- Email: [email protected]
Effective Radiology Reporting
OPINION
Effective Radiology Reporting Jeffrey B. Ware, MD, Saurabh Jha, MBBS, Jenny K. Hoang, MBBS, Stephen Baker, MD, Jill Wruble, DO
INTRODUCTION As the primary means by which radiologists communicate with referring physicians and other health care providers, the radiology report must be concise, clear, and clinically relevant. Suboptimal radiology may lead to both under- and overinvestigation, spurring under- and overtreatment. In the changing landscape of health care reimbursement, we expect increasing scrutiny to be paid to the quality of radiology reports. Here, we summarize the key elements of effective radiology reporting.
ORGANIZE YOUR THOUGHTS A well-organized radiology report is easy to read and conveys relevant information. A well-organized report requires clarity of thought, consistent format, deep knowledge of imaging, and an awareness of clinical context. These tenets allow information to flow, reduce errors of omission, and avoid multiple interpretations of the same term. In addition to mention of positive findings, the report should mention negative findings pertinent to the clinical context. Radiologists should strive for brevity and use short, readable paragraphs to separate ideas. Declarative sentences are easier to understand than sentences with many dependent clauses. The use of standardized reports can help with logical flow while improving reproducibility and utility, so long as context is not eschewed. As the most important component of the report, the “impression,” should
contain only the most relevant findings, as well as the radiologist’s interpretation as to the cause and significance of those findings in the context of the clinical question. When findings are equivocal, a long list of differential diagnoses is less valuable than a clear direction regarding the next step. Recommendations for management and follow-up, when appropriate, should be evidence-based rather than an imperative to reduce risk.
BE CLEAR Radiological jargon with no clinical meaning, such as shotty and prominent, should be avoided. When using adjectives such as significant, the facts that justify their use should be explained. Qualification of the presence and the extent of an abnormality should be reported and, when appropriate, measurements should be included. Equally, it is important not to overdo measurements on an entity that is patently benign, such as a renal cyst. Adding terms such as identified and evidence of to the negativity of a finding, as in “no evidence of aortic dissection,” is redundant and should generally be avoided except in cases in which the imaging modality is clearly suboptimal for the evaluation of certain pathology. For example, in reporting a noncontrast abdominal CT in a patient with colon cancer, it is reasonable to say “no metastasis in the liver identified” to emphasize the limitation of this modality in detecting liver masses. However, excessive use of such terms can give the impression that the
ª 2017 Published by Elsevier on behalf of American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.01.045
radiologist is evasive, noncommittal, and unwilling to accept responsibility for the care of the patient. Similarly, when imaging is obtained to re-evaluate a finding, the phrase “no significant interval change” often appears. This phrase is redundant because interval is implied. Rather than use redundant terminology, it is better to state the duration in which stability was observed; for example, “no change in size of aortic aneurysm over 2 years.”
TAKE RESPONSIBILITY The value of imaging is in reducing diagnostic uncertainty and making a specific diagnosis when possible. The phase cannot be excluded, though occasionally justified, does not reduce uncertainty but attempts to absolve the radiologist from taking responsibility. Rather, the radiologist should use conditional probabilities to advise the likelihood of possible diagnoses, creating the most value by integrating imaging expertise with clinical information. In the “rule out disease” culture of medicine, cannot exclude implies that more tests are needed and may ultimately drive unnecessary investigations that deplete resources and pose risk to patients through detection of incidental findings. All health care professionals have a responsibility to seek and incorporate relevant information for medical decisions. The phrase correlate clinically is unhelpful and regarded with disfavor by referrers who interpret it as a reminder to do their job. Use of this phrase is
1
particularly problematic when there is no clinical information that could potentially alter the radiological interpretation. When crucial clinical information is not known at the time of interpretation, the radiologist must specify what the missing information is, or which additional test is needed. For example, given the finding of proptosis and enhancing intra-orbital tissue, a report may state, “If the orbits are painful, this may represent idiopathic orbital inflammation.”
CLOSE THE LOOP ON INCIDENTAL FINDINGS The radiology report should answer the clinical question and address the organ or system suspected of causing symptoms. However, imaging covers many organs and will inevitably lead to detection of incidental findings. Some incidental findings may be of high importance, such as a spiculated lung nodule on a neck CT. Often, however, incidental findings have no concerning features and may be regarded as inconsequential. In any case, simply listing the incidental finding without guidance is of no value. Rather, the radiologist must state clearly whether an incidental finding is consequential, and if so, what the next step should be. A very common example, the incidental thyroid nodule detected on CT or MRI, can often lead to an investigation cascade of fine needle aspiration, ultrasounds, and even thyroidectomy without necessarily improving patient outcomes [1]. Averting such a cascade, when clearly unnecessary, by issuing
definitive recommendations for workup of incidental findings based on the ACR white papers [2,3] provides tremendous benefit both to patients and to the health care system.
