Structured Reporting for Urgent Care Radiology

With reimbursements for X-ray professional services declining and increasing expectations for faster report turnaround times, long gone are the days of transcriptionists in the Radiologist’s workflow. Voice recognition has solidly become the new paradigm in Radiology reporting, with an accuracy rate exceeding 99% for most users. Despite this level of accuracy and our best proof reading efforts, typographical errors remain problematic. In our busy Teleradiology Practice the typographical error rate is less than a mere 0.1% of all exams, but the rare error can be embarrassing or a potential detriment to patient care.

In an effort to reduce these risks, we have implemented Structured Reporting techniques for all exams. At one time maligned by referring Physicians and Radiologists alike for their generic look and lack of style, these Structured Reports have now been embraced as the new standard of care. This, a decade after having been first recommended by the participants of the 2007 Intersociety Conference. Indeed, at this time, the frequency with which structured reports are used is one of the quality metrics still employed by the Intersociety Conference.

An ideal structured report is subdivided into meaningful sections, which are consistently ordered and contain standard language. The structured reports are preferred by referring physicians and facilitate the extraction of key information from reports. Such information extraction is increasingly necessary to document quality metrics linked to financial incentives offered by the Medicare program and to satisfy regulatory and accreditation requirements. Urgent Care, in particular, lends itself well to Structured Reporting due to the inherent nature of the X-ray exams which, by in large, are short, straightforward positive or negative results.

So, next time you see that machine generated “canned” report for the 1000th time, rest assured that it was rendered for the sake of quality improvement and patient care.

For more information about establishing an electronic interface, or more information about Teleradiology Specialists contact Howard Reis at 845-392-2915 or hreis@teleradiologyspecialists.com.