Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports.
BACKGROUND
This work proposes to improve the transmission of information between requiring physicians and radiologists.


OBJECTIVE
Evaluate the implementation of a structured report (SR) in a university hospital.


METHODS
A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting.


RESULTS
For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/-4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/- 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/-3.8) minutes for thyroids with nodules and 3.67 (+/-2.51) minutes for thyroids without nodules. Most of the radiologists (76.2%) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80% preferred the SR.


CONCLUSIONS
From the requiring physicians' perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists.


CONCLUSIONS
The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.
Barbosa
Flavio
F
Centro de Informações e Análises (CIA), Hospital das Clinicas, Ribeirão Preto School of Medicine, University of São Paulo - Ribeirão Preto/SP, Brazil. fbarbosa@hcrp.fmrp.usp.br
Maciel
Lea Maria Zanini
LM
Vieira
Elizabeth Melmi
EM
Azevedo Marques
Paulo M de
PM
Elias
Jorge
J
Muglia
Valdair Francisco
VF
D004704:Endocrinology / Q000706:statistics & numerical data*; D006751:Hospital Information Systems / Q000592:standards; D006785:Hospitals, University; D006801:Humans; D033181:Information Dissemination / Q000379:methods*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011446:Prospective Studies; D011871:Radiology / Q000706:statistics & numerical data*; D011873:Radiology Information Systems / Q000145:classification* / Q000592:standards; D016606:Thyroid Nodule / Q000000981:diagnostic imaging; D014463:Ultrasonography