An application design supporting structured radiology reports

Radiologists use medical images to diagnose diseases. Today, medical images are commonly stored and displayed electronically. The radiologist describes the image interpretations in a report, and the electronic viewing of images opens a possibility for the radiology report to become computerized. By creating an application that supports the radiologist’s report generation, tools for creation of structured reports can be provided, generating more complete, clear reports, connected to the examination images. The structured report can also be encoded, to provide data for medical research and for statistics. This masters’ thesis establishes the requirements on a structured reporting application, by means of a literature review and by user interviews and meetings. Using the established requirements, a structured reporting application was designed, and partly implemented as a prototype. The results show that an application for structured reporting has to be made adaptive, to support different usage areas, each having their own requirements on navigation, organization and workflow. It also has to support reuse of report components, and automatic generation of sections. The resulting reports should be encoded in DICOM SR (Digital Imaging and Communications in Medicine – Structured Reporting), using the report pattern established by IHE (Integrating the Healthcare Enterprise). To provide users with a complete set of radiological terms for generation of natural language, a medical dictionary should be used. User input can be made through data entry controls, and it should be possible for the user to, in an easy way, link images and add measurement values to the report content.