MAKE REPORTS READABLE FOR PATIENTS As patients increasingly access their health data, including radiology reports, it will become even more important for radiologists to report clearly. Although technical terms are often unavoidable, the use of unnecessarily extraneous or dramatic terms, which may increase anxiety, is not. If essentially normal means normal, it is better to say normal. Mentioning incidental findings and anatomic variants in the absence of clearly stated significance will carry a risk of spurring patient anxiety and subsequent additional unhelpful investigation.
BE AN EXPERT CONSULTANT As health care payment moves from a fee-for-service model toward a more value-based system, the quality of radiology reporting is likely to come under greater scrutiny given its crucial role in health care delivery. Clear, concise, and definitive radiology reports are the mark of an expert consultant and, in accordance with the ACR Imaging 3.0 initiative, will ensure that the radiologist continues to play a critical role in patient care. Effective radiology reporting will be required not only to inspire the highest confidence from referring physicians and our patients, but also to
demonstrate the value of radiologists by reducing the use of unnecessary and low-value procedures, thereby preserving resources to ensure that highvalue services are appropriately and consistently utilized.
CONCLUSION In the changing landscape of health care delivery, the quality of radiology reporting is likely to attract greater scrutiny. Effective radiology reports require clarity, a logical structure, and appropriate word choice. Increasingly important, however, is that radiologists assert themselves as expert consultants by rendering definitive opinions about the question at hand, with a paucity of disclaimers. Radiologists should seek to characterize uncertainty as accurately as possible and guide physicians to subsequent care. Clearly stating the significance of incidental findings will prevent unnecessary investigation cascades while ensuring that necessary investigations are undertaken. Ultimately, effective reporting allows the highest possible quality of imaging care to be delivered, increasing efficiency and improving patient outcomes.
REFERENCES 1. Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg 2014;140:317-22. 2. Berland LL. Overview of white papers of the ACR incidental findings committee II on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. J Am Coll Radiol 2013;10:672-4. 3. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 2015;12:143-50.
Jeffrey B. Ware, MD and Saurabh Jha, MBBS, are from the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Jenny K. Hoang, MBBS, is from the Department of Radiology, Duke University, Durham, North Carolina. Stephen Baker, MD, is from the Department of Radiology, Rutgers New Jersey Medical School, Newark, New Jersey. Jill Wruble, DO, is from the Department of Radiology, Yale New Haven Health System, New Haven, Connecticut. The authors have no conflicts of interest related to the material discussed in this article. Dr Jeffrey Bright Ware, MD: Hospital of the University of Pennsylvania, Department of Radiology, 3400 Spruce Street, Philadelphia, PA 19104; e-mail: [email protected].
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Journal of the American College of Radiology Volume - n Number - n - 2017
Effective Radiology Reporting Jeffrey B. Ware, MD, Saurabh Jha, MBBS, Jenny K. Hoang, MBBS, Stephen Baker, MD, Jill Wruble, DO
INTRODUCTION As the primary means by which radiologists communicate with referring physicians and other health care providers, the radiology report must be concise, clear, and clinically relevant. Suboptimal radiology may lead to both under- and overinvestigation, spurring under- and overtreatment. In the changing landscape of health care reimbursement, we expect increasing scrutiny to be paid to the quality of radiology reports. Here, we summarize the key elements of effective radiology reporting.
ORGANIZE YOUR THOUGHTS A well-organized radiology report is easy to read and conveys relevant information. A well-organized report requires clarity of thought, consistent format, deep knowledge of imaging, and an awareness of clinical context. These tenets allow information to flow, reduce errors of omission, and avoid multiple interpretations of the same term. In addition to mention of positive findings, the report should mention negative findings pertinent to the clinical context. Radiologists should strive for brevity and use short, readable paragraphs to separate ideas. Declarative sentences are easier to understand than sentences with many dependent clauses. The use of standardized reports can help with logical flow while improving reproducibility and utility, so long as context is not eschewed. As the most important component of the report, the “impression,” should
contain only the most relevant findings, as well as the radiologist’s interpretation as to the cause and significance of those findings in the context of the clinical question. When findings are equivocal, a long list of differential diagnoses is less valuable than a clear direction regarding the next step. Recommendations for management and follow-up, when appropriate, should be evidence-based rather than an imperative to reduce risk.
BE CLEAR Radiological jargon with no clinical meaning, such as shotty and prominent, should be avoided. When using adjectives such as significant, the facts that justify their use should be explained. Qualification of the presence and the extent of an abnormality should be reported and, when appropriate, measurements should be included. Equally, it is important not to overdo measurements on an entity that is patently benign, such as a renal cyst. Adding terms such as identified and evidence of to the negativity of a finding, as in “no evidence of aortic dissection,” is redundant and should generally be avoided except in cases in which the imaging modality is clearly suboptimal for the evaluation of certain pathology. For example, in reporting a noncontrast abdominal CT in a patient with colon cancer, it is reasonable to say “no metastasis in the liver identified” to emphasize the limitation of this modality in detecting liver masses. However, excessive use of such terms can give the impression that the
ª 2017 Published by Elsevier on behalf of American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.01.045
radiologist is evasive, noncommittal, and unwilling to accept responsibility for the care of the patient. Similarly, when imaging is obtained to re-evaluate a finding, the phrase “no significant interval change” often appears. This phrase is redundant because interval is implied. Rather than use redundant terminology, it is better to state the duration in which stability was observed; for example, “no change in size of aortic aneurysm over 2 years.”
