Top 5 Report Creation Annoyances in Radiology

March 26th, 2014 / By Sue Belley, RHIA

It’s about productivity and accuracy – anything else is a distraction

Guest blog by Dr. Arnold Raizon, MD, a physician consultant with 3M ChartScriptMD for Radiology.

One of my biggest frustrations as a radiologist is dealing with the quirks of the software tools I must use to create my reports. Some applications look like they were not really created from the ground up for radiology use, but merely a collection of patches over generic software that frustrate busy radiologists like me. Let’s examine in more detail some of the common annoyances that hinder radiologists’ ability to stay productive and, more importantly, how to address them.

1. Unbillable report! – A large number of radiology reports are returned with questions from coding and billing because the documentation is insufficient. Often times, the order we receive doesn’t come with adequate history, so we must interpret the images without the helpful context of the patient’s story. Viable solution? Having access to the EHR would help the radiologist produce a report that is far more pertinent to that specific patient, supports medical necessity, and indicates a more definitive diagnosis. This would also promote ICD-10 compliance and, ultimately, enhance patient care.

2. Busy user interfaces – A major problem with some speech recognition and report creation programs is that they are overloaded with unnecessary features, and radiologists spend an inordinate amount of time finding what’s applicable to them. This greatly decreases efficiency and productivity. Having software that’s streamlined and created specifically for radiology reporting is an investment, yes, but let’s face it, radiology is a big revenue generator in a hospital. My guess is that the investment is worth the money!

3. Having to start from scratch – Another thing that I want to avoid as a radiologist is starting a report from a blank screen. A great jump-start into report creation is to have the ability to populate the report with as much information as possible before dictating. One way to achieve this is to have CPT® driven templates that contain appropriate sections and questions to help increase productivity, while also ensuring that all required elements are present in the documentation.

4. What if I just want to dictate? – Radiologists, like other specialties, are often being forced to adopt software mandated by the hospital. While it is understandable that a hospital would want to select one vendor for all of their documentation needs, reality is that one size does not always fit all. Some radiologists are used to dictating and sending to transcription, some like the use of templates (I happen to be one of them), and others like to be in control of the report creation process using front-end speech recognition. There are many methods of creating reports, and radiologists should have the flexibility to choose the methodology that works best for them.

5. Oops, here comes another addendum – Fellow radiologists out there are going to agree, no question about it, that the biggest annoyance is hitting the “complete report” button only to realize – usually, after a microsecond – that you forgot to mention or verify ONE last thing. Now the report is sent, off it goes to the coding and billing department and YOU KNOW it will come back with questions or marked as “unbillable.” Intelligent software that includes an “oops queue” that can be set up and customized could greatly reduce the need for addenda.

As high revenue generators for our hospitals, radiologists are great influencers into the kinds of tools hospitals will purchase to facilitate our jobs. Making it our business to know the latest in report creation technology that can accommodate our unique needs is our responsibility, especially if we want to increase our productivity and accuracy. As ICD-10 is implemented, radiologists are going to be pressured even more. Let’s make our lives easier by seeking out and implementing tools that address these common workflow issues.

Dr. Arnold Raizon, MD, is a physician consultant with 3M ChartScriptMD for Radiology. He is a practicing radiologist in the Washington, DC, metro area