A Framework for Improving

Radiology Reporting
Chris L. Sistrom, MD, MPHa, Curtis P. Langlotz, MD, PhDb

The interpretative reports rendered by radiologists are the only tangible manifestation of their expertise,
training, and experience. These documents are very often the primary means by which radiologists provide
patient care. Radiology reports are extremely variable in form, content, and quality. The authors propose a
framework for conceptualizing the reporting process and how it might be improved. This consists of standard
language, a structured format, and consistent content. These attributes will be realized by modifying the clinical
reporting process, including the creation, storage, transmission, and review of interpretative documents. The
authors also point out that changes in training and evaluation must be a part of the process, because they are
complementary to purely technical solutions.
Key Words: Reporting and communication, radiology reporting, speech recognition, structured reporting,
radiology lexicon, RadLex
J Am Coll Radiol 2005;2:159-167. Copyright © 2005 American College of Radiology

INTRODUCTION referring colleagues, they also challenge the way we think

Signed reports have long served as the primary means of
communication between radiologists and referring phy-
sicians. Their findings and conclusions often are the basis
for vital medical treatment decisions. Not surprisingly,
today’s health care professionals need timely online ac-
cess to well-organized, accurate image reports. Yet the
process of medical image interpretation, dictation, and
transcription has been fundamentally unchanged for de-
cades. In most hospitals and clinics, radiology reports are
still prepared by radiologist dictation followed by human
transcription. The report documents are stored as simple
free text, either electronically or printed on paper. Refer-
ring physicians review radiology report by reading the
written documents.
There are several important limitations to these con-
ventional reporting methods, including slow report turn-
around, suboptimal report quality and accuracy, and the
unsuitability of report information for quality improve-
ment and research. New technologies, such as speech
recognition and so-called structured reporting systems,
have been developed to address these shortcomings. Al-
though these new technologies provide opportunities for
radiologists to improve the services they provide to their
a
University of Florida, Department of Radiology, Gainesville, Florida.
b
Department of Radiology, University of Pennsylvania, Philadelphia, Penn-
sylvania.
Corresponding author and reprints: Chris L. Sistrom, University of Florida,
Department of Radiology, P.O. Box 100374, Gainesville, FL 32610; e-mail:
sistrc@radiology.ufl.edu.
about reporting.
Numerous commercial vendors specifically target the
radiology market with computer software to create inter-
pretative documents for general imaging, including large
diversified medical imaging companies and smaller,
early-stage companies. The presumption is that these
automated radiology reporting systems are superior to
the status quo and will lead to improved interpretation
quality, better patient outcomes, and systematic cost sav-
ings. Yet several questions arise regarding these new re-
porting methods. Who are the intended beneficiaries of
improved reporting? How might these benefits be real-
ized? How can improvements related to new reporting
methods be measured? What are the possible unintended
consequences of replacing traditional methods of dictat-
ing while viewing images?
In this paper, we provide a framework for answering
these questions and for improving radiology reporting, in
part by defining and justifying a hierarchy of relevant
reporting terms. We also discuss the potential unintended
consequences of the trend toward automated reporting and
suggest some approaches to minimizing detrimental effects
of automation. Our framework articulates three specific as-
pects of reports and how they may be improved: standard
language, a structured format, and consistent content.
These improvements may be achieved by transforming
the processes of ordering, production, storage, distribu-
tion, and review of radiology tests and associated reports.
Innovative software for creating, archiving, transmitting,
and displaying reports is only one of several ways that

© 2005 American College of Radiology 159

0091-2182/05/$30.00 ● DOI 10.1016/j.jacr.2004.06.015
160 Journal of the American College of Radiology/ Vol. 2 No. 2 February 2005
radiology communication might be improved. Two
other important methods are the targeted education of
radiology trainees and practitioners and the adoption of
widespread standards for radiology report content, lan-
guage, and style.
