structured reporting: coronary ct angiography
TRANSCRIPT
I
Ttprriadrtheptte
a
b
c
d
e
f
Da
7
Structured Reporting:Coronary CT Angiography
A White Paper from the American College ofRadiology and the North American Society for
Cardiovascular ImagingArthur E. Stillman, MD, PhDa, Geoffrey D. Rubin, MDb, Shawn D. Teague, MDc,
Richard D. White, MDd, Pamela K. Woodard, MDe, Paul A. Larson, MDf
With the growing use of electronic medical records, the trend of diagnostic imaging reporting is toward a morestructured format. Advantages include improved quality and consistency of the reporting and ease of datamining. The essential elements of a structured report are provided and illustrated for coronary artery computedtomographic angiograms.
Key Words: Diagnostic image reporting, coronary artery computed tomographic angiography, radiologyimaging reporting, structured reporting
J Am Coll Radiol 2008;5:796-800. Copyright © 2008 American College of Radiology
ap
pmHiniemti
madbageda
tsi
NTRODUCTION
here is a growing trend in diagnostic imaging to struc-ure reports of imaging procedures [1-3]. Structured re-orting is important for several reasons. First, structuredeporting can improve quality through consistency. Keyeport elements are less likely to be omitted if the reports structured and elements are listed systematically within standard template. The development of lexicons stan-ardizes descriptors. Reports convey similar informationegardless of the imager’s background and are similarhroughout and across institutions. Referring physiciansave access to an end product from which it is easier toxtract the pertinent results because they are in an ex-ected location in the report and in standard definederminology. In addition, data mining may be facilitatedhrough structure with entries serving as data cells inlectronic medical records. Finally, structured reporting
Emory University School of Medicine, Atlanta, Georgia.
Stanford University Medical Center, Palo Alto, California.
Indiana University School of Medicine, Indianapolis, Indiana.
University of Florida, Department of Radiology, Jacksonville, Florida.
Mallinckrodt Institute of Radiology, St. Louis, Missouri.
Radiology Associates of the Fox Valley, SC, Neenah, Wisconsin.
Corresponding author: Arthur E. Stillman, MD, PhD, Emory University,epartment of Radiology, 1364 Clifton Rd NE, Atlanta, GA 30322; e-mail:
96
lso ensures that all required elements for billing pur-oses are contained within the report.It is understood that although there is the desire to im-
ose more structure in reports, some degree of flexibilityust be permitted to accommodate unusual circumstances.owever, this should be kept to a minimum. Moreover, the
ndications for assessing coronary arterial anatomy by coro-ary computed tomographic angiography (CCTA) are var-
ed. When associated with nonatherosclerotic coronary dis-ase, congenital heart disease, acquired diseases of theyocardium, valves, aorta, and pulmonary arteries, addi-
ional relevant findings referable to these diseases should bencluded in the report.
Probably the most thoroughly developed and usedethod of standard reporting language is found associ-
ted with mammography. The American College of Ra-iology Breast Imaging Reporting and Data System® haseen in use for more than a decade [4]. Other specialtyreas in radiology have proposed standardized report lan-uage, including lower limb veins [5], lumbar disk dis-ase [6,7], and chest disease [8-10]. RadLex® is beingeveloped by the Radiological Society of North Americas a comprehensive lexicon for radiology reporting [11].
Structured reports may be generated using worksta-ion software for some tests, such as single photon emis-ion computed tomography myocardial perfusion imag-ng and CCTA. Alternatively, dictation templates or
acros in transcription software may be used [1].
© 2008 American College of Radiology0091-2182/08/$34.00 ● DOI 10.1016/j.jacr.2008.04.002
oaiscoci
E
E
TtodPssps
I
Tai(c9
C
Tsr
P
Rrsdsccs
F
Afitsac
I
Alimbilsr
A
Ibpofi
msCbltacsfsfn(cp
miamrasipn
iai
Stillman et al/Structured Reporting 797
The future of structured reporting includes capturingf imaging findings during the imaging process (point-nd-click approaches) [12] that may translate directlynto text, image-annotated text, and templates with con-trained, coded vocabulary. These specific utilities, whichan assist with data capture, direct comparison of data,utcomes assessment, and improved patient outcomes,an be facilitated by digital imaging and communicationn medicine-structured report mechanisms [13].
