Structured Reporting Software Creates Less Complete and Accurate Radiology Reports than Free Text

WINSTON-SALEM, N.C. – As many software companies work to create programs that will give uniform structure to the way radiological test results are reported, a new study by researchers at Wake Forest University School of Medicine shows that such a system does not improve, but rather decreases the completeness and accuracy of the reports.

The study, published recently in Radiology, compared the accuracy and completeness of reporting test results in a free text, narrative format versus using standardized words and phrases from a pull-down menu (structured reporting).

“This research is our attempt to evaluate a new technology that is a pretty hot topic in medicine right now and has been for a few years,” said Annette J. Johnson, M.D., M.S., an associate professor of radiology and lead investigator on the study. “Since radiology began, we have been creating our reports in a free text, narrative format. The rationale behind efforts to change this format is that all of the reports that we create could potentially be a very useful data base for clinical care and research if they were standardized.”

source: Wake Forest University Medical Center