It is easy to focus solely on how changes in the inter-
pretative task affect radiologists, but this temptation
must be resisted. Studying the entire process of reporting
gives radiologists a unique opportunity to examine and
refine their role in medical care. In particular, it is useful
to focus on the consumers of radiologists’ work products,
referring clinicians. It is through clinicians that reports
have their effect on patients’ outcomes. Reports take on
added importance as methods for electronic delivery be-
come more widespread and radiologists cede exclusive
“ownership” of diagnostic images. Because radiologists
must deliver clearly perceived value via the interpreta-
tions that they render, report structure and content ulti-
mately must be tailored to suit the needs of clinicians.
The unalloyed desires of referring physicians must, how-
ever, be tempered by what is practical for radiologists as
well as by cost constraints, patients’ concerns, and ethical
considerations.
BACKGROUND
In 1922, Hickey [1] made a plea for the standardization
of radiology reports. Now, more than 80 years later, the
study of the variability and quality of interpretative re-
ports remains an active area of clinical research, with little
resulting change in clinical practice. Several studies have
shown that referring clinicians frequently express the
need for improvements in report quality at their institu-
tions [2-6]. Some specialists, most notably orthopedists,
have questioned the practice of the formal interpretation
by radiologists of routine x-rays of their patients [7-12].
Frequently, these arguments are predicated on the fact
that radiologists’ reports often reach their intended recip-
ients days (or even weeks) after the images have been
viewed and acted on. Newer automated reporting sys-
tems, such as computer speech recognition and struc-
tured reporting systems, reduce median report turn-
around times to minutes or hours rather than days.
However, if clinicians perceive the substantive content of
radiology reports as being irrelevant to patient care, it
makes no difference how rapidly they are available.
There are two terms that must be carefully defined
within the construct of radiology reporting. Radiology
report shall be taken to mean the document containing
the official interpretation of a single radiology examina-
tion or procedure. This document generally contains a
variable amount of text and in a large and growing num-
ber of settings is stored and viewed electronically. The
term document has already begun to acquire a more flex-
ible definition within hospital information systems.
Rather than being simply a long string of words and
punctuation, documents may now contain self-defining
formatting information, images, links to other docu-
ments, and embedded computer language code. A perfect
example of a single type of document that may take on
many diverse forms and functions is a Web page found on
the Internet. The corollary term radiology reporting is de-
fined as the aggregate of all clinical processes directly related
to the creation, storage, distribution, and display of inter-
pretive documents. We intend for radiology reporting to
represent the entire chain of activities, beginning with
the time a radiologist makes a determination of findings
and their clinical impact through the receipt of that in-
formation by the clinician taking care of the patient.
STRUCTURED REPORTING IS NOT
ENOUGH
The term structured reporting recently has been used in
the medical literature to represent newer automated re-
porting methods, often involving point-and-click inter-
faces for data capture. We propose that the term struc-
tured reporting represents simply one set of computer
tools aimed at reducing variability and enhancing the
clinical utility of formal radiology interpretations. The
term structured reporting is suboptimal because, as we
describe below, the structure of reports is only one of
several attributes targeted for efforts at improvement. A
dialogue about improved radiology reporting expands
the scope of discussion beyond a narrow focus on the
form and content of a document itself into the realms of
training, professionalism, interpersonal interaction, and
clinical decision making. Furthermore, radiology reports
are already structured, albeit in a rather loose and imper-
fectly standardized manner. Virtually all of them have an
implicit format that includes patient-identifying infor-
mation, clinical indications, comparison studies, current
examination details, findings, and an impression.
KEY ATTRIBUTES OF RADIOLOGY
REPORTS
The goal of improved radiology reporting may be artic-
ulated as a series of relatively independent subgoals. The
most immediately relevant of these are decreasing varia-
tion and reducing error in clinical reports. Other sub-
goals include enabling research, quality assessment, and
process improvement. We explicitly identify these goals
because they have motivated many past attempts to study
and improve reporting. But if radiology researchers hope
to achieve these goals by studying clinical processes, mea-
suring their effects, and implementing changes to im-
prove them, these same researchers also must have an
explicit framework to guide their analyses. Any such

framework must articulate the attributes of interpretative
reports that should serve as specific targets for study and
modification. The following sections identify and discuss
three distinct attributes of radiology reports: format, lan-
guage, and content. For each of these, we include an
adjective to further specify the type of improvement be-
ing contemplated.
