Key words
report turnaround time - subspecialized reporting - report availability - reporting
workflow - productivity
Introduction
In an era of decreasing reimbursements for radiologic operations, radiology departments
strive to optimize workflow to increase the number of examinations and to gain market
share. External referring physicians request short turnaround times for radiology
reports (TAT). Reporting times may influence the selection of a radiologic institution
[1]. Furthermore, reducing TAT and increasing productivity in a radiology department
helps to reduce the length of hospital stay of inpatients and therefore contributes
to the overall cost effectiveness of the hospital [1]. It also enables faster clinical decision making and implementation of required
therapy. Therefore, there is a concordant demand to expedite radiology report TAT
for imaging studies of inpatients and outpatients [1]
[2].
According to previous publications, report TATs of up to 24 hours might still be acceptable
for outpatient studies [1], while reporting times of less than 8 hours have been described as a “must-have-requirement”
for inpatient studies [3]. For emergency department studies, report TATs of ≤ 1 hour are expected [1]
[4].
For the last 2 decades there has been a trend towards subspecialization in radiology
with an increasing number of subspecialty-trained and -certified radiologists working
primarily in their field of expertise, while the importance of a broadly skilled general
radiologist has declined [5]
[6]. This trend has been observed not only in academic hospitals, but also in community
hospital settings and in private practices. Smith et al. [6] published the results of a survey regarding subspecialization in radiology conducted
by the American College of Radiology. 62.9 % of practicing radiologists “reported
recent expansions of subspecialization within their practices” [6]. 91.5 % of radiology trainees intend to pursue a fellowship and 89.9 % plan to subspecialize.
Looking for new ways to expedite TAT and to improve performance in our radiology department,
we assessed the influence of changing workflow from general reporting (board-certified radiologists report imaging studies of all areas [abdominal, musculoskeletal
imaging, etc.]) to subspecialized reporting (board-certified radiologists with subspecialty training solely report imaging studies
of their subspecialty field [e. g. musculoskeletal]).
Our hypothesis was that switching from general to subspecialized reporting would expedite
the turnaround time of radiology reports, increase the fraction of radiology reports
available within 24 hours (R< 24 h) and also increase radiologists’ productivity.
Materials and Methods
Performed as a quality improvement initiative, this study was not formally subject
to review by the institutional review board.
Department Specifications
The study was performed at the department of radiology of a 355- bed community-based
hospital with a radiology resident training program. The radiology department covers
all imaging modalities (X-ray including mammography, fluoroscopy, computed tomography
[CT], magnetic resonance imaging [MRI] and ultrasound) and all subspecialties – musculoskeletal,
cardiac and thoracic, abdominal, pediatric, neuroradiological, women’s imaging and
interventional radiology. Throughout the study period, images were interpreted by
a constant number of 10 board-certified radiologists and 8 residents.
Workflow
An integrated RIS (RadCentre: i-Solutions Health GmbH, Mannheim, Germany) / PACS (Centricity:
GE Healthcare, Barrington, IL, USA) solution and voice recognition software (SpeechMagic
SDK: Nuance Communications, Dublin, Ireland) were successfully implemented long before
the study was conducted and all radiologists are familiar with the technique. Since
residents do not have permission to sign reports, preliminary reports of residents
require final signature of a board-certified radiologist.
Outcome Measures
According to the most commonly used definition in the literature, report TAT was defined
as “the time from completion of image acquisition until availability of the final
radiology report” [7]. TATs were extracted from the RIS using a self-developed calculation tool, which
was integrated into the software RadCentre Analyzer (Transact GmbH, Hamburg, Germany).
Additionally, the fraction of radiology reports available within 24 hours was calculated.
Regarding emergency department studies, a preliminary report is available shortly
after image acquisition. However, the TAT was calculated based on the final signature
of the radiology report by a board-certified radiologist.
Productivity was defined as the number of generated radiology reports per full-time
radiologist (FTR) per month (productivity = reports/FTR/month). To obtain the number
of full-time radiologists (= 100 % employment), percentages of full-time and part-time
employees were cumulated considering absences of four or more successive weeks. Only
board-certified radiologists were considered FTRs since they have to provide the final
signature for all reports.
