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Efficacy, Education, Administration, Informatics

E1132. Structured Reporting in the Academic Setting: What the Referring Clinician Thinks

Lather J1,  Bieszczad J1,  Saltzman B.2 1. University of Toledo Medical Center , Toledo, OH; 2. University of Toledo School of Public Health, Toledo, OH

Address correspondence to J. Lather (jason.lather@utoledo.edu)

Objective: Variability can be seen when comparing radiology reports among a group of radiologists in terms of organization and reporting style. As technology has progressed, voice-to-text dictation software has changed the needs of radiology departments, with less need for transcriptionists. Radiologists now have the ability to design their report in whatever manner they decide would best convey their impression(s) to the referring clinician. Dictation software also allows a practice to develop a standard template for a given type of study and make that template their default organization. The current literature focuses on the radiologist opinion of template reports, but largely neglects possibly the most important opinion, the referring clinician.

Materials and Methods: After institutional review board approval, a link was shared with referring clinicians of our medical center; participants included third- and fourth-year medical students, nurse practitioners, physician assistants, residents, and attending physicians. The survey used two fictional reports containing the same information but with different organization. After 2 months of polling, the survey was closed and the data were analyzed using chi-square analysis after dividing participants into three categories of novice, intermediate, and advanced practitioners. Medical students and first-year postgraduate residents were novices; nurse practitioners, physician assistants, and fourth-year postgraduate residents were intermediate; and fifth-year postgraduate residents and attending physicians were considered advanced.

Results: A total of 218 responses out of a potential 1058 were received, with a response rate of 20.6%. The majority of participants preferred the structured report to a prose report (152/218, 69.7%; p < 0.0001), whereas the minority (54/218, 24.8%) preferred the paragraph style of reporting. The remainder had no preference. The majority also felt that the template was more clinically useful (113/218, 51.8%; p < 0.0001). After the participants were divided into subgroups, the novice group contained 102 participants, the intermediate group contained 53 participants, and the advance group contained 63 participants. Each group showed a statistically significant preference for the organized template (70/102, 38/53, and 41/63, respectively; p < 0.0001 for each). The template report was found to be most clinically useful in all groups (53/102, 28/53, and 30/63, respectively, with p < 0.0001, p = 0.004, and p = 0.0074, respectively).

Conclusion: When looking at the study population as a whole, there is a statistically significant preference for a standardized template compared to reports written in prose. Furthermore, our results indicate that reports written using an organized template is more clinically useful than other reporting styles. Our data show that irrespective of level of training, clinicians prefer an organized template report to prose or paragraph style reporting. Our data also show that referring clinicians of all levels of expertise find template reports to be more clinically useful compared to prose reports.