Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach
Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach
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DOI：
10.1067/j.cpradiol.2016.12.004
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发表时间：
2017-07-01
影响因子：
1.4
通讯作者：
Scheinfeld, Meir H.
中科院分区：
文献类型：
--
作者：
Goldberg-Stein, Shlomit;Walter, William R.;Scheinfeld, Meir H.
目的：描述一个结构化的报告倡议在一个大型城市学术radiologydepartment.Methods的成功实施：我们描述我们的过程中，妥协，并在改革传统的报告实践和全面实施结构化的报告在我们的机构的十大经验教训。为了实现我们的目标，我们采取了深思熟虑的步骤来建立共识，进行了多步模板细化，并与技术人员，部门编码员和医院信息技术人员进行了密切合作。在机构审查委员会豁免后，我们通过评估12种常见检查类型的100个连续病例来审核放射科医生的依从性。Fisher精确检验，以确定实习生的初始报告起草和模板compliance.Results之间的关联的意义：我们生产和实施结构化的报告模板为95%的所有部门的计算机断层扫描，磁共振和超声检查。结构化模板包括符合美国放射学会报告和数据系统（ACR's RADS）建议的专业报告（例如Lung-RADS和Li-RADS）。我们在2年内达到了94%的放射科医生的合规性，没有任何经济激励。结论：我们提供了一个蓝图，如何成功地实现结构化报告使用协作多步骤的方法。(C)2017爱思唯尔公司All rights reserved.
Purpose: To describe the successful implementation of a structured reporting initiative in a large urban academic radiology department.Methods: We describe our process, compromises, and top 10 lessons learned in overhauling traditional reporting practices and comprehensively implementing structured reporting at our institution. To achieve our goals, we took deliberate steps toward consensus building, undertook multistep template refinement, and achieved close collaboration with the technical staff, department coders, and hospital information technologists. Following institutional review board exemption, we audited radiologist compliance by evaluating 100 consecutive cases of 12 common examination types. Fisher exact test was applied to determine significance of association between trainee initial report drafting and template compliance.Results: We produced and implemented structured reporting templates for 95% of all departmental computed tomography, magnetic resonance, and ultrasound examinations. Structured templates include specialized reports adhering to the American College of Radiology's Reporting and Data Systems (ACR's RADS) recommendations (eg, Lung-RADS and Li-RADS). We attained 94% radiologist compliance within 2 years, without any financial incentives.Conclusions: We provide a blueprint of how to successfully achieve structured reporting using a collaborative multistep approach. (C) 2017 Elsevier Inc. All rights reserved.