For a random sample of 100 radiology reports, the word count was calculated.
Reports of imaging studies completed during core working hours on weekdays (Monday
– Friday: 7:30 AM to 5:00 PM) between January 2, 2012 until March 31, 2015 were included
in this study. Reports of imaging studies acquired outside core working hours, on
weekends and on public holidays were excluded. In rare cases of revision of a finalized
radiology report, the date and time of the initial final signature were used for the
calculation of the report TAT.
The number of generated radiology reports is substantially lower than the number of
examinations performed since the results of two or more exams are frequently integrated
into one report, e. g. a combined report for an MRI of the head and neck.
No additional actions such as “pay for performance” procedures were taken to influence
TAT and performance.
Reorganization from general to subspecialized reporting
In 2012 and in the first half of 2013, the workflow was organized as general reporting indicating that board-certified radiologists with or without subspecialty training
and residents were assigned to report imaging studies of all areas (abdominal, musculoskeletal
imaging, etc.). Board-certified radiologists were assigned to report all imaging studies
of a certain imaging modality (X-ray, CT, MRI or ultrasound), with weekly rotation
from one modality to another. In this system all board-certified radiologists were
working as general radiologists. Examinations were performed and reported by only
3 subspecialty-trained and -certified radiologists only in interventional radiology.
Between June 2013 and January 2014, radiological reporting was changed to a subspecialty-based
reporting system as a continuous process (implementation period) by first replacing
general radiologists with newly employed subspecialized radiologists, second assigning
already subspecialized radiologists to their subspecialty field instead of working
as general radiologists and third by training and preparing already employed board-certified
general radiologists to adopt a subspecialty. In January 2014, reporting was completely
changed to subspecialized reporting, indicating that subspecialty-trained board-certified radiologists solely reported
and provided the final signature for imaging studies in their subspecialty field (e. g.
musculoskeletal) independent of the imaging modality. Each subspecialty was covered
by 1 – 2 subspecialty-trained board-certified radiologists. Residents continued to
be assigned to report imaging studies of all areas. Due to a limited number of staff
radiologists, subspecialized reporting was not practicable outside core working hours
(Monday – Friday: 5:00 PM – 7:30 AM), on public holidays and on weekends. During the
entire study period, potential confounding factors (number of radiologists, technicians,
CT and MRI scanners, ultrasound units, case demonstrations per week as well as RIS,
PACS and voice recognition software) remained constant.
Statistical Analysis
Since report TAT was not normally distributed, it is presented as median with interquartile
range (25th percentile to 75th percentile). Report TAT of a 12-month period of general reporting (January-December
2012) was compared to a 12-month period of subspecialized reporting (April 2014 to
March 2015) using the Mann-Whitney U-test. Separate analysis was performed for report
TAT of X-ray, CT, MRI and ultrasound studies.
The impact on the fraction of radiology reports available within 24 hours was assessed
by Pearson chi-square test and odds ratios for both periods. The development of the
proportion of radiology reports available < 24 h over time was evaluated using logistic
regression with smooth non-parametric regression line and automatic smoothing parameter
selection using package gam [8] in mgcv for R.
With respect to report TAT and R< 24 h, separate analysis was performed for radiology
reports generated primarily by residents and finalized by a board-certified radiologist
and for radiology reports generated solely by board-certified radiologists for both
periods. To assess the homogeneity of the odds ratios, the Breslow-Day test was used.
The productivity of board-certified radiologists during both periods was compared
using the Mann-Whitney U-test.
The word count of 100 randomly selected reports of oncological CTs of the thorax and
abdomen during the period of general reporting (50 reports) and subspecialized reporting
(50 reports) was compared using the student’s t-test.
Statistical analysis was performed using SPSS (Version 22, IBM Corporation, Armonk,
NY, USA). Significance was assumed for any value of p < 0.05.
Results
116 498 radiology reports of imaging studies completed during core working hours on
weekdays between January 2, 2012 and March 31, 2015 were included in this study. 32 199
reports were generated during the period of general reporting (January to December
2012) and 38 498 reports during the period of subspecialized reporting (April 2014
to March 2015).
