Radiologe最新文献

Clinical issue: Structured reporting has been one of the most discussed topics in radiology for years. Currently, there is a lack of user-friendly software solutions that are integrated into the IT infrastructure of hospitals and practices to allow efficient data entry.

Standard radiological methods: Radiological reports are mostly generated as free text documents, either dictated via speech recognition systems or typed. In addition, text components are used to create reports of normal findings that can be further edited and complemented by free text.

Methodological innovations: Software-based reporting systems can combine speech recognition systems with radiological reporting templates in the form of interactive decision trees. A technical integration into RIS ("radiological information system"), PACS ("picture archiving and communication system"), and AV ("advanced visualization") systems via application programming interfaces and interoperability standards can enable efficient processes and the generation of machine-readable report data.

Performance: Structured and semantically annotated clinical data collected via the reporting system are immediately available for epidemiological data analysis and continuous AI training.

Evaluation: The use of structured reporting in routine radiological diagnostics involves an initial transition phase. A successful implementation further requires close integration of the technical infrastructure of several systems.

Practical recommendations: By using a hybrid reporting solution, radiological reports with different levels of structure can be generated. Clinical questions or procedural information can be semi-automatically transferred, thereby eliminating avoidable errors and increasing productivity.

Clinical/methodical issue: Introduction and application of structured reporting in radiology private practice.

Standard radiological methods: Ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), digital x‑ray (DR), mammography (MG).

Methodological innovations: Structuring and predefinition of entire reports and report parts.

Performance: Structured reporting in radiology presumably allows for higher report quality, reproducibility and easier access to data mining. Also the communication with the referring physicians can be improved. Although these advantages are well acknowledged, structured reporting does not prevail in private radiology practices. This article sheds light on the current situation of structured reporting in radiology private practice and provides information for the faltering implementation as well as perspective for individual potential solutions to overcome this situation.

Achievements: Structured reporting is not yet standard. Growing acceptance of structured reporting can be expected.

Practical recommendations: The application of structured reporting can improve report quality. The use of structured reporting should be considered for common examinations.

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Numerous publications have shown the value of structured reporting in communication with referring physicians and for further usage of clinical report data in other contexts. Despite the topic being present and known in radiology for many years now, widespread adoption of structured reporting in clinical routine is still lacking. All major radiological societies have published position statements in favor of structured reporting and are pursuing various related initiatives. Among those are the development and the maintenance of openly available structured report template repositories as well as quality control of report templates and development of standardized terminologies. This article highlights the efforts of the German Radiological Society and the European Society of Radiology on the topic of structured reporting and provides an overview of pros and cons as well as publicly available resources.

Structured reporting has become established in many radiological applications over the last 20 years. However, its significance is often still seen as being limited to a narrow section of clinical workflows-image reporting and the creation of radiological reports. By placing every clinical and radiological finding in a semantic context from which its clinical meaning can be reproduced at any time, even by digital assistance systems, structured handling of medical data is essential for the interoperability of clinical systems along the entire diagnostic and therapeutic pathway.

A clinically meaningful use of structured reporting, which in the opinion of numerous scientific societies and experts is a very important prerequisite for the further development of radiological findings, especially under quality aspects, requires corresponding standards for implementation in IT systems. In addition to DICOM ("digital imaging and communication in medicine"), these are other standards for coding, for example RadLex ("radiological lexicon") or the specification of so-called interoperability profiles, as they are being developed by IHE ("integrating the healthcare enterprise"). The management of radiology report templates (MRRT) profiles is the central building block for this. The building blocks for efficient IT implementation, which also allow harmonization, for example at a national level, are currently available. Users in radiology should familiarize themselves with them and demand appropriate solutions from manufacturers.