Daniel L. Rubin MD, Presenter: Research grant, General Electric Company

Vladimir Kleper, Abstract Co-Author: Nothing to Disclose

Adam E. Flanders MD, Abstract Co-Author: Research Consultant, Geron Corporation

David S. Channin MD, Abstract Co-Author: Officer, Hotlight, Inc Shareholder, Hotlight, Inc Speaker, Carestream Health, Inc

Pattanasak Mongkolwat PhD, Abstract Co-Author: Nothing to Disclose

We have developed an open source structured reporting tool integrated into an image viewing workstation the permits comprehensive collection of information required for imaging research studies. Our harmonized model permits the tool to record quantitative and qualitative image annotations and generate a structured report as a full text document or DICOM SR.

Clinical radiology research depends on robust collection of complete information, quantitative and qualitative, about each case. Our goal was to develop an approach to structured reporting of comprehensive image information that can be introduced into the clinical workflow.

We reviewed the existing information models for structured capture of image interpretation from the RSNA structured reporting initiative, from imaging case report forms for tumor response in cancer clinical trials, and from the Annotation and Image Markup (AIM) standard of caBIG. We created an information model to harmonize these approaches, and we implemented that model in an open source image annotation plugin (called “ClearCapture”) to the ClearCanvas open source workstation. The plugin provides a graphical structured reporting form that captures comprehensive description of quantitative and qualitative information in images and saves it in the standard AIM format. ClearCapture enforces use of controlled terminology and alerts the user if invalid or incomplete information is reported. A neuroradiologist used ClearCapture to report the findings in 10 MRI cases of brain glioma and evaluated the usability of the tool.

We have developed a tool integrated into an image viewing workstation that enables structured reporting of cases in a comprehensive manner. In addition, the structured report is stored in compliance with the emerging AIM standard. The tool was reported by the radiologist to be intuitive to use, though it was more time-consuming to record the report data using the menu-driven tool than using unconstrained dictation. On the other hand, ClearCapture ensured complete reports, cuing the radiologist if any necessary information was omitted.

Rubin, D, Kleper, V, Flanders, A, Channin, D, Mongkolwat, P, An Approach to Structured Reporting in Clinical Research.  Radiological Society of North America 2010 Scientific Assembly and Annual Meeting, November 28 - December 3, 2010 ,Chicago IL. http://archive.rsna.org/2010/9003875.html