Systematic Approach and Tools for Migrating from Text-Based Reports to Structured Reports: Based on the DICOM Structured Reporting Guidelines

Abstract

A structured reporting system is a set of standard-compliant practices that guides the physicians in order to create structured documents, organizing and simplifying their workload. In spite of this advantages, many physicians still use conventional methods to write their findings, like free-text reports. One main reason for this is the little convention on how to disseminate a structured reporting routine in the report environment. This work proposes a systematic approach to migrate a system routine from free-text reports to structured reports, focusing on the DICOM Structured Reporting guidelines. To evaluate this proposal, a structured reporting system was created in the context of the Santa Catarina State Integrated Telemedicine and Telehealth System (STT/SC), in Brazil, and, in a case study covering obstetric ultrasonography reports, was evaluated by a group of experts using the AdEQUATE model, showing a high user perception from the system. The results are a set of defined premises and steps that turns a telemedicine system into a complete structured reporting environment.