Structured Report Format
The concept of structure applies most naturally to the
format of reports and should be considered from the
point of view of their readers. In other words, report
format is what referring clinicians will actually see on
paper or computer screens when reading the reports of
studies that have been ordered. This notion has received
little formal attention, though it may be central to “cus-
tomer satisfaction” and the efficiency of information
transfer. One format option is to have a radiology report
laid out as an ordered list of headings (often anatomic or
physiologic functional units), with findings listed under
each one. This format is a natural extension of the ad hoc
organization currently used by most radiologists for re-
ports (i.e., indication, comparison, examination, find-
ings, and impression). But such a subdivision of the
report only achieves its objectives when the subparts are
explicitly and consistently labeled. Additionally, the
findings (and possibly the impression) would be further
divided and labeled as appropriate to the examination
and indication.
Many automated reporting systems provide report
templates that can assist radiologists producing organized
and formatted interpretative documents. A radiology re-
port template is analogous to the checklists that airlines
use to ensure safe flight operations. Therefore, the term
format refers to the actual layout of the content of a report
as seen by both its producer (a radiologist) and its reader
(a referring physician). Table 1 shows an example of a
report of an abdominal ultrasound examination to illus-
trate these principles. Simple report structure is a power-
ful idea that has great potential for improving outcomes
in patients having imaging studies, even when radiolo-
gists have no restrictions on the text that can be placed
under each heading.
Standard Report Language
Radiology reports are generally written using the radiol-
ogists’ “dialect” of the allopathic physicians’ language.
Unfortunately, this dialect is quite variable; a single radi-
ologist reporting two examinations with similar findings
can use very different words and phrases [13,14].
In our framework, standard language refers to the ex-
tent to which the terminology in a radiology report is
consistent with respect to clinical indications, anatomy,
imaging findings, diagnoses, and uncertainty. In theory,
Sistrom, Langlotz/Improving Radiology Reporting 161
Table 1. Example of abdominal ultrasound
findings in a structured format
LIVER: Demonstrates diffuse increased
echogenicity, likely due to fatty infiltration. There
are no focal lesions.
GALLBLADDER: Normally distended with no
gallstones. There is no pericholecystic fluid, wall
thickening, or sonographic Murphy’s sign.
BILIARY: No intrahepatic ductal dilatation is
identified. The common duct measures 6 mm at
the porta hepatis.
PANCREAS: Limited visualization due to gas in
the stomach and colon.
SPLEEN: Measures 9.9 cm in length and is
normal.
KIDNEYS: The right kidney measures 11.9 cm.
There is an echogenic structure within the
inferior pole of the right kidney with posterior
shadowing, likely a renal stone. It measures 8
mm. There is no right hydronephrosis or
hydroureter. The left kidney measures 12.3 cm
and is normal.
VASCULAR: The abdominal aorta is
nonaneurysmal.
OTHER FINDINGS: The bladder was empty and
not evaluated.
IMPRESSION: No gallstones and no evidence of
cholecystitis. There is an 8 mm stone within the
inferior pole of the right kidney without evidence
of hydronephrosis.
radiologists and their clinical colleagues receive training
that produces a shared conceptual model of human
pathophysiology using mutually understood language.
Ideally, this training prepares these physicians to com-
municate effectively, both orally and by creating and
reading narrative text documents. Of course, we do not
live in that ideal world; the problems of miscommunica-
tion are well documented [14].
Perhaps the most well-known, widely used, and success-
ful effort to standardize report language is the ACR’s Breast
Imaging Reporting and Data System (BI-RADS), which
has been in use for almost a decade [15,16]. Several efforts in
other specialty areas have defined standard terminology for
interpretative reports, including lower limb veins [17], brain
arteriovenous malformations [18], lumbar disk pathology
[19,20], and chest disease [21-23].