LEMENTS OF A STRUCTURED REPORT
xamination
he examination briefly describes the specific procedurehat was performed. Together with the technical detailsf the procedure (provided under the heading “Proce-ure” below), this may be used to assign a Currentrocedural Terminology® (CPT) code [14] for thetudy. Generally, the listed examination of the reporthould be the same as that requested by the referringhysician and scheduled in the radiology informationystem.
ndication
he indication should include pertinent clinical historylong with signs, symptoms, and relevant results of med-cal tests. Abbreviations and acronyms should be avoidedeg, SOB � shortness of breath). There should be aorresponding International Classification of Diseases,th revision code (ICD-9) [15].
omparison Studies
he date(s) of previous studies used for comparisonhould be listed. If the examination type differs from theeported study, the examination type should be listed.
rocedure
elevant technical details of the examination that areequired to assign a CPT® [14] to the study should betated. All pharmaceutical agents, including contrast me-ia, that were used as part of the imaging procedurehould be listed along with the dose administered. Anyomplication of the procedure, steps taken to treat theomplication, and disposition of the patient at dischargehould be stated.
indings
logical division of anatomy should be used in statingndings for each organ system or body part. Descriptiveerms should be part of standardized lexicon when pos-ible. Quantitative measures should be used as appropri-te. Links to pertinent representative images may be in-
orporated into the report. 1mpression/Conclusions
succinct summary of the important findings should beisted. A numbered list is desirable, presenting the resultsn order of decreasing importance. Recommendations
ay be provided concerning additional studies that maye required to answer the clinical question or to work upncidental findings. The use of the phrase “clinical corre-ation is recommended” should be avoided because ituggests a lack of responsibility on the part of the refer-ing physician.
ttestation
n academic institutions where residents or fellows maye reporting, it is important that the interpreting staffhysician state that he or she was present for the entiretyf the procedure (if an interventional procedure was per-ormed) or that all images were personally reviewed. Thiss a requirement of Medicare.
Structured reporting is increasingly used by otheredical specialties. It is widely incorporated in reporting
ystems for assessing echocardiograms, for exampleCTA, in particular, lends itself to structured reportingecause there are limited anatomic elements and patho-
ogic variations. Workstations are now providing struc-ured reports that are generated in the course of imagenalysis. However, many radiology information systemsannot accept these reports at the present time. Dictationystems are more commonly used. Quantitative measuresor data (eg, ejection fraction) may be provided. At theame time, semiquantitative descriptors may be needed,or example, coronary stenoses are generally graded asormal (0% stenosis), mild (�50% stenosis), moderate50%-70% stenosis), severe (�70% stenosis), or oc-luded because the spatial resolution is inadequate to berecise.Templates that may be used with electronic reportingechanisms and that use many of the described report-
ng elements are provided below.1 Local preferences maydd to or modify these templates, but the essential ele-ents of the report are provided [16]. Other variations in
eporting may be necessary in the presence of coronarynomalies or bypass grafts and to describe findings out-ide of the coronary arterial tree. The template for report-ng the results of coronary artery bypass grafts, for exam-le, may require considerable editing depending on theumber, type, and location of bypass grafts present.The type (left internal mammary artery [LIMA], right
nternal mammary artery [RIMA], saphenous vein graft,nd radial artery), artery of distal anastomosis, and prox-mity of the graft to the sternum should be noted. In
Templates may be downloaded from www.acr.org and www.nasci.org
asstslittoTatte
T
C
Iw�pm
C
[
P
Cuimo[amcalmaCptrwud[w
E
Tamstb
A
Tad([c
C
TvTvVpe�
F
T[mmtol
C
Tiiatm
�oc
[mcc
798 Journal of the American College of Radiology/Vol. 5 No. 7 July 2008
ddition, the position of the graft in relationship to theternal notch should be reported if the graft abuts theternum. Proximity of the grafts and cardiac chambers tohe sternum is of concern to avoid damage during a redoternotomy. The sternal notch is selected as a surfaceandmark that is readily identifiable by the surgeon. Min-mally invasive surgery may require a modification of theemplate to localize the proximal graft anastomosis withhe distance of the graft origin from the anterior surfacef the brachiocephalic artery origin or the aortic annulus.hese landmarks are integral to the ascending aorta and
s such are not apt to change the relationship relevant tohe graft origins with changes in the mediastinum posi-ion relative to the sternum, such as from a pericardialffusion.
