Joshua Matthew Polster MD, Presenter: Nothing to Disclose

Mahmoud Michael Khair BA, Abstract Co-Author: Nothing to Disclose

Morgan Jones MD, Abstract Co-Author: Nothing to Disclose

Naveen Subhas MD, Abstract Co-Author: Nothing to Disclose

Carl Scherman Winalski MD, Abstract Co-Author: Nothing to Disclose

David William Piraino MD, Abstract Co-Author: Medical Advisory Board, Siemens AG Advisory Board, TeraRecon, Inc

Coordinating terminology with reference standards is important for using structured reporting to obtain accuracy data.

Structured reporting of radiology results offers a great opportunity to have data sets that can be used to determine accuracy and outcomes measurements.  Much work has been done by radiologists to develop standard terminology for use in these reports.  However, to fully realize this potential, structured reporting should be developed in a way that is directly comparable to the reference standard against which radiology is to be evaluated.  This presentation shares our experience developing structured reporting of knee MRIs and arthroscopic surgery of the knee with our orthopedic surgery colleagues.

We developed a structured report to be used for knee MRI reports.  Structures to be evaluated were chosen along with pathology, severity and location of abnormalitites of these structures.  23 knee MRIs with surgical correlation were reviewed and scored by a single radiologist using the structured report format and the reports were compared to the original operative reports.  In 8/23 cases, the surgeon used terminology to describe a meniscus tear that was not available as a choice in the structured report.   In 4/23 cases, no meniscus description was provided at all for one of the menisci. In 6/23 cases, the operative report did not indicate the size of high grade partial thickness or full thickness chondral defects.

While structured reporting offers great promise for research and quality measures, this potential will be limited if these templates are developed without involvement and participation by those that report the reference standard for the pathology being evaluated.  We compared knee MRIs to operative reports and found that a significant number of cases had descriptors that either were different than those available in the structured report format or that were incomplete making evaluation of accuracy limited.  As a team of both radiologists and orthopedic surgeons, we are using this experience to standardize report terms in both operative reports and radiology reports to allow more precise data analysis.

Polster, J, Khair, M, Jones, M, Subhas, N, Winalski, C, Piraino, D, Coordinating Structured Reports with Reference Standards.  Radiological Society of North America 2008 Scientific Assembly and Annual Meeting, February 18 - February 20, 2008 ,Chicago IL. http://archive.rsna.org/2008/6009984.html