Recently, the Radiological Society of North America
initiated the RadLex project, a comprehensive approach
to develop a unified imaging terminology resource for
clinical reports, teaching files, and research data. This
effort, which is supported by the ACR and subspecialty
organizations, will seek to build and promulgate a con-
162 Journal of the American College of Radiology/ Vol. 2 No. 2 February 2005
sensus of terminology for radiology reports, teaching
files, and research data [24]. A preliminary version of the
RadLex thoracic lexicon, developed in collaboration with
the Fleischner Society and the Society of Thoracic Radi-
ology, is available on the RadLex Web site (http://
mirc.rsna.org/radlex/service/).
Consistent Report Content
The consistent content of medical imaging reports rep-
resents the goal radiologists should be trying to achieve in
their communications. The medical content in radiology
reports can vary widely [13,14,25-28]. This variation
exists among institutions, among radiologists, and even
among reports created by the same radiologist over time.
Consistent content means that for a given examination
and clinical context, reports have the same elements
mentioned in the same order, regardless of the author.
Thus, the concept of consistent content is distinct from
the notion of structured format. A radiologist could cer-
tainly create reports with a structured format such as the
one shown in Table 1 yet vary ordering and the choice of
report headings. Thus, the content might not be consis-
tent, even though the format was structured.
The brevity of the above description of consistent con-
tent should not be construed to represent the importance
we ascribe to this third attribute. To the contrary, the
consistency of report content is a critical issue for both
radiologists and clinicians. Even though it is simple to
articulate, the idea that imaging interpretations should
have common contents presented in a consistent order is
both powerful and potentially controversial. Physicians
are rewarded for being autonomous and authoritative,
traits that are sometimes at odds with externally imposed
practice proscriptions. Radiologists are no exception, and
any such program perceived as restricting their indepen-
dence concerning the interpretation process, the essence
of what radiologists do, will be resisted.
IMPROVING THE RADIOLOGY REPORTING
PROCESS
Donabedian’s [29,30] schema of structure, process, and
outcomes for studying the quality of medical care is use-
ful for thinking about how to improve radiology report-
ing. Structure refers to the characteristics of settings in
which medical care is delivered. Process describes all of the
activities undertaken by members of the health care sys-
tem to render care to patients. For example, to say that a
hospital has a picture archiving and communication sys-
tem tightly coupled with a speech recognition system
(SRS) is to speak about structure. If we go on to describe
a common set of examination-specific radiology report-
ing templates, agreed on and used by all the radiologists
in the hospital, we are describing process. Modifications
of structure and process such as those just described likely
will lead to measurable improvements in outcomes.
The clinical benefits of improved radiology reporting
will be mediated by modifying the structure and process
of the ordering, preparation, storage, distribution, and
review of radiology report documents. The benefits will
be realized during ordering of radiology examinations by
clinicians, the preparation of reports by radiologists, and
the review of the reports by referring physicians. Consid-
erations about the storage and distribution of report doc-
uments are mostly invisible to practitioners but are inte-
gral to technical innovations in reporting. Many
radiologists and clinicians have already encountered
some of these concepts through experience with
BI-RADS for mammographic interpretation. The sys-
tem, as originally conceived, represented a national effort
to standardize the entire process from ordering through
review. Although several studies have shown that there is
still measurable variation among radiologists using
BI-RADS [15,31,32], other studies have shown signifi-
cant improvement in interobserver agreement after spe-
cific training about the BI-RADS lexicon and assessment
categories [33,34].
