|The primary function of a clinical information system is to allow health care
practitioners to report and retrieve clinical findings about their
patients. In most systems, these findings are stored in the patient record
database as free text. The problem with free text is that it lacks
structure: information is trapped in the language of the report,
making it difficult to compare reports or find a specific detail without reading
through the text. For example, following the progress of a particular
lesion across a series of reports requires the radiologist to scan through many
lines of text. By contrast, a structured reporting system would allow the
information to be standardized and presented in a clear, organized format,
tracking the attributes of each finding (size, location, etc), and prompting the
radiologist for changes or impressions. In addition to improving report
readability, structured reporting can be more time-efficient than dictation, facilitate automated billing
and order entry, and support analysis for research and decision-support.
Structured Reporting has been a research topic for many years, but only
recently is it beginning to make its way into the marketplace as a viable
technology. This site is dedicated to providing an overview of structured
reporting resources available over the net.
- The Next Digital Frontier. Decisions in Imaging Economics, 6/2003.
aims to make dictation faster, cheaper. Auntminnie.com, 1/2002.
radiology technology streamlines patient care. Triad Business
reporting methods may provide competitive edge. RSNA News,
- 4-year case study of 160,000 structured
reports (pdf). StructuRad LLC, RSNA presentation, 11/2001.
- Structured reporting
in radiology, SHSRR, 12/2000.
- eDictation - eDictation uses a
combination of structured reporting, electronic signature and speech
recognition to create and distribute radiology reports. The application
automatically remembers unique terms and phrases to produce one-click
reports for many common combinations of findings. See the site for an
- REX by PointDx - PointDx's
flagship product, REX, integrates image analysis and structured reporting in
a unique workflow process, creating a new paradigm for radiology reporting.
The inefficient and costly steps associated with analysis, dictation,
transcription, approval and distribution are reduced to a single step,
permitting instantaneous distribution of web-based reports.
- StructuRad - The
StructuRad application features an extensive set of knowledge base modules for generating report phrases, based on decision trees developed over 5
years by practicing radiologists. presentation.pdf
- PenRad - Structured reporting
- Clinical reporting for cardiologists.
- DICOM - The ubiquitous standard for
medical image distribution is being augmented with an information model for
describing the findings contained in those images. Presentations from
the DICOM SR Workshops in March
2002 and June
2001. Technical specification: supplement23-1999.pdf.
- IHE - Integrating the
Healthcare Enterprise is an initiative to promote cross-vendor
interoperability; includes a "Report Integration Profile"
that specifies a template for diagnostic reporting. Slides.ppt.
- HL7 - Health Level 7 is the
leading standard for transmission of medical records; defines the Reference
Information Model for specifying attributes, roles, and transactions.
- SNOMED - Systemized Nomenclature
of Medicine is the largest controlled vocabulary, codifying hundreds of
thousands of concepts across different categories.
- UMLS - Unified
Medical Language System is an expansive collection of semantic networks
and hierarchical lexicons for representing knowledge across a wide range of
Model of Anatomy - Part of the UMLS semantic network, this resource is
particular useful for structured reporting, which requires deep anatomical
knowledge to support context-sensitive menus and prompts.
- Feasibility study to develop a unified lexicon for indexing medical
RSNA MIRC - Medical
Imaging Resource Center was originally conceived as a proposal to
develop a central repository of medical images and text for supporting
research and education. The emphasis of the project has shifted towards the
development of resources for linking distributed medical image
repositories. A demo is available.
(c) 2002, StructuredReporting.com