kaiser Permanente, Santa Clara, California) is part of a 21-hospital network comprising 300 radiologists, 50 of whom are neuroradiologists. Led by a committee chairperson, a committee search was initiated to identify radiologists interested and knowledgeable about structured reporting and informatics. The subspecialty regional leaders of neuroradiology within brain, neurovascular, head/neck, pediatric neuroradiology, and spine imaging were recruited. After the committee was created, common examination indications and diseases within neuroradiology were culled from examination data, and templates were drafted. For each template created, the committee members provided revisions and ensured that the templates contained content contextual to the disease process or examination indication. Following committee voting and approval, each of the templates was sent to a subspecialty clinician who was an expert in the specific topic to provide additional suggestions. Before template publication within our radiology dictation software (Radiator; Napa, California), the informatics leader of the committee coded the template, ensuring the templates were practical to use and creating pick list options when appropriate.
The templates were mapped to the procedural codes of our institution within the radiology information system, which are closely modeled after the current procedural terminology codes, with the exception of more granularity to permit more complex associations between the procedures and structured templates. This mapping permits the template to automatically load in the reporting software when the examination is opened for interpretation. The templates were then made available to all radiologists to use in clinical practice, and a hyperlink was inserted within the dictation software for users to provide suggestions for change, which were reviewed and revised when appropriate. To orient the radiologists with the contextual templates at the onset of deployment, the template committee gave a lecture on the types of templates developed, the advantages of contextual reporting, and reference to available imaging guides for certain templates.
For the purposes of this publication and to make the contextual templates easily accessible to other radiologists without our proprietary reporting software, the templates were also created in Nuance Powerscribe360 (Burlington, Massachusetts). A downloadable Powerscribe 360 file can be accessed here (https://drive.google.com/open?id=1AlPUmfAXPzjkMFcHf7vGKF4Q-vIdpflT) and is compatible with versions 3.5 and 4.0.
RESULTS
Because this proof of concept was favorable with the neuroradiology contextual templates, our group is planning to develop contextual templates for other radiology subspecialty diseases. Our group believes that contextual reporting is the next generation of structured reporting.
Contextual reporting could theoretically have a substantial role in data tracking and machine learning. Because contextual reports are disease-specific and structured, common data elements can be gathered from the reports so that computers can read and understand the content. These natural language-processing techniques could permit data extraction to populate national registries and aid research.36,37 Furthermore, contextual reports could also potentially be the framework for computer-generated reports if machine learning can reliably interpret certain radiologic examinations. Further studies are needed to substantiate these ideas.
CONCLUSIONS
Contextual reporting is a method of structured reporting specifically related to the disease or examination indication. Contextual templates are individually tailored to the diagnosis, they ensure that all pertinent points are addressed in a checklist fashion, and they educate trainees by providing a systematic approach for clinical interpretation. The included library of neuroradiology contextual templates can help neuroradiologists transition to a new method of structured reporting.
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Editor’s Choice
Contextual reporting is an alternative method of structured reporting that is specifically related to the disease or examination indication. These disease-specific reports provide content focused on the clinical diagnosis or symptom, discuss appropriate differential diagnoses, and highlight pertinent positives and negatives. The authors created a library of 50 contextual structured reports for neuroradiologists and emphasize their clinical value over noncontextual structured reporting.