One of the greatest benefits of the entire BI-RADS
initiative arises from the mandated forced choice be-
tween clinically meaningful diagnostic categories. The
conclusions of all mammogram reports now contain
widely understood terms (standard language and consis-
tent content). This clarity not only improves mammo-
gram reports but also makes the interpretative process
itself easier to teach and perform. The system also facili-
tates clinicians’ review of radiology reports. For example,
the literature provides data on the probability of malig-
nancy for each BI-RADS category. Such information
about the positive predictive value of a mammographic
result can be essential to clinical decision making. Al-
though it is entirely possible to produce fully compliant
BI-RADS reports using traditional dictation and tran-
scription methods, there are now several automated
mammography reporting and tracking systems that
make compliance easier. Inherent in the design of these
products is a database from which reports and profiles
can be extracted to comply with the legal requirements
for generating periodic practice audits.
Report Storage
The issue of report storage has received a tremendous
amount of attention over the past several years. Most
notably, the Structured Reporting Working Group of
the Digital Image Communications in Medicine
(DICOM) Standards Committee (Working Group 8)
has rigorously defined a complex schema for storing
structured reports [35-37]. This schema is now an ap-
proved part of the DICOM standard for medical im-

age representation, usually referred to as DICOM-SR
[38,39]. In its basic form, DICOM-SR describes a
series of interrelated and hierarchical container objects
for imaging findings, which can in turn be associated
with specific locations on the images themselves. The
imaging findings may be explicitly coded either using
a widely available or vendor defined terminology or as
free-text items. Because DICOM-SR defines only a
storage schema, it does not itself directly affect either
the production or review of reports. However, soft-
ware that adheres to the new standard can provide
interoperability between systems for radiologists and
clinicians to use in report generation and review. Ad-
ditionally, several DICOM working groups are devel-
oping reporting templates for specific imaging modal-
ities, including cardiology, vascular ultrasound,
obstetric ultrasound, thoracic imaging, and breast im-
aging. If these content-specific report formats are
widely adopted, the DICOM-SR standard will have a
direct effect on future report language, format, and
content.
Report Distribution
The classic method for distributing reports of inpatients’
radiology examinations consists of printing paper copies
and placing them in patients’ charts. Reports of outpa-
tients’ examinations are routinely mailed and/or faxed to
referring physicians’ offices. These methods for distrib-
uting reports have traditionally been supplemented by
individual radiologists’ efforts to personally contact rele-
vant physicians or nurses with urgent or unexpected find-
ings. With the advent of picture archiving and commu-
nication systems and radiology management and
information systems, reports and images are no longer
stored as paper documents and hard-copy films. The
archival repositories for both items are now primarily
digital. Many health care institutions also have capability
for the electronic distribution and display of radiology
reports (and often images) throughout the enterprise.
Computerized methods for handling reports, though
more rapid and consistent, are still essentially passive in
that those caring for patients must retrieve the docu-
ments to read the contents. Radiologists still are obliged
to notify referring physicians about findings that are
deemed critical to patients’ care. This direct method for
the distribution of interpretative information must not
be discounted or neglected. In a significant fraction of
cases, timely personal contact between radiologists and
clinicians is critical to positive patient outcomes; report
documents serve only as passive static records.
There is growing interest in “push technology” for
report distribution. This refers to methods for alerting
clinicians of imaging test results at the time they become
available. In settings with electronic medical records,
Sistrom, Langlotz/Improving Radiology Reporting 163
computerized alerts can be triggered to notify clinicians
of important developments in their patients’ courses.
New findings or events might “pop up” when clinicians
sign on to their accounts or during existing sessions.
There is considerable interest in distributing small wire-
less computers to clinicians. These can enhance access to
electronic patient records as well as supporting order
entry and clinical documentation. Through these de-
vices, alerts about significant clinical events can reach the
relevant physician almost instantly. Another popular new
distribution method creates and sends alphanumeric
pages with summaries of critical events or findings [40].
This solution has the advantage of using preexisting in-
frastructure, because almost all physicians and ancillary
personnel already carry pagers. Laboratory, pathology,
and pharmacy departments share this need to actively
distribute information to clinicians.
