Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

Tobias Jorg; Moritz C Halfmann; Gordon Arnhold; Daniel Pinto Dos Santos; Roman Kloeckner; Christoph Düber; Peter Mildenberger; Florian Jungmann; Lukas Müller

doi:10.1186/s13244-023-01408-7

Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

Insights Imaging. 2023 Apr 11;14(1):61. doi: 10.1186/s13244-023-01408-7.

Authors

Affiliations

¹ Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany. tobias.jorg@unimedizin-mainz.de.
² Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckst. 1, 55131, Mainz, Germany.
³ Department of Radiology, University Hospital of Cologne, Cologne, Germany.
⁴ Department of Radiology, University Hospital of Frankfurt, Frankfurt, Germany.
⁵ Institute of Interventional Radiology, University Hospital Schleswig-Holstein - Campus Lübeck, Lübeck, Germany.

^# Contributed equally.

Abstract

Background: To evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years.

Methods: We analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology.

Results: As of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes.

Conclusions: The increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR.

Key points: 1. Structured reporting usage increased markedly since its implementation at our institution in 2016. 2. Mean usage for the ten most popular structured reporting templates was 77% in 2022. 3. Both radiologists and referring physicians preferred structured reports over free-text reports. 4. Our data shows that structured reporting can be successfully implemented. 5. We strongly encourage others to implement structured reporting at their institutions.

Keywords: Free-text reporting; Radiology workflow; Structured reporting.