EMPLATE FOR CCTA
CTA with Coronary Artery Calcium Score
ndication: A [��]-year-old [�man� �woman�]ith [�chronic chest pain� �atypical chest pain�abnormal single photon emission computed tomogra-
hy study� �exertional angina� �prevalve replace-ent� � �].
omparison
�type�] [�date�]
rocedure
omputed tomography (CT) of the heart was obtainedsing prospective electrocardiography (ECG) triggering
nitially without the use of contrast media. A [��]-sliceultidetector CT coronary angiogram was subsequently
btained using retrospective ECG gating. [��] mL of��] contrast was administered intravenously. In prep-ration for the examination, the patient received [��]g [�intravenous� �oral�] [�metoprolol�, �cal-
ium channel blocker�] for heart rate/rhythm controlnd [��] mg sublingual nitroglycerin [�spray� �tab-et�] for coronary vasodilation. Before medication ad-
inistration, the heart rate was [��] beats per minutend blood pressure was [��] mm Hg. At the time ofT, the heart rate was [��] beats per minute and bloodressure was [��] mm Hg. [�There were no complica-ions� � �]. [�ECG tube modulation was used toeduce the radiation exposure� �ECG tube modulationas not used because of arrhythmia� �ECG tube mod-lation was not used because of the need for systolic andiastolic imaging�]. The CT dose index-volume was��] mGy, and dose length product of the examination
as [��] mGy-cm. nxtracardiac Findings
he visualized lungs [��] and mediastinum [��]. Im-ges of the upper abdomen demonstrate [��]. The pul-onary arteries are [�normal� �enlarged�]. The vi-
ualized thoracic aorta is [�normal� �enlarged�]. (Ifhe aorta is enlarged or dissected, description and size shoulde provided.)
gatston Score
otal coronary artery calcium score is [��], distributeds left main (LM) coronary artery [��], left anteriorescending (LAD) [��], left circumflex coronary arteryLCx) [��], right coronary artery (RCA) [��];��]% of similar patients have less coronary artery cal-ium.
ardiac Morphology
he right atrium is [�normal� �dilated�]. The rightentricle is [�normal� �dilated� �hypertrophied�].he left atrium is [�normal� �dilated�]. The leftentricle is [�normal� �dilated� �hypertrophied�].alves [��]. [�The pericardium is normal� �Theericardium is thickened� �There is a small pericardialffusion� �There is a moderate pericardial effusion�There is a large pericardial effusion�].
unction
he calculated left ventricular ejection fraction is��]%, left ventricular end-diastolic volume is [��]L, and left ventricular end-systolic volume is [��]L. There [�are no regional wall motion abnormali-
ies� �is hypokinesia/akinesia/dyskinesia of the anteri-r/anterolateral/inferolateral/inferior wall/septum of theeft ventricle�].
oronary CT Angiogram
he overall quality of the CT angiographic examinations [�excellent� �good� �fair� �poor�] and is lim-ted by [�poor arterial opacification� �misregistrationrtifacts� �patient motion�]. The coronary artery sys-em is [�right� �co-� �left�] dominant with [�nor-al� �anomalous�] origins.The LM [�has no stenosis� �has mild stenosis�has moderate stenosis� �has severe stenosis� �is
ccluded� �is nonevaluable�] with [�no� �noncal-ified� �mixed� �calcified�] plaque.
The proximal LAD and first diagonal branch (D1)�have no stenosis� �have mild stenosis� �haveoderate stenosis� �have severe stenosis� �are oc-
luded� �are nonevaluable�] with [�no� �noncal-ified� �mixed� �calcified�] plaque.
The mid-distal LAD, D2 and D3 branches [�have no ste-
osis� �have mild stenosis� �have moderate stenosis�
�afi
ssl�
p(s��c
db�occd
I
[
TA
C
I[ms�
C
[
P
AcEtt[refbAmw
tt�nio
E
Tamstb
C
TvTvVpe�w
F
T[mT�tv
C
Tiiatm
�oc
[mcc
s
Stillman et al/Structured Reporting 799
have severe stenosis� �are occluded� �are nonevalu-ble�] with [�no� �noncalcified� �mixed� �calci-ed�] plaque.
There is a ramus intermedius branch that [�has notenosis� �has mild stenosis� �has moderate steno-is� �has severe stenosis� �is occluded� �is noneva-uable�] with [�no� �noncalcified� �mixed�
calcified�] plaque.The LCx and its obtuse marginal (OM) [and �left
osterior descending artery (LPDA)/left posterolateralLPL)�] branches [�have no stenosis� �have mild steno-is� �have moderate stenosis� �have severe stenosis�
are occluded� �are nonevaluable�] with [�no�noncalcified� �mixed� �calcified�] plaque. (If left or
odominant: LPDA and LPL branches need to be addressed.)The RCA and acute marginal [and �right posterior
escending artery (RPDA)/right posterolateral {RPL}�]ranches [�have no stenosis� �have mild stenosis�have moderate stenosis� �have severe stenosis� �are
ccluded� �are nonevaluable�] with [�no� �non-alcified� �mixed� �calcified�] plaque. (If right orodominant: RPDA and RPL branches need to be ad-ressed.)
