Strategies for radiology reporting and communication. Part 1: challenges and heightened expectations.

The overall effectiveness of any medical reporting instrument is tied to its ability to serve as a method for communication of data, ideas, and concepts in a clear and unambiguous fashion. In addition to these functional requirements, a number of practical and technical requirements should be considered; which involve elements of timeliness, security, confidentiality, accessibility, transmission, and verification. Regardless of how “functionally” accurate and complete the report is, its overall value in positively effecting medical care is limited if the information is not received by its intended recipients in a timely fashion, with a complete and thorough understanding of its contents. In the present form, most medical reports serve as a method of notification, in which one party (e.g., radiologist) interprets a dataset (e.g., imaging) and composes a report (e.g., radiology), in which the interpreted findings are conveyed to a recipient (e.g., referring clinician), who in turn utilizes this report information to direct patient care decision making. In this common scenario, the medial report serves a method of one-way notification. Once it has been sent (and presumably received), the sender of the report (e.g., radiologist) assumes the recipient will correctly assimilate these report data into a timely and accurate care plan. This is often an erroneous assumption given the current state of report ambiguity and uncertainty [1, 2], not to mention the increasing workload demands and data overload facing radiologists [3]. As a result of these existing challenges and deficiencies, the report should be viewed not as an end-all, but instead as a first step in the communication and decision-making process. In the “old” analog days of medical imaging practice restrictions on imaging data accessibility, workflow, and delays in report turnaround fostered a more collaborative working environment than currently exists. A referring clinician wanting timely information regarding a recently performed imaging study would literally have to travel to the radiology department, request access to the corresponding images, and then engage in a direct consultation with the interpreting radiologist. While this dynamic presented a number of workflow limitations (for all participants), it also presented a number of distinct advantages relating to direct information exchange, bidirectional understanding, and collaboration. In most cases, once the radiologist–clinician consultation had been completed, both parties had a better and more complete understanding of the clinical scenario, imaging data analysis, and follow-up requirements. This interpersonal dialogue also involved interdepartmental imaging staff (e.g., radiologists, technologists, clerical staff, and administrators) who were encouraged to routinely dialogue with one another over matters regarding imaging exam selection, scheduling, protocoling, quality assurance, clinical/imaging history, and imaging data findings, all of which indirectly or directly affected the radiology report. In addition, analog report workflow was far different, with report transcription outsourced to third party transcriptionists. This introduced significant time delays (and transcription errors) into report turnaround, which was measured in days as opposed to hours. While these reporting delays created frustration on the part of referring clinicians (and their staff), they did come with a positive effect, in fostering a greater degree of consultation and interpersonal communication between the parties. With the digitization of medical imaging and the introduction of digital information system technologies such as the picture archival and communication system (PACS) and radiology information system, a number of dramatic changes occurred in practice which profoundly affected radiology reporting. On a positive note, imaging data were instantaneously and ubiquitously accessible to medical staff, both in and outside of the healthcare enterprise. This meant that a referring clinician (with the appropriate credentials) could access imaging data in his/her office, obviating the need to physically travel to the imaging department, which was far more workflow efficient. At the same time, the widespread adoption of speech recognition software changed report transcription and turnaround, which was now measured in hours (or even minutes). These combined factors not only caused a dramatic change in imaging and report accessibility and timeliness, but indirectly modified report evaluation, from reporting content and consultation, to reporting workflow. In the analog imaging practice, essentially all reports required days to receive, thereby promoting radiologist–physician consultations. As a result, many physicians evaluated radiologist performance by the perceived quality of the report and consultations. Once the transition to digital imaging was complete and images/reports made readily available, these consultations became less necessary [4]. While report content remained important, an increasing focus of imaging performance evaluation was on report turnaround time and efficiency of report delivery. In addition to these changes in imaging data accessibility and timeliness, other profound technologic and economic changes were taking place inside of the radiology department affecting deliverables. The advent of PACS provided a mechanism in which radiologist service was no longer required on site, and more service providers utilized teleradiology for radiology outsourcing. This assisted in addressing practical challenges related to increasing exam complexity and volume, but made radiologists less accessible to consultations. While phone conversations remained a viable alternative, the increasing workload demands and time constraints facing clinicians, lack of familiarity between the parties, and relative lack of technologic support (regarding remote consultation functionality) have made remote consultations relatively inefficient and less desirable. While radiologists would normally be expected to proactively promote consultations to address these practice changes, the increasing workload, exam complexity, and service demands placed upon them have created an environment of relative indifference. This indifference has arguably been further aggravated by continued declines in reimbursement and the commoditization of radiology services [5]. In an attempt to maintain revenue, many radiology providers opt to optimize productivity and workflow, which has the potential to further reduce consultations. The lack of interpersonal communication (among multiple stakeholders) has adversely affected data accessibility and understanding, which in turn has the potential to negatively impact clinical outcomes. While encouraging more face-to-face communication would serve as an important step to counteract these trends, this would be the equivalent of trying to put the genie back in the bottle. Technology has served as the principle catalyst of negative change in reporting and communication and, if properly channeled, can also serve as the catalyst for improvement. Reporting strategies (and technologies) must begin to adapt to these changing needs by serving as a proactive source of collaboration, consultation, education, and customization.