How to Ensure Meaningful and Timely Patient Centered Radiology Reports

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How to Ensure Meaningful and Timely Patient Centered Radiology Reports

Researchers say that efforts to improve radiology reporting and care should focus on delivering meaningful patient-centered reports.

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Radiology reporting has undergone significant changes over the past two decades. The traditional method of crafting a radiology report involved referring physicians conducting faceto-face discussions with radiologists to review film-based images and exam findings. At the end of the discussion, physicians would have all the information necessary to provide treatment.

After dictating their findings, radiologists would get them documented with the help of a medical transcription service provider specialized in radiology transcription. The report would then be finalized and signed.

The introduction of digital imaging in the late 1980s changed the way radiology reports are created, according to an article published in a 2016 issue of the ACR Bulletin. PACS allowed referring physicians to view the imaging studies in their own office. Radiologists had to produce formal written reports to communicate their findings and recommendations to referring physicians. These reports need to be easy to understand and digest. The article cites Michael A. Bruno, MD, FACR, professor of radiology and medicine at the Penn State Milton S. Hershey Medical Center as saying, “If the report is unclear and poorly written, then we will have failed to add value to the patient’s care.”

In the era of value-based care, radiology reporting has a new meaning. Providers are focused on making imaging reports are now more readily available to patients. An article published in the American Journal of Roentgenology (AJR) in 2018 notes that as health care evolves, the radiology report also needs to change to meet physician and patient expectations. While satisfying the basic requirement of addressing the needs of referring clinicians and clearly conveying the radiologist's clinical judgment, the radiology report needs to be patient-friendly.

Patient-centered concepts need to be incorporated into report language, formatting, and delivery.

The article notes that the modern radiology report will be “a powerful, flexible document that strengthens the connection between the radiologist and the patient”.

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Patient-centered Radiology Reports

Here are four strategies to produce patient-centered radiology reports: 

Use appropriate report language: A 2018 published Radiol Bras article cited a study of X-ray reports in which 39% of referring physicians found the report was confusing and 51% stated that the initial reason for the examination to be requested was not mentioned at all. After diagnostic accuracy, clarity of language is one of the most important requirements of a radiology report. Clarity in radiology reports ensures that the information conveyed is precise and can be completely understood, which will directly benefit the patient.

Here are important suggestions about language and content in

radiology reports: -

Language used should be universally understood. Unclear or technical language can be a problem for both referring physicians and patients. Excessive use of technical jargon can lead patients to misinterpret the diagnosis and cause anxiety and confusion. Using medical terminology that is a more universally understood is the solution.

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Lengthy complex sentences can affect readability and should be avoided.

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Reducing unnecessary verbiage and avoiding potentially unclear abbreviations will make it more useful and intelligible to the readers. The report should focus on the most salient findings and recommendations

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The level of diagnostic certainty should be expressed as a percentage rather than using vague qualifying terms that can be misunderstood. For instance, the ACR Bulletin published article advises against using ambiguous phrases, such as “cannot exclude” and “correlate clinically,” without a detailed explanation.

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Avoid using abbreviations.

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Don’t use language that can seem ‘hostile’. For instance, “the patient declined” should be preferred over “the patient declined (www.radiologybusiness.com).

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The radiologist should avoid elaborating on insignificant findings that could cause patients unnecessary alarm.

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Clear communication also means using appropriate punctuation, correct spelling, and good sentence structure.

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Using words correctly is also important. In addition to causing confusion, incorrect wording can have unintended legal consequences

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Radiologists should avoid any comments in the report that are critical of their clinical colleagues.

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Ensure timely communication: ACR guidelines mandate specific documentation of the time and the person notified on the findings. Urgent or unexpected findings should be communicated to the referring physician and, if unavailable, directly to the patient.

Timely medical transcription services play a crucial role here. The AJR article cites a case where a report of a skull fracture that was dictated but was not transcribed for 2 days, resulting in nonroutine radiologic findings not being communicated to the emergency department. The patient was discharged and developed complications that required a return to the hospital for emergency neurosurgery. The patient died on the same day due to the skull fracture and large epidural hemorrhage. The malpractice suit against the radiologist and hospital ruled in favor of the plaintiff since the radiologist had known about the transcription delay and failed to promptly bring a report to the attention of the emergency department physician, which eventually led to the death of the patient.

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Link to supplementary information: Along with standardized reporting language, an additional way to enhance the utility of the report for the patient is by incorporating hypertext that links text elements of the report to supplementary information. This will allow patients to do their own research online and improve understanding.

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Proofread the report: According to a report in Radiology Business, some specialists may not proofread their work to save time. When workloads and volume of complex cases increase, radiologists would have less time for adequate proofreading. One practical way to overcome this challenge is by outsourcing transcription. Experienced radiology transcription service providers have stringent quality control measures in place to ensure high-quality reports free from spelling and voice recognition errors.

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Patient engagement is an integral part of value-based health care. With an increasingly educated, highly engaged base of patients, providers will need to adopt patient-centered radiology strategies. To contribute effectively to improve patient care, radiologist should focus on consistently producing well-organized, accurate, and meaningful findings reports for the referring doctor as well as the patient.

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