mpression
��]
EMPLATE FOR CCTA WITH CORONARYRTERY BYPASS GRAFTS
T Coronary Angiogram
ndication: [��]-year-old [�man� �woman�] with�chronic chest pain� �atypical chest pain� �abnor-al single photon emission computed tomography
tudy� �exertional angina� �presurgical assessment��].
omparison
�type�] [�date�]
rocedure
[��]-slice multidetector computerized tomographyoronary angiogram was obtained using retrospectiveCG gating. [��] mL of [��] contrast was adminis-
ered intravenously. In preparation for the examination,he patient received [��] mg [�intravenous� �oral�]�metoprolol� �calcium channel blocker�] for heartate/rhythm control and [��] mg sublingual nitroglyc-rin [�spray� �tablet�] for coronary vasodilation. Be-ore medication administration, the heart rate was [��]eats per minute and blood pressure was [��] mm Hg.t the time of CT, the heart rate was [��] beats perinute and blood pressure was [��] mm Hg. [�There
ere no complications� � �]. [�ECG tube modula- sion was used to reduce the radiation exposure� �ECGube modulation was not used because of arrhythmia�
ECG tube modulation was not used because of theeed for systolic and diastolic imaging�]. The CT dose
ndex-volume was [��] mGy, and dose length productf the examination was [��] mGy-cm.
xtracardiac Findings
he visualized lungs [��] and mediastinum [��]. Im-ges of the upper abdomen demonstrate [��]. The pul-onary arteries are [�normal� �enlarged�]. The vi-
ualized thoracic aorta is [�normal� �enlarged�]. (Ifhe aorta is enlarged or dissected, description and size shoulde provided.)
ardiac Morphology
he right atrium is [�normal� �dilated�]. The rightentricle is [�normal� �dilated� �hypertrophied�].he left atrium is [�normal� �dilated�]. The leftentricle is [�normal� �dilated� �hypertrophied�].alves [��]. [�The pericardium is normal� �Theericardium is thickened� �There is a small pericardialffusion� �There is a moderate pericardial effusion�There is a large pericardial effusion�]. The heart [� isell separated from� �abuts�] the sternum.
unction
he calculated left ventricular ejection fraction is��]%, left ventricular end-diastolic volume is [��]L, left ventricular end-systolic volume [��] mL.here [�are no regional wall motion abnormalities�is hypokinesia/akinesia/dyskinesia of the anterior/an-
erolateral/inferolateral/inferior wall/septum of the leftentricle�].
oronary CT Angiogram
he overall quality of the CT angiographic examinations [�excellent� �good� �fair� �poor�] [and is lim-ted by �poor arterial opacification� �misregistrationrtifacts� �patient motion�]. The coronary artery sys-em is [�right� �co-� �left�] dominant with [�nor-al� �anomalous�] origins.The LM [�has no stenosis� �has mild stenosis�has moderate stenosis� �has severe stenosis� �is
ccluded� �is nonevaluable�] with [�no� �noncal-ified� �mixed� �calcified�] plaque.
The proximal LAD and first diagonal branch (D1)�have no stenosis� �have mild stenosis� �haveoderate stenosis� �have severe stenosis� �are oc-
luded� �are nonevaluable�] with [�no� �noncal-ified� �mixed� �calcified�] plaque.
The mid-distal LAD, D2 and D3 branches [�have notenosis� �have mild stenosis� �have moderate steno-
is� �have severe stenosis� �are occluded� �are non-
e�
ssl�
[mcccd
b�occd
B
Aa�at[an
d[[b�v
d[[b�v
I
[
R
1
1
1
1
1
1
1
800 Journal of the American College of Radiology/Vol. 5 No. 7 July 2008
valuable�] with [�no� �noncalcified� �mixed�calcified�] plaque.[There is a ramus intermedius branch that �has no
tenosis� �has mild stenosis� �has moderate steno-is� �has severe stenosis� �is occluded� �is noneva-uable�] with [�no� �noncalcified� �mixed�
calcified�] plaque.The LCx and its OM [and �LPDA/LPL�] branches
�have no stenosis� �have mild stenosis� �haveoderate stenosis� �have severe stenosis� �are oc-
luded� �are nonevaluable�] with [�no� �noncal-ified� �mixed� �calcified�] plaque. (If left orodominant: LPDA and LPL branches need to be ad-ressed.)
