Management of Radiology Report Templates - Detailed Proposal

1. Proposed Workitem: Management of Radiology Report Templates

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

Summary

The variability in radiology report structure, content and terminology makes reports difficult to process and can cause communication errors. In response to these shortcomings, RSNA has created a library of best-practices report templates. This library now contains over 100 templates in three languages. Many radiology practices have also accumulated large libraries of report templates, and some practices are beginning to standardize their format and appearance. Managing and distributing templates based on standard ontologies would promote convergence among radiology practices and would facilitate migration of templates between reporting systems from different vendors. However, the relevant systems are not available to support and encourage the use of consistent report templates.

Over the past year, we have drafted a white paper that could serve as the basis of a Management of Report Templates (MRT) profile. The white paper describes a proposed information model and format for radiology report templates. This model could serve as the underpinning for queries of template libraries, the transfer of templates between libraries and reporting systems, and the use of standard templates created by radiology practices, professional organizations, and vendors.

Individuals from the RSNA Reporting Committee are prepared to continue their participation in Profile development.

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 find the information they need in 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 the Reporting Committee, chaired by Drs. Langlotz and 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 100 templates over 2 years. These templates became available in a searchable web site at the time of the 2010 RSNA annual meeting.

Likewise, 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 ontologies will facilitate machine processing of report information, enabling decision support, integration with other elements of the electronic medical record, and improved quality of care.

3. Key Use Cases

Report Template Single Download/Upload

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

• Rad searches 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 tools provided by the reporting system .
• Rad selects the template and proceeds to create a 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.

Key Design Decision

The group working on this profile over the last year made a fundamental design decision: there is no need to develop a search/query/retrieve infrastructure for radiology report templates. Individual template libraries will implement their own methods, which will result in a file that contains one or more templates in a standard format. Therefore, the work of the group, and the bulk of the white paper focus on the information model for the template and the format of that file.

4. Standards & Systems

Systems involved:

• Any system that creates a radiology report from a template, primarily speech recognition systems and structured reporting systems, but also some RIS and PACS systems

Relevant Standards:

• XML, including RelaxNG and CDA
• HL7
• RadLex and other terminology systems, such as LOINC and SNOMED
• IHE ITI Profile: Shared Value Sets (SVS)
• IHE QRPH Profile: RPE (Retrieve Protocol for Execution)?

The intent is for the standard templates to facilitate the creation of report instances that are HL7 CDA compliant. A preferred encoding method for templates has not been selected.

5. Technical Approach

Over the past year, we have reached agreement that template search, filter, download methods are outside the scope of this project. We have also reached substantial agreement on the elements that should be included in report templates as they are managed. For a detailed description of the proposed report elements, please refer to the draft white paper.

Reports contain text and "fields", which have pre-defined types. Elements of the report can refer back to terms from a standard terminology.

The profile will provide a method to load and save templates and their embedded terminology information to/from 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

In the coming year we will accomplish the following tasks

• Decide on a preferred encoding for templates. The RSNA templates have been encoded in RelaxNG, a schema language for XML. However, the draft white paper describes template features that are not currently a part of the RSNA library. A key next step will be to select an encoding method(s) for templates. Because HL7 CDA and the RSNA report templates both are encoded in XML compatible formats, a dialect of XML would be a logical choice. A DICOM-compatible encoding should also be considered.
• 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 be necessary.
• Produce 2-3 sample templates encoded using the preferred encoding method(s). 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.

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.
• RSNA will continue to encourage vendor involvement and support and intends to hold a second radiology reporting forum in 2012.
• At least one reporting vendor has already encoded many of the RSNA templates in their system.

7. Risks

• Might not be able to get the reporting workstation vendors to participate/implement
  • At least one reporting vendor has 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.

8. Open Issues

• Is this a radiology profile or should it be handled in PCC or ITI?
  • Probably Radiology. Radiology is uniquely and solely focused on the creation of reports from diagnostic images. The vendors involved, the workflows involved, and many of the concepts are Radiology specific, but it likely has good overlap with the image report creation activities in Cardiology, endoscopy, and in the future, Pathology.
  • Not clear there is a benefit to abstracting this further to "templates for any medically-related report generation", since diagnostic imaging reports have an internal structure that is significantly different than most other medical documents.

• Are these templates used by speech recognition as well?
  • Yes, the information model described in the white paper is intended to be compatible with the simpler case of blanks within the macros of current speech recognition systems, and the report exchange profile should address that use case, since speech recognition systems are currently the most common type of installed reporting systems.

• For additional open issues, please refer to the draft white paper.

9. Tech Cmte Evaluation

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

• 20% if basic encoding and transport of templates between systems

Responses to Issues:

See italics in Risk and Open Issue sections

Editor:

Curtis Langlotz