By Amy Thompson

Reporting in imaging IT has evolved over the last 5 years and has the potential, with innovative technology such as AI, to fundamentally change how radiologists work and how products are designed. Following a challenging period during the COVID-19 pandemic, focus is increasing on reading efficiency and service-line cost for radiology services, making reporting competency a potential differentiator in purchasing decisions. Furthermore, with new focus in the market on companion diagnostics, the use of imaging data in the pre-clinical and research arena, and data federation, structured reporting creates new opportunities for vendors in this sector.

There are different levels of reporting in use today. Fig.1 outlines the distinction between reporting competencies. Throughout this article, when referring to structured reporting, I will be referencing level 2, with the express focus on IT-based tools that go beyond basic templates.
Structured reporting is used across the hospital in departments such as neurology, oncology, and invasive cardiology already. Radiology adoption past level 1, “structured layout”, has been minimal; free-form text reports are still most common today; therefore, creating a structured report is a substantial change.

There are providers in the U.S., such as academic hospitals, who are proactively adopting structured reporting (level 2) solutions and looking to optimise the data output available. Yet for most of the market, adoption so far as been nascent.

Why is structured reporting important?
The utilisation of structured reporting provides both departmental and enterprise benefits, which supports physician collaboration and improved quality of care provision.

Traditional free-form reports in radiology produce a unique and individualised approach to reporting, which while endearing, can create ambiguity and inconsistency in both the information collated in the report and the terminology used to describe the findings.

Structured reporting provides the means to ensure that all appropriate information needed to inform decisions on care delivery and procedures is included. Along with standardised terminology, referring physicians and other clinicians are better supported to understand findings and conclude care decisions. With greater multidisciplinary collaboration also important in this new era of outcome-based care, supporting new care teams (such as Tumour Boards) and diverse users within integrated care pathways is now critical. The availability of standardised reports across the imaging ecosystem can improve the output of these collaborative meetings and support better patient care and diagnosis.

In addition to patient care, the completeness of reports and automation of reporting workflow, creates financial and operational benefits for providers, by reducing the risk of lost revenue through incomplete reports, as well as supporting efficiency in report generation. In context of the post-pandemic recovery from the economic impact of COVID-19, this is a substantial driver.

Longer-term benefits of structured reporting?
The completeness and the standardization of structured reports not only supports diagnosis and care today, but the outputs can be aggregated to build a pool of standardised and “clean” data that can drive better-informed care delivery in the future.

Aggregation of standardised data can also help health systems move one step closer to precision medicine. Greater personalisation of care, combining and analysing the patients' history and health record against a wealth of past patients’ data, can better support medical decisions and support development of targeted therapies. To truly enhance data for precision medicine, structured reporting will need to be adopted at substantial scale.

Alongside precision medicine, standardised and machine-readable data will also support the development of technologies such as AI, improving accuracy and improving the real-life application of detection, analysis, or triage tools in radiology.

Why is it difficult to adopt?
Despite the benefits of structured reporting, adoption in radiology across the U.S. and globally is limited.

Due to the free-form nature of radiology reporting, creating a framework of standardised terminology and processes is a complex task, with limited progress to date. There are many considerations needed ahead of creating a standardised framework, such as:

• Which terminology and process are best rolled out across a national or international framework?
• Who is in the best position to lead this initiative?
• Which stakeholders across the enterprise need to be involved to support defining the standards?
• How do you overcome the difference in regional or local care protocols and standards?

Some best-of-breed reporting vendors have released structured reporting tools that are being utilised in the U.S. and pockets of Western Europe. However, more widespread use will be restricted to leading imaging IT and PACS software vendor resources, due to the configuration required to map each provider’s individual processes and implement the structured reporting solution in the incumbent imaging IT platform.

The culture and tradition of reporting in radiology has also created barriers to broader structured reporting adoption — with radiologists utilising free-form text reports for decades, whether that be dictated by technology or by an administrator. This method has allowed radiologists to incorporate their personal touch and flare into their work. Structured reporting takes this away from radiologists with templates and pre-determined sentence structure or drop-down menus, leading to a battle of “reporting culture” versus structured reporting tools.

