What is the radiology reporting initiative?

The clinical report is an essential part of the service you provide to your patients. As a tool that communicates information to referring physicians, records that information for future use and serves as the legal record that documents the episode of care, it is of the utmost importance that the report be uniform, comprehensive, easily managed and "readable" to humans and machines alike.

The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates. These templates make it possible to integrate all of the evidence collected during the imaging procedure, including clinical data, coded terminology, technical parameters, measurements, annotations and key images. Twelve subcommittees of subspecialty experts have created a library of best-practices radiology report templates. They are free and not subject to license restrictions on their reuse. These report templates:

• Create uniformity and improve your communication with referring providers
• Enable your practice to meet accreditation criteria
• Help your practice earn pay-for-performance incentives

Through this initiative, RSNA is encouraging reporting vendors to develop software products that enable radiologists to create high-quality radiology reports more efficiently.

How is it used?

The report template library serves as a starting point for radiology practices wishing to improve the quality of their reports by standardizing format, content and structure. These new report templates represent best-practices that can be adapted and adopted based on your local practice patterns. The templates are published in a form that is accessible to you—whether you use automated speech recognition or other reporting tools.

In addition to the clinical benefits, these templates have advantages for research and education. For researchers, these report templates capture information in a uniform, easily extracted format that facilitates clinical, translational and health services research. Educators find these templates can help trainees learn the important elements of reports in each subspecialty area and encourage the proper use of radiology terms, such as those found in RadLex™. 

Who is involved?

Beginning in 2009, 12 RSNA template development subcommittees—comprising over 100 experts—created 68 radiology report templates in collaboration with more than a dozen radiology subspecialty organizations. A radiology vendor forum attracted 12 companies who demonstrated their radiology reporting software and learned how they can incorporate the new templates into their systems. These vendors will continue to be engaged through the RSNA IHE platform. There are now more than 100 templates available in the RSNA template library.

How do I adopt this solution?

1. You or your IT administrator can obtain the templates from the download page, in both a text format that is human-readable and an XML-format that will be familiar to vendor representatives and your technical staff. The text templates can serve as a starting point to develop a consensus among the radiologists in your practice. Once your practice has agreed upon a set of consensus templates, they can be incorporated into your reporting system by your IT administrator or your reporting vendor.
2.  Participate in the template development process. Each template development subcommittee uses a news group to coordinate its activities. Anyone can request to join one of these groups. The subcommittee chairs also welcome suggestions for needed templates. Comments can be submitted to reporting@rsna.org 

Related Publications

The following publications have been authored by the committee and its members:

• Dunnick NR, Langlotz CP: The radiology report of the future: A summary of the 2007 Intersociety Conference. Journal of the American College of Radiology 5(5): 626-9, May 2008
• Weiss DL and Langlotz CP: Structured reporting: Patient care enhancement or productivity nightmare? Radiology 249: 739-47, Dec 2008.
• Douglas PS, Hendel RC, Cummings JE, Dent JM, Hodgson JM, Hoffmann U, Horn RJ 3rd, Hundley WG, Kahn CE Jr, Martin GR, Masoudi FA, Peterson ED, Rosenthal GL, Solomon H, Stillman AE, Teague SD, Thomas JD, Tilkemeier PL, Guy Weigold W: American College of Cardiology Foundation (ACCF). ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. J Am Coll Cardiol. 2009; 53(1):76-90.
• Kahn CE, Langlotz CP, Burnside ES, Carrino JA, Channin DS, Hovsepian DM, Rubin DL: Towards best practices in radiology reporting. Radiology. September 2009. 252:852-856
• Langlotz CP: Structured radiology reporting: Are we there yet? Radiology. October 2009 253(1):23-25
• Burnside ES: The ACR BI-RADS® experience: Learning from history. JACR 2009. (In press.)
• Langlotz CP: The ACR BI-RADS® system for breast imaging communication: A roadmap for the rest of radiology. JACR 2009. (In press.)