TAKE RESPONSIBILITY The value of imaging is in reducing diagnostic uncertainty and making a specific diagnosis when possible. The phase cannot be excluded, though occasionally justified, does not reduce uncertainty but attempts to absolve the radiologist from taking responsibility. Rather, the radiologist should use conditional probabilities to advise the likelihood of possible diagnoses, creating the most value by integrating imaging expertise with clinical information. In the “rule out disease” culture of medicine, cannot exclude implies that more tests are needed and may ultimately drive unnecessary investigations that deplete resources and pose risk to patients through detection of incidental findings. All health care professionals have a responsibility to seek and incorporate relevant information for medical decisions. The phrase correlate clinically is unhelpful and regarded with disfavor by referrers who interpret it as a reminder to do their job. Use of this phrase is
1
particularly problematic when there is no clinical information that could potentially alter the radiological interpretation. When crucial clinical information is not known at the time of interpretation, the radiologist must specify what the missing information is, or which additional test is needed. For example, given the finding of proptosis and enhancing intra-orbital tissue, a report may state, “If the orbits are painful, this may represent idiopathic orbital inflammation.”
CLOSE THE LOOP ON INCIDENTAL FINDINGS The radiology report should answer the clinical question and address the organ or system suspected of causing symptoms. However, imaging covers many organs and will inevitably lead to detection of incidental findings. Some incidental findings may be of high importance, such as a spiculated lung nodule on a neck CT. Often, however, incidental findings have no concerning features and may be regarded as inconsequential. In any case, simply listing the incidental finding without guidance is of no value. Rather, the radiologist must state clearly whether an incidental finding is consequential, and if so, what the next step should be. A very common example, the incidental thyroid nodule detected on CT or MRI, can often lead to an investigation cascade of fine needle aspiration, ultrasounds, and even thyroidectomy without necessarily improving patient outcomes [1]. Averting such a cascade, when clearly unnecessary, by issuing
definitive recommendations for workup of incidental findings based on the ACR white papers [2,3] provides tremendous benefit both to patients and to the health care system.
MAKE REPORTS READABLE FOR PATIENTS As patients increasingly access their health data, including radiology reports, it will become even more important for radiologists to report clearly. Although technical terms are often unavoidable, the use of unnecessarily extraneous or dramatic terms, which may increase anxiety, is not. If essentially normal means normal, it is better to say normal. Mentioning incidental findings and anatomic variants in the absence of clearly stated significance will carry a risk of spurring patient anxiety and subsequent additional unhelpful investigation.
BE AN EXPERT CONSULTANT As health care payment moves from a fee-for-service model toward a more value-based system, the quality of radiology reporting is likely to come under greater scrutiny given its crucial role in health care delivery. Clear, concise, and definitive radiology reports are the mark of an expert consultant and, in accordance with the ACR Imaging 3.0 initiative, will ensure that the radiologist continues to play a critical role in patient care. Effective radiology reporting will be required not only to inspire the highest confidence from referring physicians and our patients, but also to
demonstrate the value of radiologists by reducing the use of unnecessary and low-value procedures, thereby preserving resources to ensure that highvalue services are appropriately and consistently utilized.
CONCLUSION In the changing landscape of health care delivery, the quality of radiology reporting is likely to attract greater scrutiny. Effective radiology reports require clarity, a logical structure, and appropriate word choice. Increasingly important, however, is that radiologists assert themselves as expert consultants by rendering definitive opinions about the question at hand, with a paucity of disclaimers. Radiologists should seek to characterize uncertainty as accurately as possible and guide physicians to subsequent care. Clearly stating the significance of incidental findings will prevent unnecessary investigation cascades while ensuring that necessary investigations are undertaken. Ultimately, effective reporting allows the highest possible quality of imaging care to be delivered, increasing efficiency and improving patient outcomes.
REFERENCES 1. Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg 2014;140:317-22. 2. Berland LL. Overview of white papers of the ACR incidental findings committee II on adnexal, vascular, splenic, nodal, gallbladder, and biliary findings. J Am Coll Radiol 2013;10:672-4. 3. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol 2015;12:143-50.
Jeffrey B. Ware, MD and Saurabh Jha, MBBS, are from the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Jenny K. Hoang, MBBS, is from the Department of Radiology, Duke University, Durham, North Carolina. Stephen Baker, MD, is from the Department of Radiology, Rutgers New Jersey Medical School, Newark, New Jersey. Jill Wruble, DO, is from the Department of Radiology, Yale New Haven Health System, New Haven, Connecticut. The authors have no conflicts of interest related to the material discussed in this article. Dr Jeffrey Bright Ware, MD: Hospital of the University of Pennsylvania, Department of Radiology, 3400 Spruce Street, Philadelphia, PA 19104; e-mail: [email protected].
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Journal of the American College of Radiology Volume - n Number - n - 2017