Vendors recognise this culture and have begun embedding technology such as voice commands and NLP (natural language processing). This technology reduces the number of clicks required by the radiologist, allowing radiologists to continue dictating the report findings, whilst the software codifies the language used to match the standard terminology created in the structured reporting tool. This minimises disruption or the creation of “extra work” for the radiologist, but requires quite advanced and refined competency of the software to successfully implement across the breadth of radiology reporting complexity.

The integration of structured reporting
Depending on the region, the route to market for structured reporting differs. For example, in Western Europe structured reporting is a feature function of a RIS, PACS or enterprise imaging (EI) contract. However, in the U.S., reporting is sold either as a module of the EMR or a module of PACS / EI deals. Increasingly we’re seeing the reporting component transfer to PACS / EI deals as the more basic EMR-based reporting tools are unable to meet the radiologists need.

Despite the modular structure of procurement today, and with many imaging IT vendors fulfilling this capability through third party partnerships, direct integration of structured reporting into the diagnostic workflow is required to maximise adoption and minimise the disruption to radiologists.
To maximise the report quality, structured reporting tools cannot work in isolation and instead need to centrally connected within enterprise imaging system deployment. As seen in Fig.2, we expect a two phased approach to structured reporting integration; primarily offering direct integration into the diagnostic workflow (PACS in the US), with data from the EMR available to supplement reading and reporting, then evolving to exchange quantifiable findings from image analysis tools such as AI and AV.

Many vendors are also beginning to integrate AI algorithms into their tools to pre-populate findings into the reporting template, or through NLP technology to codify a radiologist’s dictation of findings.

Despite the multiple sources of information being centralised to supplement structured reports, radiologists will engage with structured reporting via the diagnostic workflow – in the U.S., that will be within the PACS environment. Supporting tools (EMR data, Advanced Visualisation, AI tools) will be seamlessly integrated to provide a single UI in the reading environment. Although some vendors are leading the way with AI and AV integration, phase 2 integration becoming widely available is not anticipated for another 3-5 years, such is the complexity and variety of tools required for a broad reporting solution today.

Different stakeholders’ role to support adoption
To conclude, despite the benefits available from using structured reporting tools, such as leveraging “clean” and standard data, improved collaboration and care quality, and the financial benefits to providers, the U.S. radiology market is unlikely to see mass adoption until the mid-term (3-5 years). For mass adoption to be possible, stakeholders from across radiology need to play a role.

For regulators and national societies, driving the creation of a standardised framework that can be used as the foundation of radiologist reporting will be fundamental. These bodies are in the best position, having reach across the U.S. and engagement with all aspects of the ecosystem; from the radiologists, provider c-level executives, and vendors.

To support structured reporting implementation, healthcare providers need to initiate projects to support the transformation of their radiology departments, overcoming the reporting culture seen today. However, it’s important that this project not only include radiologists, but involve all stakeholders that are involved or affected by radiology reporting.

Lastly, is the role of the vendors. Both best-of-breed structured reporting providers and imaging IT platform vendors need to consider product development, creating automated tools that reduce clicks and pre-populates findings to maximise the quality and efficiency of reporting. Using technology such as NLP, AI and integrating enterprise-wide tools such as AV platforms. Without a substantial effort, the growing promise of structured reporting in radiology could be curtailed, limiting the potential of a new era of diagnosis. Radiology has long upheld a reputation of technological advances and care innovation — it’s time it put its reputation on the line again and finally delivered mature structured reporting adoption at scale.

About the author: Amy Thompson is a market analyst, specializing in imaging informatics at Signify Research. Amy joined Signify Research as part of the Healthcare IT team, focusing on Imaging and Clinical IT. Signify Research is an independent supplier of market intelligence and consulting services to the global healthcare technology industry, with expertise across Healthcare IT, Medical Imaging, Clinical Care and Digital Health.