Management of Radiology Report Templates - Detailed Proposal - 2012-2013

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1. Proposed Workitem: Management of Radiology Report Templates

  • Proposal Editor: David S. Mendelson, Curtis Langlotz, Charles Kahn
  • Editor: Curtis Langlotz
  • Domain: Radiology

2. The Problem

Radiology reports today display significant variation in structure, content and terminology. Consequently, referring clinicians and radiologists find it much more difficult to glean the information they need from radiology reports, which vary significantly in content and structure. This variability hampers communications and creates risk of misunderstanding. Variable report formats also complicates accurate machine extraction of facts from the report, making it extremely difficult to re-use the data in the radiology report for decision support, data mining or fully integrated electronic medical records.

In 2007, the ACR Intersociety Summer Conference reached consensus that a structured and standardized reporting method was optimal, provided that automated reporting tools become available to create reports efficiently. The conference group also recommended that professional societies begin developing a set of best-practices report templates.

In 2008, the RSNA convened a Reporting Committee, chaired by Dr. Langlotz and co-chaired by Dr. Kahn, to create a set of report templates. An initial community forum was held to select technical standard and to develop a set of standard report sections. Thirteen subcommittees of clinical experts were convened and have created more than 200 templates over 3 years. These templates are now available on a searchable web site. A second vendor forum was held in July 2012, and was well attended by reporting vendors and radiologists. recently established a template exchange site where radiologists and others could upload their own templates for others to adopt. DICOM WG8 has begun work on a supplement to describe standards for the representation of report instances that would be created from radiology report templates.

At the same time, many institutions have created their own large libraries of templates. Some vendors provide libraries of templates as well. Despite this proliferation of templates, there are no reliable vendor-independent methods to exchange templates among individuals, systems, and organizations. This creates an inefficient market for reporting systems, since customers must consider the substantial cost of migrating templates between potentially incompatible proprietary vendor template formats.

Standardized templates such as those recently developed by RSNA, would make reports clearer and easier to consume quickly, resulting in better speed and quality of care. A profile to manage and exchange report templates will result in wider dissemination of best-practices, will improve the quality of radiology communication, and will reduce the risk of errors. The increased use of underlying standard terminology will facilitate machine processing of report information, enabling decision support, integration with other elements of the electronic medical record, and improved quality of care.

There is a rapidly growing consensus among radiologists that template-based radiology reporting is the optimal method to create imaging reports. Radiology practices are looking for reporting products that incorporate advanced template functionality, enable rapid editing and adoption of templates, and provide a means for template distribution and data migration among vendor systems.

A profile to manage these templates would accelerate the adoption of key template features in products and thereby accelerate the adoption of templated reporting by radiologists and others.

3. Key Use Cases

Report Template Single Download/Upload

A radiologist is using a vendor-supplied reporting system in the reading room to report an exam type for which he has not yet created a satisfactory template.

  • Rad browses the RSNA or other template library to find a template that would be ideal for the exam being reported.
  • Rad clicks the “Download Template” button and saves the template as a file on his desktop.
  • Rad selects “Upload Template” in the reporting software, selects the file on his desktop
  • Reporting software imports the template and adds it to the template/macro list
  • Rad optionally edits the template using the reporting system tools
  • Rad selects the template and proceeds with report.

Report Template Bulk Download/Upload A vendor is installing a new reporting system at an institution that would like to go live with a significant portion of RSNA or other radiology template library ready for use. A radiologist from that institution browses the RSNA template library, selecting the templates he would like to be available at go live, and downloads them as a single file containing multiple templates. That file is uploaded to a particular user or group profile in the reporting system, where all of the templates are available for use by the radiologist.

Report Template Data Migration An institution is changing speech recognition vendors, but would like to retain the templates that the radiologists have been using in the old system, which have been refined over many years of use. The informatics staff use the “Export Templates” function on the old system to create an export file containing all of the templates in the old system, organized by group and user profile. An “Import Templates” function on the new system is then used to make those same templates available in the corresponding profiles in the new reporting system.