Report Preparation
Recent efforts to improve on traditional dictation and
human transcription for the preparation of reports rely
on computerized speech recognition and/or some form
of screen-mouse-keyboard interaction. Each alternative
offers significant improvement in report turnaround
time by eliminating the transcription portion of the re-
port production cycle. Both SRSs, when used in self-
correction mode, and menu-driven interfaces upload re-
ports to information systems immediately on electronic
signature by radiologists. However, problems with
speech recognition accuracy cause radiologists to spend
considerable extra time on reporting.
Discrete SRSs became available in the mid-1980s. Ra-
diology has presented an attractive area for the applica-
tion of this technology. Robbins et al. [41,42] described
preliminary experience with such systems having 1000-
word and then 5000-word dictionaries. In these early
experiments, the use of key words or phrases to “trigger”
text expansion was anticipated. In fact, Dershaw [43]
found this to be the only way to use such a system,
because free-text recognition was problematic. Hansen et
al. [44] were even more pessimistic and articulated the
problem of having radiologists spend too much cognitive
effort and time with the mechanics of producing reports
with discrete SRSs. About 7 years ago, Kurzweil and
others finally achieved the “holy grail” of speech recogni-
tion in real-time on personal computers with no special
hardware. This software allows the user to speak at a
natural (continuous) pace and achieve accuracy of well
over 90% for most individuals. Continuous SRSs with
large radiology specific vocabularies and context-sensi-
tive language modeling represent a significant improve-
ment over discrete SRS predecessors, and commercial
versions have been brought to market and adopted at an
increasing rate [45-47]. Initial experience with the full-
164 Journal of the American College of Radiology/ Vol. 2 No. 2 February 2005
scale implementation of SRSs in various settings leads to
several conclusions. There is nearly universal agreement
that report turnaround times are significantly reduced
almost immediately, and transcription costs decrease
steadily within a year of implementation [47-51].
The benefits of SRSs come at the expense of increased
effort by radiologists to edit and verify reports during
clinical interpretation, and these tasks may increase re-
porting times by 50% to 100%, even after considerable
experience with the systems [48,49,51-53]. A further
disadvantage to SRSs has to do with the loss of the other
functions sometimes performed by transcriptionists.
Many radiologists are in the habit of making verbal re-
quests directed to transcriptionists at the end of dicta-
tions. For example, a radiologist might say, “Please fax
this report to Dr. Jones” and be certain that it would be
done. An experienced and motivated transcriptionist can
often greatly assist a radiologist and improve the quality
of care by pointing out potential errors or inconsistencies
in reports. Such a productive working relationship be-
tween a radiologist and a dedicated departmental tran-
scriptionist is much more likely to develop than between
other physicians and workers in a large pool of transcrip-
tionists employed by a hospital or a large commercial
transcription vendor.
Newer modes of interaction have been termed menu-
driven or “point-and-click” interfaces because they typi-
cally require mouse navigation through lists or nested
menus to select relevant findings and diagnoses. Before
the advent of continuous SRSs, several groups at aca-
demic centers experimented with computer-generated
radiology reports. Workers at Johns Hopkins University
[54-57], the University of California [58-60], Harvard
University [61-63], and others [64,65] have developed
and described such systems. Often, the scope of reports
generated by these systems is limited to a specific practice
area, such as musculoskeletal imaging, mammography,
or obstetric ultrasound. Different methods for user inter-
actions were used, including mark-sense forms, keyboard
input, mouse navigation, touch-screen input, and voice
activation. Using barcodes to quickly input patients’ de-
mographics or to implement a menu-driven reporting
scheme has been described as well [66-68].
Computer-mediated (menu-driven) report generation
remains a viable option for several reasons in addition to
presenting an alternative to the frustrations of SRS inac-
curacies. In current SRS implementations, no attempt is
made to codify the findings or standardize a radiologist’s
choice of language. By design, SRSs produce simple text
documents that are easily stored and displayed in a wide
variety of information system configurations. Rudimen-
tary report shells (templates) are supported, but their
creation is left up to individual users [69]. On the other
hand, menu-driven reporting systems are built around a
semantic model or knowledge base with explicitly stan-
dardized language. These reporting systems use en-
hanced storage concepts and keep a dedicated database of
reports, often stored in a highly formalized and codified
format. Because most hospital information systems are
not prepared to accept these complex documents, reports
are usually rendered into simple text before being up-
loaded to the official electronic record. However, the
structured elements remain in the reporting system’s da-
tabase and are available for quality assessment and re-
search activities.
