The Challenges of Implementing Structured Reporting

Realising the effectiveness of conveying information in a structured form, several researchers have developed models and proposals to apply structured reporting as a method to create radiology and ultrasound reports [5, 43] as early as the 90’s. Most of these early structured reporting systems were constructed using checkboxes and radio buttons to complete a report. One example of a structured reporting application that has been developed and used before is UltraSTAR (Ultrasound STructured Attribute Reporting) which is an application that allows sonographers to construct reports inter- actively by using checkboxes and radio buttons in a graphical user interface to select concepts from a hierarchical standardised vocabulary [5]. The concepts selected from the checkboxes and radio buttons were used to answer a set of predefined questions in order to construct the content of the report. Figure 2.3 illustrates an example of the interface of an early structured reporting application.

Figure 2.3: User interface of early structured reporting [5]

This method of designing a structured reporting application has formed the basis of most reporting applications. A more advanced implementation of structured reporting includes a predictive data entry feature [43] where it provides suggestions on concepts based on several letters that have been typed by the radiologist. Whilst this type of sys- tems have been used in some Radiology Departments [4], there are several challenges which have limited their wider implementation. These challenges can be grouped into three which are the rigidity of the reporting applications, the technological constraints and the radiologists’ resistance to change.

One of the biggest downfalls of structured reporting is the rigidity of the reporting applications developed [25, 70]. These applications often limit the inclusion of addi- tional information [36, 46] that could be important for the case and would not allow the form to be submitted with certain fields being left blank. It is important that reporting applications allow for these options as sometimes reports may contain more informa- tion than the fields provided and in some instances, some information cannot even be obtained. This caused the radiologists to find that the implementation of structured reporting was time consuming [36, 46] as a lot of time was spent figuring out how to include all the necessary information in the structured form.

The effect caused by the rigidity of reporting applications was visible in the study conducted by Johnson et al. [36] where there was a huge decrease in completeness and slight decrease of accuracy in the reports written by its intervention group using standard reporting compared to its control group that used free-form report. As a result of this limitation, structured reporting was seen as better for normal findings compared to abnormal and complex cases [89, 92]. This contravenes with the benefit of using structured reporting which is to promote completeness and accuracy thus making the effort of implementing structured reporting ineffective.

Another challenge in expanding the implementation of structured reporting is the technological constraints faced by the radiologists. This is hugely contributed by the design of the reporting applications that requires a lot of mouse clicking, keyboard command and complicated hierarchical menu [33] which often interferes with the ex- amination process. Other than that, Reiner and Siegel [71] stated that concerns over computer literacy among radiologists and the steep learning curve are among the rea- sons for the minimal adoption of structured reporting. These technological constraints are however not too worrying as technology improves over time. This will enable the reporting applications to be developed in a way which no longer frustrates the radiol- ogists. Computer illiteracy and steep learning curve can also be resolved by providing trainings and consultations to the radiologists.

The major challenge however is the radiologists’ resistance to change. A recent study undertaken by Tran, Wadhwa and Mann [89] demostrated evidence towards this concern. A departmental wide implementation of structured reporting has been con- ducted in their centre’s ultrasound department where the implementation was executed in three phases. The first phase was the template development phase where reporting templates from the Radiological Society of North America (RSNA) and the Ameri- can College of Radiology (ACR) was modified according to their needs. The second

phase was the implementation of structured reporting where it was executed for seven months. Finally, the evaluation phase was conducted during the final month of the implementation where audit was completed and feedback was acquired.

During the implementation, the study saw a very small number of consistent usage of structured reporting. Some radiologists used structured reporting but not consis- tently while most did not even use structured reporting in constructing their reports. The study also saw higher usage of structured reporting between trainees as compared to staff radiologists with feedbacks expressing that it was difficult for them to change and adopt the new reporting style. This signals resistance towards change from the staff radiologists. The shift to structured reporting is indeed a proactive effort espe- cially when the staff radiologists were so accustomed to the free-form format [71]. We view the radiologists’ resistance to change as the biggest challenge in ensuring broader implementation of structured reporting as it is impossible to force people to accept something unfamiliar to them.