The RCA and acute marginal [and �RPDA/RPL�]ranches [�have no stenosis� �have mild stenosis�have moderate stenosis� �have severe stenosis� �are
ccluded� �are nonevaluable�] with [�no� �non-alcified� �mixed� �calcified�] plaque. (If right orodominant: RPDA and/or RPL branches need to be ad-ressed.)
ypass Grafts
[�LIMA� �RIMA� �saphenous venous� �radialrtery� �gastroepiploic artery�] graft to the [�LAD�diagonal� �OM� �RCA� � posterior descending
rtery {PDA}�] [�is well separated from� �abuts�]he sternum [�� cm below the sternal notch]. The graft�has no stenosis� �has mild stenosis� �has moder-te stenosis� �has severe stenosis� �is occluded� �ison-evaluable�].A [�LIMA� �RIMA� �saphenous venous� �ra-
ial artery� �gastroepiploic artery�] graft to the�LAD� �diagonal� �OM� �RCA� �PDA�]�is well separated from��abuts�] the sternum [�� cmelow the sternal notch]. The graft [�has no stenosis�has mild stenosis� �has moderate stenosis� �has se-
ere stenosis� �is occluded� �is non-evaluable�].A [�LIMA� �RIMA� �saphenous venous� �ra-
ial artery� �gastroepiploic artery�] graft to the�LAD� �diagonal� �OM� �RCA� �PDA�]�is well separated from��abuts�] the sternum [�� cmelow the sternal notch]. The graft [�has no stenosis�has mild stenosis� �has moderate stenosis� �has se-
ere stenosis� �is occluded� �is nonevaluable�].
mpression
��]
EFERENCES
1. Liu D, Zucherman M, Tulloss WB Jr. Six characteristics of effectivestructured reporting and the inevitable integration with speech recogni-tion. J Digit Imaging 2006;19:98-104.
2. Reiner BI, Knight N, Siegel EL. Radiology reporting, past, present, andfuture: the radiologist’s perspective. J Am Coll Radiol 2007;4:313-19.
3. Sistrom CL, Langlotz CP. A framework for improving radiology report-ing. J Am Coll Radiol 2005;2:159-67.
4. BI-RADS® Atlas. American College of Radiology. 2007. Available at:http://www.acr.org/SecondaryMainMenuCategories/quality_safety/BIRADSAtlas.aspx. Accessed February 23, 2008.
5. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, PartschH. Nomenclature of the veins of the lower limbs: an international inter-disciplinary consensus statement. J Vasc Surg 2002;36:416-22.
6. Appel B. Nomenclature and classification of lumbar disc pathology. Neu-roradiology 2001;43:1124-5.
7. Fardon DF, Milette PC. Nomenclature and classification of lumbar discpathology. Recommendations of the Combined task Forces of the NorthAmerican Spine Society, American Society of Spine Radiology, andAmerican Society of Neuroradiology. Spine 2001;26:E93-113.
8. Austin J, Simon M, Trapnell D, Fraser RG. The Fleischner Societyglossary: critique and revisions. AJR Am J Roentgenol 1985;145:1096-8.
9. Austin JH, Muller NL, Friedman PJ, et al. Glossary of terms for CT of thelungs: recommendations of the Nomenclature Committee of the Fleis-chner Society. Radiology 1996;200:327-31.
0. Marwede D, Schulz T, Kahn T. Indexing thoracic CT reports using apreliminary version of a Standardized Radiological Lexicon (RadLex). JDigit Imaging 2007 Jul 28 [Epub ahead of print].
1. Radlex®: A lexicon for uniform indexing and retrieval of radiology infor-mation resources. Radiological Society of North America. Available at:http://www.rsna.org/radlex/. Accessed February 23, 2008.
2. Loef C, Truyen R. Evidence and diagnostic reporting in the IHE context.Acad Radiol 2005;12:620-5.
3. Bertaud V, Lasbleiz J, Mougin F, Burgun A, Duvauferrier R. A unifiedrepresentation of findings in clinical radiology using the UMLS andDICOM. Int J Med Inform 2008 Jan 4 [Epub ahead of print].
4. CPT® (Current Procedural Terminology). American Medical Association.Available at: http://www.ama-assn.org/ama/pub/category/3113.html. Ac-cessed February 23, 2008.
5. International Classification of Diseases (ICD). World Health Organiza-tion. Available at: http://www.who.int/classifications/icd/en/. AccessedFebruary 23, 2008.
6. Zimmet JM, Miller JM. Coronary artery CTA: imaging of atherosclerosisin the coronary arteries and reporting of coronary artery CTA findings.
Tech Vasc Interv Radiol 2006;9:218-26.