Gerald Diaz MD, Presenter: Nothing to Disclose

Jeffrey Li MD, Abstract Co-Author: Nothing to Disclose

Safwan Halabi MD, Abstract Co-Author: Nothing to Disclose

Structured reporting has significant implications in the standardization of radiology report terminology, consistent presentation of imaging findings, and improved data mining capabilities. Historically, radiologists have been reluctant to embrace structured reporting due to the lack of adequate reporting software, fear of decreased efficiency and loss of reporting autonomy. The dimensional complexity of the spine provides a unique opportunity to complement the textual report with a pictorial representation of the pertinent imaging findings.

A reporting graphical user interface was created to facilitate the generation of structured reports for CT and MR examinations of the lumbar spine. The interpreting clinician is presented with an intuitive two-dimensional map of the lumbar spine which can be modified to represent abnormal findings of interest via mouse clicks, mouse scrolls and keyboard shortcuts. A structured report is automatically generated along with a picture representation that conveys the pertinent imaging findings.

The structured reporting software allows for granular expression of the major types of degenerative and other clinically significant changes found in a routine lumbar spine exam while maintaining a simple, uncluttered user interface and experience. The tool can be used to generate the majority of the report, with more complex findings added on as free-text. The interface doubles as a visual representation of the pertinent study findings which can be uploaded to PACS or EHR to provide a visually appealing, and clinically pertinent, report to the referring clinician. The software interface can be customized to incorporate other body parts and imaging modalities.

A simple tool to generate textual and pictorial structured reports of the lumbar spine can be implemented into the radiologist interpretation workflow. Adoption of structured reporting enables the radiologist to communicate imaging findings in a consistent and visually appealing way which benefits the referring clinician and patient care.

Diaz, G, Li, J, Halabi, S, The Spine Reporting Widget: A Unique Interface for Generating Structured Reports and Pictorial Representations of Lumbar Spine Imaging Findings.  Radiological Society of North America 2012 Scientific Assembly and Annual Meeting, November 25 - November 30, 2012 ,Chicago IL. http://archive.rsna.org/2012/12029273.html