Structured Reporting Among Methods for Improving Communication
Monday, Nov. 28, 2016
Communication is vital among all members of a multidisciplinary team working to develop individual treatment plans for cancer patients, according to presenters of a Sunday session.
For example, it's critical that content in radiology reports be communicated clearly to other physicians, said Herbert Alberto Vargas, MD. Yet recent surveys gauging the value of radiology reports found that 20 percent of responding clinicians said the language and style used in radiology reports was unclear, said Dr. Vargas, director of genitourinary radiology at the Memorial Sloan Kettering Cancer Center in New York. Another study determined that referring clinicians may reach different conclusions when reading the same reports, he said.
To that end, structured reporting, which allows for effective communication of imaging findings by standardizing format, terminology and content, is an effective solution, said Dr. Vargas.
"We need uniform ways to communicate radiologic findings, clinical impressions and management recommendations," he said.
Another important issue relevant to standardized reporting is the expression of diagnostic certainty, Dr. Vargas said.
"Radiologists are often tasked with summarizing multiple findings and rendering an opinion with regard to potential explanations for the radiographic findings," Dr. Vargas said. "There are scenarios in which no differential diagnoses are warranted and the findings are reported in terms of the absolute presence or absence of a pathologic process, for example, 'no fracture.'"
In other cases, findings are not definitive, and radiologists need to indicate their level of certainty for their interpretation of the imaging findings, Dr. Vargas said. In a study of patients with prostate cancer, 38 different terms were used in MRI reports to express the levels of certainty for the presence of extracapsular extension (ECE), prior to the introduction of a five-point "certainty lexicon," he said.
"The lexicon not only simplified the communication of the radiologists' level of suspicion but also allowed more objective quantification of the diagnostic performance of MRI for diagnosing ECE," Dr. Vargas said.
There are many key elements necessary to maximize the clinical utility of diagnostic imaging exams, including a pertinent clinical indication, adequate technical acquisition, accurate interpretation and effective communication of the imaging findings, Dr. Vargas said.
"The literature suggests that structured reporting in radiology leads to clearer and more thorough communication of relevant diagnostic findings than does conventional, free-form reporting," he said.
In a study of body oncologic CT examinations, structured reports were given significantly higher satisfaction ratings by both radiologists and referring physicians compared to "free-form" reports, Dr. Vargas said.
Structured reporting software offers such features as drop-down menus which facilitate data entry and minimize the amount of free-text entries.
"However, the benefits of structured reporting cannot be accepted dogmatically," Dr. Vargas said. "An accurate interpretation reported in 'free-form' style is more clinically useful than a structured report containing erroneous information."
Subspecialty Opinions Demonstrate Benefits to Cancer Patients
While Dr. Vargas discussed how radiologists report using standardized, structured reports, presenter Fergus Coakley, MD, professor and chairman of Diagnostic Radiology at the Oregon Health and Science University in Portland, spoke about who is reporting and the importance of that person being a subspecialist.
Communication is critical in subspecialty opinions given after an initial radiology reading — which is often critical to a patient's care, Dr. Coakley said.
In an analysis of published data on the value of subspecialist reads in journals including Radiology and the Journal of Otolaryngology — Head & Neck Surgery, Dr. Coakley determined that subspecialist opinions often alter the initial reading of radiological studies in cancer patients.
"The bottom line is, if you get a subspecialist opinion, 10 to 20 percent of the time it will result in actionable change," Dr. Coakley said. "And usually — roughly 80 to 90 percent of the time — that change is for the better."
Dr. Coakley cited cases where diagnoses were changed after readings by a subspecialist. In one case, a 51-year-old man diagnosed with pancreatic cancer was referred for the Whipple procedure. But a subsequent read by a subspecialist indicated the patient did not have pancreatic cancer — he had autoimmune pancreatitis that was successfully treated with medication and not surgery, Dr. Coakley said. "He needed steroids rather than a pointless operation," Dr. Coakley said.
In another case, a patient diagnosed with pancreatic cancer underwent four rounds of chemotherapy before a subspecialist reinterpreted the images. "There was no cancer, there had never been a cancer," Dr. Coakley said.
In light of his analysis, Dr. Coakley said that offering formal second opinions for cancer imaging studies is a service that academic radiology departments may want to consider.