Turnaround time of radiology reports (TAT)
The report TAT decreased from a median of 17:04 (3:32 to 29:37) hours (h) during the
period of general reporting to 3:38 (1:22 to 17:22) hours for the period of subspecialized
reporting, resulting in a 4.7-fold improvement (p < 0.001) ([Fig. 1, ]
[Table 1]). The TAT improved 5.9-fold (p < 0.001) for X-ray reports, 1.7-fold (p < 0.001)
for CT reports, 1.6-fold (p < 0.001) for MRI reports and 5.8-fold (p < 0.001) for
ultrasound reports ([Table 1]). For reports generated primarily by residents and finalized by a board-certified
radiologist, the TAT improved 4.1-fold, from a median of 22:39 h to 5:31 h (p < 0.001).
The TAT of reports solely generated by board-certified radiologists decreased from
a median of 6:28 h to 2:16 h, resulting in a 2.9-fold improvement (p < 0.001).
Fig. 1 Turnaround time of radiology reports (in hours) of all imaging studies presented
as median with 25th percentile and 75th percentile during the period of general reporting
(January to December 2012) and for the period of subspecialized reporting (April 2014
to March 2015).
Abb. 1 Befunddurchlaufzeit radiologischer Berichte (in Stunden) aller Bilduntersuchungen,
dargestellt als Median mit 25. Perzentile und 75. Perzentile während des Zeitraumes
allgemeiner Befundung (Januar bis Dezember 2012) und für den Zeitraum subspezialisierter
Befundung (April 2014 bis März 2015).
Table 1
Turnaround time of radiology reports during general and subspecialized reporting.
Tab. 1 Befunddurchlaufzeit radiologischer Berichte während allgemeiner und subspezialisierter
Befundung.
|
imaging
study
|
general reporting
TAT (hours)
median (IQR)
|
subspecialized reporting
TAT (hours)
median (IQR)
|
p[1]
|
|
all
|
17:04
(3:32 – 29:37)
|
3:38
(1:22 – 17:22)
|
< 0.001
|
|
X-ray
|
18:56
(3:51 – 34:16)
|
3:12
(1:10 – 16:15)
|
< 0.001
|
|
CT
|
7:31
(2:43 – 24:35)
|
4:26
(1:40 – 17:59)
|
< 0.001
|
|
MRI
|
8:25
(3:01 – 24:12)
|
5:18
(2:05 – 22:04)
|
< 0.001
|
|
US
|
17:11
(4:15 – 30:15)
|
2:57
(1:08 – 7:37)
|
< 0.001
|
Turnaround time of radiology reports (TAT) (in hours) of all imaging studies (all)
and different imaging studies (X-ray, CT, MRI, US) presented as median with interquartile
range (IQR) during the period of general reporting (January to December 2012) and
for the period of subspecialized reporting (April 2014 to March 2015), respectively;
CT: computed tomography; MRI: magnetic resonance imaging; US: ultrasound.
Befunddurchlaufzeit radiologischer Berichte (TAT) (in Stunden) aller Bilduntersuchungen
(all) und von verschiedenen Bilduntersuchungen (Röntgen, CT, MRI, US), dargestellt
als Median mit Interquartilsabstand (IQR) jeweils während des Zeitraumes allgemeiner
Befundung (Januar bis Dezember 2012) und für den Zeitraum subspezialisierter Befundung
(April 2014 bis März 2015); CT, Computertomografie; MRI, Magnetresonanztomografie;
US, Ultraschall.
1 Mann-Whitney U-test.
Fraction of radiology reports available within 24 hours (R< 24 h)
Regarding the impact of subspecialized reporting on the availability of radiology
reports, the fraction of reports available within 24 hours increased by 22 %, from
65.2 % during the period of general reporting to 87.2 % for the period of subspecialized
reporting (p < 0.001) ([Table 2]). R< 24 h increased by 28.2 % (p < 0.001) for X-ray reports, by 11.9 % (p < 0.001)
for CT reports, by 5.7 % (p < 0.001) for MRI reports and by 26.1 % (p < 0.001) for
ultrasound reports ([Table 2]). For reports generated primarily by residents and finalized by a board-certified
radiologist, R< 24 h increased by 30.2 %, from 54.4 % to 84.6 % (p < 0.001). R< 24 h
of reports solely generated by board-certified radiologists increased from 73.1 %
to 90.9 %, resulting in an improvement of 17.8 % (p < 0.001).
