Vosshenrich Jan, Brantner Philipp, Cyriac Joshy, Jadczak Adam, Lieb Johanna M, Blackham Kristine A, Heye Tobias
Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Radiology, Gesundheitszentrum Fricktal, Riburgerstrasse 12, 4031 Rheinfelden, Switzerland.
Acad Radiol. 2023 Apr;30(4):727-736. doi: 10.1016/j.acra.2022.05.011. Epub 2022 Jun 9.
To assess the effects of a change from free text reporting to structured reporting on resident reports, the proofreading workload and report turnaround times in the neuroradiology daily routine.
Our neuroradiology section introduced structured reporting templates in July 2019. Reports dictated by residents during dayshifts from January 2019 to March 2020 were retrospectively assessed using quantitative parameters from report comparison. Through automatic analysis of text-string differences between report states (i.e. draft, preliminary and final report), Jaccard similarities and edit distances of reports following read-out sessions as well as after report sign-off were calculated. Furthermore, turnaround times until preliminary and final report availability to clinicians were investigated. Parameters were visualized as trending line graphs and statistically compared between reporting standards.
Three thousand five hundred thirty-eight reports were included into analysis. Mean Jaccard similarity of resident drafts and staff-reviewed final reports increased from 0.53 ± 0.37 to 0.79 ± 0.22 after the introduction of structured reporting (p < .001). Both mean overall edits on draft reports by residents following read-out sessions (0.30 ± 0.45 vs. 0.09 ± 0.29; p < .001) and by staff radiologists during report sign-off (0.17 ± 0.28 vs. 0.12 ± 0.23, p < .001) decreased. With structured reporting, mean turnaround time until preliminary report availability to clinicians decreased by 20.7 minutes (246.9 ± 207.0 vs. 226.2 ± 224.9; p < .001). Similarly, final reports were available 35.0 minutes faster on average (558.05 ± 15.1 vs. 523.0 ± 497.3; p = .002).
Structured reporting is beneficial in the neuroradiology daily routine, as resident drafts require fewer edits in the report review process. This reduction in proofreading workload is likely responsible for lower report turnaround times.
评估从自由文本报告改为结构化报告对神经放射科日常工作中住院医师报告、校对工作量和报告周转时间的影响。
我们的神经放射科于2019年7月引入了结构化报告模板。回顾性评估了2019年1月至2020年3月日间住院医师口述的报告，使用报告比较中的定量参数。通过自动分析报告状态（即草稿、初步报告和最终报告）之间的文本字符串差异，计算读出会议后以及报告签署后报告的杰卡德相似度和编辑距离。此外，还调查了临床医生获得初步报告和最终报告的周转时间。参数以趋势线图的形式可视化，并在报告标准之间进行统计学比较。
3538份报告纳入分析。引入结构化报告后，住院医师草稿与放射科工作人员审核的最终报告的平均杰卡德相似度从0.53±0.37提高到0.79±0.22（p<.001）。读出会议后住院医师对草稿报告的平均总体编辑次数（0.30±0.45对0.09±0.29；p<.001）以及报告签署期间放射科工作人员的编辑次数（0.17±0.28对0.12±0.23，p<.001）均减少。采用结构化报告后，临床医生获得初步报告的平均周转时间减少了20.7分钟（246.9±207.0对226.2±224.9；p<.001）。同样，最终报告平均提前35.0分钟可得（558.05±15.1对523.0±497.3；p=.002）。
结构化报告在神经放射科日常工作中有益，因为住院医师草稿在报告审核过程中需要的编辑较少。校对工作量减少可能是报告周转时间缩短的原因。
