The 21st Century Cures Act was signed into law in 2016 and mandated that patients have immediate access to their radiology reports. While having immediate access provides for greater transparency and control for patients, it also risks the misinterpretation of report language. Radiology reports are often filled with medical jargon that can cause unnecessary stress and confusion for a patient. For example, edema means swelling, and “unremarkable” means perfectly normal. When it comes to lung imaging, many patients are startled to see the finding of a nodule in their imaging exam, unaware that benign lung nodules appear in half of all adult CTs and X-rays. At some facilities, this has even caused an increase in direct calls from patients to radiology departments; patients are looking at their reports before they even hit the referring physician’s desk. 

Randy Miles, MD, MPH, Chief of Breast Imaging at Denver Health and Associate Professor of Radiology at the University of Colorado, said to the Radiology Society of North America, “We need to maintain the integrity of these reports because it’s a primary source of communication between the radiologists writing the report and the referring physician, other radiologists, and members of the care team. But we can take the extra step of supplementing our reports with definitions of technical and medical terms and categorizing our findings as benign or probably benign, when applicable, to bring peace of mind to the patient reading the report.”

Some facilities have begun producing a patient-facing versus a physician-facing report. Others have developed new workflows to quickly alert referring physicians when a report is ready so they can review it before the patient calls as 82% of patients still want to receive direct communication from the provider who ordered the exam rather than the radiologist. 

Strategies for Simplification 

Radiologists shouldn’t reduce the standard of report writing but rather can offer additional clarification for patients and physicians (and avoid clunky phrases). Simplified radiology reports contribute to a culture of patient-centered care. They foster trust, improve patient satisfaction, and promote a collaborative approach to healthcare decision-making. One surveyed group of patients said that a physician who speaks without jargon is more caring and empathetic (and 91% preferred that physician over one using more jargon). It’s not just patients; even referring physicians can misinterpret radiology language and have called for greater standardization across reporting.  Here are a few simple strategies to add clarification to reports. 

1. Define and Explain: Instead of using terms like “edema,” clarify by explaining it as “fluid buildup.”
   
2. Use Analogies: Analogies can make complex findings more relatable. For instance, comparing the size of a tumor to familiar objects (e.g., a pea or a walnut) can provide a clearer mental image.
   
3. Limit Abbreviations: Abbreviations confuse; use them sparingly and always define them when first mentioned.
   
4. Patient-Centric Language: Tailor reports to the audience. When addressing patients directly, use clear language without oversimplifying the medical content.
   
5. Collaborative Efforts: Encourage feedback from patients and referring physicians on the clarity of reports. Their insights can help refine communication practices.

A Push For Standardization

The call for standardization in radiology reports has emerged as a critical initiative. An in-depth- study on report standardization found that despite challenges, structured reporting enhances clarity, improves communication, and offers greater precision and accuracy of diagnostic information. 

Standardization initiatives often involve leveraging technology for report generation and distribution. Integration with existing electronic health record (EHR) systems and imaging platforms requires careful planning and investment in interoperable solutions. The journey towards standardized and jargon-free radiology reporting demands collaboration among radiologists, referring physicians, IT professionals, and more. Although a complex endeavor for any healthcare facility, streamlined reporting will improve patient care and experience in the long run. It’s a win-win for all.