Table 2
Fraction of radiology reports available within 24 hours during general and subspecialized
reporting.
Tab. 2 Anteil der innerhalb von 24 Stunden freigegebenen radiologischen Berichte während
allgemeiner und subspezialisierter Befundung.
|
imaging study
|
general reporting
R< 24 h (%)
|
subspecialized reporting
R< 24 h (%)
|
difference (%)
|
p[1]
|
OR
(95 % CI)
|
|
all
|
65.2
|
87.2
|
22.0
|
< 0.001
|
3.6
(3.5 – 3.8)
|
|
X-ray
|
61.3
|
89.5
|
28.2
|
< 0.001
|
5.4
(5.1 – 5.6)
|
|
CT
|
73.3
|
85.2
|
11.9
|
< 0.001
|
2.1
(1.9 – 2.3)
|
|
MRI
|
74.2
|
79.9
|
5.7
|
< 0.001
|
1.4
(1.3 – 1.5)
|
|
US
|
64.2
|
90.3
|
26.1
|
< 0.001
|
5.2
(4.5 – 6.0)
|
Fraction of radiology reports available within 24 hours (R < 24 h) of all imaging
studies (all) and different imaging studies (X-ray, CT, MRI, US) during the period
of general reporting (January to December 2012) and for the period of subspecialized
reporting (April 2014 to March 2015), respectively with odds ratios (OR) and 95 %
confidence interval (CI); CT: computed tomography; MRI: magnetic resonance imaging;
US: ultrasound.
Anteil der innerhalb von 24 Stunden freigegebenen radiologischen Berichte (R < 24 h)
aller Bilduntersuchungen (all) und von verschiedenen Bilduntersuchungen (Röntgen,
CT, MRI, US), jeweils während des Zeitraumes allgemeiner Befundung (Januar bis Dezember
2012) und für den Zeitraum subspezialisierter Befundung (April 2014 bis März 2015)
mit Quotenverhältnissen (OR) und 95 %-Konfidenzintervall (CI); CT, Computertomografie;
MRI, Magnetresonanztomografie; US, Ultraschall.
1 Pearson chi-square test.
The odds of a radiology report being available within 24 hours was 3.6-fold higher
for subspecialized compared to general reporting ([Table 2]). [Fig. 2] shows the development of the proportion of radiology reports available < 24 h over
time.
Fig. 2 Development of the proportion of radiology reports available < 24 h over time. Outcome
variable: odds ratio (closed line) with 95 % confidence interval (dashed lines). The
odds of a radiology report to be available within 24 hours increased by changing from
general reporting (January to December 2012) to subspecialized reporting (April 2014
to March 2015).
Abb. 2 Entwicklung des Anteils der < 24 h freigegebenen radiologischen Berichte im Beobachtungszeitraum.
Zielvariable: Quotenverhältnis (durchgehende Linie) mit 95 %-Konfidenzintervall (gestrichelte
Linien). Die Chance eines radiologischen Berichtes innerhalb von 24 Stunden freigegeben
zu werden erhöhte sich nach dem Wechsel von allgemeiner Befundung (Januar bis Dezember
2012) zu subspezialisierter Befundung (April 2014 bis März 2015).
The odds of a radiology report being available within 24 hours was higher for subspecialized
compared to general reporting for both reports generated primarily by residents and
finalized by a board-certified radiologist and reports generated by board-certified
radiologists alone. However, improvement was greater for reports of residents (odds
4.6-fold higher) compared to reports of board-certified radiologists (odds 3.7-fold
higher) (p < 0.001).
Radiologists’ Productivity
The productivity of board-certified radiologists increased from a median of 301 (290
to 333) (reports/FTR/month) during the period of general reporting to 376 (350 to
407) (reports/FTR/month) for the period of subspecialized reporting (p = 0.001) ([Fig. 3]).
