Templates, Modules, and Common Data Elements: Building Blocks of Structured Reporting

Background:

The report is mostly considered the main product of a radiology department, the quality of which affects the success and impact of the institution and radiologist. The current trend of using electronic tools for the enhancement of the quality of reports reveals that structured reporting has undeniable advantages over free-text reporting. But, why this method has not been widely adopted?

Objectives:

By listening to this lecture, the audience is expected to:

1. List the barriers to using structured reporting in clinical practice.

2. Describe the advantages of modular vs. template-based structured reporting.

3. Explain the importance of common data elements in standardized reporting.

Outline:

There are multiple technical, conceptual, professional, and cultural reasons preventing radiologists to make use of structured reporting in their day to day practice. From the professional or clinical point of view, the flexibility of the system to provide the most relevant items while being reasonably short is the main reason why radiologists cannot report in a structured manner even if they like. Templates are the most popular containers of the predefined elements every radiologist plans to include in his/her report. But, the templates available for structured reporting are not comprehensive enough to cover all potential pathologies. In addition, there should be a basic standard to define how everybody describes a particular situation. These standards can be defined through the common data elements concept.