4. Standards & Systems

Systems involved:

  • Speech recognition and structure reporting systems / RIS systems / PACS systems

Relevant Standards:

  • Terminology: RadLex, LOINC, SNOMED
  • Template format: defined by profile, based on XML
  • Report instance format: defined by DICOM WG8, likely based on HL7 CDA

5. Technical Approach

For a detailed description of the technical approach, please refer to the draft white paper. We have reached agreement that template search, filter, download methods are outside the scope of this profile. We have also reached substantial agreement on the elements that should be included in report templates as they are managed. Reports contain text and "fields", which have pre-defined types. Elements of the report can be associated with coded content, including terms from a standard terminology.

The profile will describe an XML-based file format that can be used to exchange one or more templates and their embedded terminology information to/from report libraries and report creation systems. The format of the resulting report will be determined by the report system that utilizes the template, but template may specify some behaviors of the report creation system during report creation (i.e. what it's required to do in response to "instructions" in the templates).

Breakdown of tasks that need to be accomplished

  • Convert the MRRT white paper to a profile
  • Create 2-3 examples of the template encoding described in the profile. These template examples will be chosen from the RSNA library, will be linked to controlled vocabulary, and in the subsequent year can serve as a testbed that vendors could use to demonstrate that their systems can load, save, and use template files.
  • Coordinate activities with DICOM WG8. DICOM WG8 (Structured Reporting) is currently working on an HL7 CDA encoding of the reports that would be produced from these templates. Close coordination of the two groups through Drs. Kahn and Langlotz will continue to be necessary.

Existing actors

  • Report Creator

New actors

  • None

Existing transactions

  • Consider use of the SVS transactions for distributing terminologies.

Impact on existing integration profiles

  • Likely synergy with Reporting Workflow

New integration profiles needed

  • This concerns a new profile for Management of Reporting Templates (MRT)

6. Support & Resources

  • The RSNA Reporting Committee and its subcommittees are committed to working with the IHE and DICOM WG8 to create a profile to enable the exchange of radiology report templates. Dr. Langlotz, who chairs that RSNA committee, is the primary author of the white paper, and Dr. Kahn, who co-chairs that RSNA committee, also serves as the co-chair of DICOM WG8, which is working on HL7 CDA compatibility of report instances.
  • The RSNA RadLex Committees have been responsive to requests for new terms that have been needed to create new report templates, and view the structured reporting effort as a primary showcase for the clinical deployment of their ontology development work.
  • At least one reporting vendor has already encoded many of the RSNA templates in their reporting product.

7. Risks

  • There is always a potential risk of lack of vendor participation, but given customer needs, and vendor participation in the recent RSNA forum, this is unlikely to become a serious problem. Several reporting vendors have actively participated in the drafting of the white paper, and several others are following developments closely. RSNA is engaging with reporting vendors through its vendor forum, and sends periodic emails to update group of over a dozen interested vendors.
  • This profile requires active participation from clinical experts, but the proposal authors editor is a radiologist and can call on the relationship with RSNA when additional clinical input is needed.

8. Open Issues & Discussion

The IHE has produced a white paper that describes an information model and format for the representation and exchange of radiology templates and the fields they contain. The completed MRRT white paper was submitted for public comment earlier this week. The purpose of this brief proposal is to gain approval for the additional work necessary to convert this white paper into a formal IHE profile, and to create template samples that could be used with this profile as part of the IHE connect-a-thon process.

Image reporting is a workflow issue that is a natural extension of other IHE work. While many IHE profiles touch on the workflow surrounding the generation and storage of images, this missing piece involves integrating the generation and sharing of reports and the subsequent use of coded report content.

Key open issues that would need to be resolved over the coming year are as follows (taken from the open issues list of the white paper):

  • Harmonizing this framework for templates with the framework for report instances under discussion by DICOM WG8
  • Modifying existing RSNA templates to conform to the IHE framework (performed by RSNA)
  • Finalizing the scope for field identifiers for reports in which more than one template has been invoked
  • Formalizing semantics of inheritance among templates
  • Creating coded entry examples of both in-line markup and markup in a separate section
  • Providing more specific guidance on how merge fields should be specified and retrieved using coded content
  • Exploring more flexible methods for representation of coded content

9. Tech Cmte Evaluation

Effort Evaluation (as a % of Tech Cmte Bandwidth):

  • 30%
    • working through packaging this as a Content Profile will be significant
    • embedding WG-8 CDA output templates is out of scope (WG-8 still WIP and this profile should not mandate the output format)

Responses to Issues:

See italics in Risk and Open Issue sections

Candidate Editor:

Curtis Langlotz
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