Fig. 3 Productivity (number of generated radiology reports per full-time radiologist [FTR]
per month) presented as median with 25th percentile and 75th percentile of the period
of general reporting (January to December 2012) and of the period of subspecialized
reporting (April 2014 to March 2015).
Abb. 3 Produktivität (Anzahl generierter radiologischer Berichte pro Vollzeitradiologe [FTR]
pro Monat), dargestellt als Median mit 25. Perzentile und 75. Perzentile während des
Zeitraumes allgemeiner Befundung (Januar bis Dezember 2012) und für den Zeitraum subspezialisierter
Befundung (April 2014 bis März 2015).
The average length of a sample of oncologic radiology reports increased from 229 words
during general reporting to 325 words during subspecialized reporting (p < 0.001).
Discussion
In our radiology department, changing the workflow from general to subspecialized
reporting yielded a statistically significant improvement of the turnaround time of
radiology reports, the fraction of radiology reports available within 24 hours and
radiologists’ productivity.
Turnaround time of radiology reports (TAT)
We demonstrated that changing from a general to a subspecialized reporting system
decreased report TAT by a factor of 4.7 (p < 0.001). To our knowledge, there is no
prior publication assessing the influence of a change from general to subspecialized
reporting on TAT. However, prior publications regarding the impact of voice recognition
software (VRS) [9]
[10] and the impact of a picture archiving and communication system (PACS) [11] on TAT of radiology reports showed similar rates of improvement. Prevedello et al.
[10] showed a 5-fold to 24-fold reduction of TAT with the introduction of VRS in a community
hospital setting without a residency training program, while Krishnaraj et al. [9] demonstrated a 2.2-fold improvement in an academic institution with radiology trainees.
In a study by Mehta et al. [11], the implementation of a PACS resulted in a 6.7-fold decrease in TAT.
According to our experience, the decrease in TAT of subspecialty-trained board-certified
radiologists might be explained by the fact that they spend less time on literature
search in their daily routine since they are more familiar with the anatomy, pathologies,
and post-therapeutic and postoperative conditions. They gain more experience in their
field of expertise due to a larger number of imaging studies reported per year. What
might be a rare pathology or variant for the general radiologist is more frequently
observed and routine for the subspecialized radiologist.
In the current study TATs were reduced substantially for all imaging studies (X-ray,
CT, MRI, ultrasound) by implementing subspecialized reporting. However, the effect
varied with the greatest reduction observed for X-ray and ultrasound reports and less
reduction for CT and MRI reports. This might be explained by the fact that the TAT
seems to plateau once a certain level is reached. Since the TATs of CT and MRI studies
were rather low already during general reporting (7:31 hours and 8:25 hours, respectively),
the potential for improvement was smaller compared to reports of X-ray and ultrasound
studies.
Fraction of radiology reports available within 24 hours (R< 24 h)
By implementing subspecialized reporting, not only the report TAT but also the fraction
of radiology reports available within 24 hours improved substantially by 22 % (p < 0.001)
with a similar explanation as stated earlier regarding the improvement of the TAT.
Similar to TATs, the improvement was greater for reports of X-ray and ultrasound studies
compared to CT and MRI studies. Again, this might be explained by the fact that R< 24 h
seems to plateau once a certain level is reached ([Fig. 2]). The improvement of R< 24 h in this study (5.7 % to 28.2 %) is similar to the improvement
achieved by the introduction of voice recognition software (4.3 % to 20.4 %) in an
academic hospital setting as published by Akhtar et al. [12].
Radiologists’ Productivity
We could show that changing from general to subspecialized reporting also significantly
increased productivity, which is most likely a consequence of a reduction in the TAT.
Subspecialized radiologists use their time more efficiently compared to general radiologists.
Of note, the core working hours were identical during both periods. An increase in
productivity was therefore not related to longer working hours but was a result of
a true increase in reports generated per radiologist.
Limitations
Our study has several limitations. First, the study was conducted at a community-based
hospital with a radiology resident training program. Results may vary in an academic
setting or in a private practice. Since reports primarily generated by residents must
be finalized by a board-certified radiologist, the performance of board-certified
radiologists might be underestimated compared to institutions without a radiology
resident training program, e. g. private practices. Furthermore, subspecialized reporting
cannot be provided by 10 board-certified radiologists during 100 % of the core working
hours. During illness, vacation or continuing medical education, staff radiologists
had to cover for other subspecialties. However, subspecialized reporting was possible
during 91 % of the time due to double coverage of almost all subspecialties.
