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结构化报告:如果、为什么、何时、如何——以及代价如何?来自八个国家的放射科专业人员焦点小组会议的结果。

Structured reporting: if, why, when, how-and at what expense? Results of a focus group meeting of radiology professionals from eight countries.

机构信息

Antwerp University Hospital, Edegem, Belgium,

出版信息

Insights Imaging. 2012 Jun;3(3):295-302. doi: 10.1007/s13244-012-0148-1. Epub 2012 Mar 14.

Abstract

PURPOSE

To determine why, despite growing evidence that radiologists and referring physicians prefer structured reporting (SR) to free text (FT) reporting, SR has not been widely adopted in most radiology departments.

METHODS

A focus group was formed consisting of 11 radiology professionals from eight countries. Eight topics were submitted for discussion. The meeting was videotaped, transcribed, and analyzed according to the principles of qualitative healthcare research.

RESULTS

Perceived advantages of SR were facilitation of research, easy comparison, discouragement of ambiguous reports, embedded links to images, highlighting important findings, not having to dictate text nobody will read, and automatic translation of teleradiology reports. Being compelled to report within a rigid frame was judged unacceptable. Personal convictions appeared to have high emotional value. It was felt that other healthcare stakeholders would impose SR without regard to what radiologists thought of it. If the industry were to provide ready-made templates for selected examinations, most radiologists would use them.

CONCLUSION

If radiologists can be convinced of the advantages of SR and the risks associated with failing to participate actively in its implementation, they will take a positive stand. The industry should propose technology allowing SR without compromising accuracy, completeness, workflows, and cost-benefit balance.

MAIN MESSAGES

Structured reporting offers radiologists opportunities to improve their service to other stakeholders. • If radiologists can be convinced of the advantages of structured reporting, they may become early adopters. • The healthcare industry should propose technology allowing structured reporting. • Structured reporting will fail if it compromises accuracy, completeness, workflows or cost-benefit balance.

摘要

目的

尽管越来越多的证据表明放射科医生和临床医生更喜欢采用结构化报告(SR)而非自由文本(FT)报告,但 SR 并未在大多数放射科得到广泛采用,本研究旨在探讨原因。

方法

组建了一个由来自 8 个国家的 11 名放射科专业人员组成的焦点小组,提交了 8 个主题供讨论。会议进行了录像、记录和分析,采用定性医疗保健研究的原则。

结果

SR 的优势包括促进研究、便于比较、减少歧义报告、嵌入与图像的链接、突出重要发现、不必口述没人会读的文本、以及远程放射学报告的自动翻译。报告被强制限制在一个僵化的框架内被认为是不可接受的。个人信念似乎具有很高的情感价值。有人认为,其他医疗保健利益相关者会不顾放射科医生的想法而强制推行 SR。如果行业能够为选定的检查提供预制模板,大多数放射科医生都会使用。

结论

如果放射科医生能够认识到 SR 的优势以及不积极参与其实施所带来的风险,他们将采取积极的立场。行业应提出允许实施 SR 而不影响准确性、完整性、工作流程和成本效益平衡的技术。

主要信息

结构化报告为放射科医生提供了改善对其他利益相关者服务的机会。

• 如果放射科医生能够认识到结构化报告的优势,他们可能会成为早期采用者。

• 医疗保健行业应提出允许结构化报告的技术。

• 如果结构化报告影响准确性、完整性、工作流程或成本效益平衡,它将失败。

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