title: Automatically inserted technical details improve radiology report accuracy.
abstract: OBJECTIVE
  To assess the effect of automatically inserted technical details on the concordance of a radiology report header with the actual procedure performed.
  
  
  METHODS
  The study was IRB approved and informed consent was waived. We obtained radiology report audit data from the hospital's compliance office from the period of January 2005 through December 2009 spanning a total of 20 financial quarters. A "discordance percentage" was defined as the percentage of total studies in which a procedure code change was made during auditing. Using Chi-square analysis we compared discordance percentages between reports with manually inserted technical details (MITD) and automatically inserted technical details (AITD). The second quarter data of 2007 was not included in the analysis as the switch from MITD to AITD occurred during this quarter.
  
  
  RESULTS
  The hospital's compliance office audited 9,110 studies from 2005-2009. Excluding the 564 studies in the second quarter of 2007, we analyzed a total of 8,546 studies, 3,948 with MITD and 4,598 with AITD. The discordance percentage in the MITD group was 3.95% (156/3,948, range per quarter, 1.5- 6.1%). The AITD discordance percentage was 1.37% (63/4,598, range per quarter, 0.0-2.6%). A Chi-square analysis determined a statistically significant difference between the 2 groups (P < 0.001).
  
  
  CONCLUSIONS
  There was a statistically significant improvement in the concordance of a radiology report header with the performed procedure using automatically inserted technical details compared to manually inserted details.
authors: Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. habujudeh@partners.org
authors: Hani H
authors: HH
authors: Abujudeh
authors: Siddharth
authors: S
authors: Govindan
authors: Ozden
authors: O
authors: Narin
authors: Jamlik Omari
authors: JO
authors: Johnson
authors: James H
authors: JH
authors: Thrall
authors: Daniel I
authors: DI
authors: Rosenthal
mesh_terms: D001331:Automation; D016009:Chi-Square Distribution; D039702:Current Procedural Terminology; D004282:Documentation / Q000592:standards; D006302:Health Services Research; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D011785:Quality Assurance, Health Care; D011872:Radiology Department, Hospital / Q000191:economics / Q000458:organization & administration*; D011873:Radiology Information Systems; D014481:United States