In the current study the TAT was calculated according to the most common definition
in the literature in order to enable comparability with previous publications. However,
there are different definitions of TAT. Breil et al. [7] analyzed the calculation of TAT in 37 publications in the radiology domain and identified
11 different time intervals: in 10 publications the definition of TAT was identical
to the current study (the time from completion of the image acquisition until availability
of the final radiology report). At least 20 publications used different definitions
that integrated fewer process steps (e. g. the time from completion of the image acquisition
until the beginning of the dictation process [6 publications]). In our institution
particularly for emergency department studies, preliminary reports are available shortly
after image acquisition. However, these preliminary reports were not used for the
calculation of TAT.
Due to the nature of the study design, the two reporting systems (general vs. subspecialized
reporting) and their influence on TAT, R< 24 h and productivity had to be tested in
consecutive order, allowing other factors that might have changed over the two study
periods to influence the results. Separate calculation and comparison of the above
performance indicators per individual radiologist was not feasible due to employee
turnover (replacement of general radiologists by newly employed subspecialized radiologists),
which is a potential confounding factor. It was also not possible to calculate and
compare performance indicators per subspecialty since examinations were not assigned
to a subspecialty during the first period of general reporting. In retrospect, it
cannot be identified whether a CT of the thorax and abdomen, for example, belonged
to musculoskeletal, abdominal, thoracic or vascular radiology.
However, potential confounding factors (number of radiologists, technicians, CT and
MRI scanners, ultrasound units, case demonstrations per week as well as RIS, PACS
and voice recognition software) were kept constant over the entire study period to
the greatest extent possible.
To avoid bias, there was no change in the resident teaching program or the individual
case reading procedure throughout the entire study period. No additional actions such
as “pay for performance” were taken to improve TAT and productivity. Also the word
count of reports did not decrease from general to subspecialized reporting as a potential
confounder. In fact, a comparison of 100 randomly selected reports of oncological
CTs of the thorax and abdomen showed a statistically significant increase in word
count.
Furthermore, the impact of subspecialized reporting on the quality of reports was
not formally evaluated. However, the quality of reports is a critical measurement.
According to our impression, there was no inverse association between report TAT and
performance, respectively, and quality of reports. This is supported by results of
Rosenkrantz et al. [13], who showed weak to no correlation between TAT and report quality (report content,
report clarity and impact on patient care). Several publications from different subspecialty
areas have even shown increasing quality of reports with subspecialized reporting.
For example, Zan et al. [14] found clinically important differences in the reports of 7.7 % of 4534 neuroradiology
studies reinterpreted for second opinion by subspecialty-trained neuroradiologists
compared to the initial report generated outside the institution usually by radiologists
without special training. In a study by Eakins et al. [15], second opinion interpretation of 773 pediatric imaging studies was performed by
subspecialists in pediatric imaging. Compared to the original report by general radiologists,
major and minor discrepancies were detected in 21.7 % and 20 %, respectively. Comparing
breast cancer detection rates of general radiologists and breast imaging specialists,
Sickles et al. [16] showed that the detection rate was significantly higher for subspecialists for both
screening and diagnostic mammography. Bell and Patel [17] reported that the degree of subspecialization of board-certified radiologists performing
second opinion interpretation had a significant impact on the detection rate of clinically
relevant discrepancies.
In conclusion, changing the workflow from a general to a subspecialized reporting
system is feasible and its implementation yields statistically significant improvement
in the turnaround time of radiology reports, the fraction of radiology reports available
within 24 hours and radiologists’ productivity at a community-based hospital with
a radiology resident training program. After reaching a plateau, further investigation
is needed particularly to further decrease the number of reports available after 24 hours.
Clinical relevance of the study
-
Subspecialized reporting improves workflow and efficiency in a radiology department.
-
Expedition of radiology report turnaround time contributes to faster patient management.
-
Faster management of inpatients contributes to the economic success of a hospital.
