James A. Overton MA, Presenter: Nothing to Disclose

Cesare Romagnoli MD, Abstract Co-Author: Nothing to Disclose

A structured reporting tool for prostate ultrasound exams uses diagrams and context-sensitive presentation to make reports easier for radiologists to create and for non-radiologists to understand.

Structured reporting promises many benefits, including more complete, more consistent reports that can easily be searched and analyzed by computers. Diagrams can convey rich information, and context-sensitive presentation can improve readability by providing only the relevant information. Structured reports can also apply biomedical ontologies to facilitate knowledge exchange. We would like to develop a tool that provides all of these benefits.

A prototype application has been developed for structured reporting of prostate ultrasound exams. The user is presented with a diagram of the prostate, and can adjust the size and shape of the gland and its transition zone. The user can then add focal lesions to the diagram, move them, adjust their size and shape, and remove them. The software calculates the volume of the gland and lesions, and the predicted PSA level. The user then fills out a series of input fields and checkboxes to describe the patient's history, PSA level, BPH change, each of the lesions, the peripheral and transitional zones, the seminal vesicles, and any biopsies performed. An unstructured (plain-text) conclusion is required at the end of the report. The application can also translate the structured report into an unstructured (plain-text) report.

The prototype application provides an accessible visual representation of the radiologist's findings. The report requires that all relevant fields be filled out, improving completeness, but hides fields that are not relevant, improving readability. The structured report data can be stored in a database for easy search and analysis. Biomedical ontologies can be used to ensure that the data is standardized and interoperable. And the unstructured translation of the structured report can be submitted to standard PACS and RIS systems. It should be possible to apply this approach to other organs and to other imaging modalities.

Overton, J, Romagnoli, C, A Tool for Effective Structured Reporting of Prostate Ultrasound.  Radiological Society of North America 2011 Scientific Assembly and Annual Meeting, November 26 - December 2, 2011 ,Chicago IL. http://archive.rsna.org/2011/11011126.html