Speech recognition and menu-driven interfaces are likely
to converge into a single comprehensive reporting product.
Some vendors of menu-driven reporting interfaces have al-
ready added speech recognition capabilities to allow voice
activation and menu navigation to their products. Likewise,
makers of SRSs likely will expand the scope and sophistica-
tion of their templates and macro features to incorporate
some menu-driven features. In both cases, free text dictation
will still be allowed for sections of the report for which no
predefined menu (or template) choices exist.
Another vision for the future of report creation inter-
faces might be called the ⬙talking template.⬙ This would
enable radiologists to interact with the reporting inter-
face almost entirely through a microphone or headset,
using speech recognition for user input and speech gen-
eration for feedback from the system. Instead of requir-
ing users to look away from images to navigate through a
report structure, a talking template would deliver voice
prompts to indicate reporting progress. Spoken key
phrases or buttons on the microphone would cause
movement through report elements. A brief example
may clarify this concept. Consider that the report outline
shown in Table 1 for general abdominal ultrasound is
appropriate for the study being interpreted. On activat-
ing the system and selecting the examination for inter-
pretation, in addition to seeing the images come up on
the picture archiving and communication system work-
station, a radiologist would hear “liver” from the micro-
phone (or a headphone). He or she would then dictate an
appropriate description in free text and press the “next”
button on the microphone. At this time, the system
would say “gallbladder” and await dictation about the
gallbladder. Again, the “next” button triggers movement
to the next section (biliary). In addition to a “next” but-
ton, a “back” button would give the user complete free-
dom to move around in the report. Within a named
section (liver, gallbladder, biliary, etc.), standard “re-
wind,” “playback,” and “dictate” buttons would be ac-
tive. Alternatively, voice commands could serve the same
functions as the microphone buttons if desired. Talking
templates free radiologists to view and manipulate the
images (if using soft copy) during the entire dictation.

Report Review
Clinicians still primarily read their radiology reports in
printed form. Even in situations in which clinicians view
their radiology reports from computer screens, they are
almost always simple blocks of text. The clinician review
phase of the reporting cycle has received very little atten-
tion by researchers or by vendors. The DICOM-SR stan-
dard is designed to support sophisticated report review func-
tions that display key images dynamically linked to report
content. Such capabilities are not yet widely available.
In many implementations, reading a radiology report
on a computer screen is often rather more difficult than
from a printed page because only part of the text is
displayed at once. Little consideration has been given to
electronic report display methods that enhance readabil-
ity and improve efficiency of information transfer. For
example, should a radiology interpretation look like a
laboratory report, with organs or structures listed in stan-
dard order, perhaps with indicators of normal and abnor-
mal? Would it be more efficient for readers if detailed
findings for individual organ systems were nested under
their respective headings and visible only when activated?
Should key terms, such as right and left, always be capi-
talized or color coded to reduce error?
Examination Ordering
As for improving the process of ordering radiology exami-
nations, we briefly mention two relevant activities. The first
is the ACR’s Appropriateness Criteria. This document is the
result of a large-scale consensus development effort by the
ACR begun in 1993. It consists of over 140 individual
guidelines that deal with more than 820 specific clinical
conditions. Under each of these, a number of candidate
imaging procedures is listed, each annotated with an appro-
priateness score [70,71]. One of us has undertaken to con-
vert the Appropriateness Criteria document into a relational
database for use in hospital information systems to provide
the underlying medical content for radiology test ordering
decision support and compliance logic [72].
