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Radiological reports: a comparison between the transmission efficiency of information in free text and in structured
Flavio Barbosa1, Lea Maria Zanini Maciel, Elizabeth Melmi Vieira
1Centro de Informações e Análises (CIA), Hospital das Clinicas, Ribeirão Preto School of Medicine, University of São Paulo - Ribeirão Preto/SP, Brazil. fbarbosa@hcrp.fmrp.usp.br
Introduction:
This work proposes to improve the transmission of information between requiring physicians and radiologists.
Objectives:
Evaluate the implementation of a structured report (SR) in a university hospital.
Methods:
A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting.
Results:
For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/-4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/- 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/-3.8) minutes for thyroids with nodules and 3.67 (+/-2.51) minutes for thyroids without nodules. Most of the radiologists (76.2%) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80% preferred the SR.
Discussion:
From the requiring physicians' perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists.
Conclusions:
The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.
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