Enabling the Next-Generation Radiology Report: Description of Two New System Standards

摘要

Currently, most radiology reports are highly variable and consist of unconstrained narrative text. This variability limits the ability to extract information from the report to guide clinical care, populate a data registry, or support quality improvement. This article introduces two newly available standards that pertain to radiology reports. Management of Radiology Reporting Templates (MRRT) is an integration profile that defines the format and exchange mechanisms for radiology report templates. Digital Imaging and Communications in Medicine Part 20 defines how reports built using MRRT-based templates can be transmitted into an electronic health record (EHR). Together, these two standards enable new ways to improve report consistency and completeness, ensure proper clinical action, and improve the quality of patient care. Commercial and open-source developers are beginning to incorporate these standards into clinical systems. The authors use an example of a patient with an incidentally detected lung nodule to illustrate how these standards improve the exchange of information. The clinical scenario follows the use of the appropriate template through the completion of the radiology report, with the incidental finding structured and coded to enable automated follow-up in the EHR.