The second is that the concept of physician order entry
(POE) by computer has become quite popular, especially
with respect to pharmacy. In fact, the LeapFrog group
has designated POE system implementation as one of
several critical quality indicators for hospitals [73]. Radi-
ology POE promises to improve the ordering process by
ensuring that appropriate studies are scheduled for the
clinical problem at hand [74,75]. The same features of
radiology POE that support compliance and appropri-
ateness will also serve to provide more consistent and
complete clinical indication data. This information can
be fed directly through and included in a report docu-
ment itself. This richer ordering process will serve to
better inform interpreting radiologists about the task at
Sistrom, Langlotz/Improving Radiology Reporting 165
hand. Additionally, the medical record will more accu-
rately reflect the context in which a radiology interpreta-
tion was rendered. Eventually, the complete integration
of information systems will allow computerized POE
choices to trigger a complex chain of events [76]. These
will include the automatic setting of procedural protocols
at the examination site and triggering predefined report
templates for radiologists. These protocols and templates
can be specific to the clinical problem, anatomic area
examined, and imaging modality employed.
A complaint commonly articulated by radiologists is
that of incomplete, inadequate, or inappropriate clinical
information from physicians requesting imaging studies
[77,78]. At the same time, clinicians express frustration
that interpretations are often not relevant to the clinical
questions they seek to answer with imaging studies. In
keeping with the tenets of the quality improvement
movement, we believe that this is a classic systems prob-
lem, rather than personal failings on the part of clinicians
and/or radiologists. Often, both parties are doing their
best in good faith to ask and answer appropriate clinical
questions but are stymied by a layer of intermediary
people and systems that distort the communication. Ide-
ally, a clinician should be permitted to ask one or more
specific questions about his or her patient that would be
answered directly by the interpreting radiologist as part
of the reporting process. During his keynote address at
the 2004 meeting of the Association of University Radi-
ologists, Thrall used the phrase “the electronic round
trip” to refer to the ideal situation, whereby a clinician is
guided by computerized online order entry, and the ex-
amination and its report shell are automatically activated.
CONCLUDING REMARKS
The attributes and methods described above are by no
means mutually exclusive; in many implementations of
improved radiology reporting, they will be quite comple-
mentary. Our framework for improvement does not pre-
ordain the medium for the ordering, production, storage,
distribution, and review of reports. For example, a well-
trained radiologist can look at images and then have a
verbal conversation with an experienced clinical col-
league in structured format, using standard language and
having consistent content. Complex, unusual, or critical
situations often require just such personal and interactive
collaboration between radiologists and clinicians for op-
timal outcomes. This highlights the transcendent impor-
tance of training, experience, and acquired skills to effec-
tive communication between medical providers.
Technological gimmickry will never replace these essen-
tially human qualities and can only complement and
extend them. Nonetheless, the methods that we have
described thus far for improving radiology reporting have
166 Journal of the American College of Radiology/ Vol. 2 No. 2 February 2005
been mostly technical in nature. A healthy degree of
skepticism about solutions relying entirely on informa-
tion technology is warranted.
The complex cognitive task of radiology reporting is
mostly learned during a resident’s education and training.
Specific didactic instruction, supervised practice, and the
rigorous evaluation of reporting skills are vital components
of any comprehensive program to improve radiology re-
porting. With this in mind, consider that a recently com-
pleted national survey of accredited radiology residency pro-
gram directors showed that 86% of training programs
devote 1 hour or less per year to formal instruction in radi-
ology reporting [79]. Likewise, 82% of programs evaluate
fewer than 1% of their residents’ clinical reports. There
clearly is room for improvement in education about report-
ing at both the residency and postgraduate levels.
We have described a framework for conceptualizing
the process of radiology reporting with the aim of im-
proving the quality, consistency, and outcomes of care
rendered by radiologists through their primary work
product: the interpretative report document. These laud-
able goals have been loosely associated with the term
structured reporting and are gaining increased attention in
academic and commercial venues. The framework de-
fines standard language, structured format, and consis-
tent content as three key attributes of radiology reports
and shows how these attributes may be improved by
transforming the ordering, production, storage, distribu-
tion, and review of radiology examinations and reports.
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