Implementation of structured reporting in clinical routine: a review of 7 years of institutional experience

BackgroundTo evaluate the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years.MethodsWe analysed the content of our image database from January 2016 to December 2022 and compared the numbers of structured reports and free-text reports. For the ten most common SR templates, usage proportions were calculated on a quarterly basis. Annual modality-specific SR usage was calculated for ultrasound, CT, and MRI. During the implementation process, we surveyed radiologists and clinical referring physicians concerning their views on reporting in radiology.ResultsAs of December 2022, our reporting platform contained more than 22,000 structured reports. Use of the ten most common SR templates increased markedly since their implementation, leading to a mean SR usage of 77% in Q4 2022. The highest percentages of SR usage were shown for trauma CT, focussed assessment with ultrasound for trauma (FAST), and prostate MRI: 97%, 95%, and 92%, respectively, in 2022. Overall modality-specific SR usage was 17% for ultrasound, 13% for CT, and 6% for MRI in 2022. Both radiologists and referring physicians were more satisfied with structured reports and rated SR better than free-text reporting (FTR) on various attributes.ConclusionsThe increasing SR usage during the period under review and the positive attitude towards SR among both radiologists and clinical referrers show that SR can be successfully implemented. We therefore encourage others to take this step in order to benefit from the advantages of SR.

Automated summary

This study evaluated the implementation process of structured reporting (SR) in a tertiary care institution over a period of 7 years. The results showed that the usage of SR increased significantly and was well received by radiologists and clinical referrers.