An open-standards grammar for outline-style radiology report templates

Abstract

Structured reporting uses consistent ordering of results and standardized terminology to improve the quality and reduce the complexity of radiology reports. We sought to define a generalized approach for radiology reporting that produces flexible outline-style reports, accommodates structured information and named reporting elements, allows reporting terms to be linked to controlled vocabularies, uses existing informatics standards, and allows structured report data to be extracted readily. We applied the Regular Language for XML-Next Generation (RELAX NG) schema language to create templates for 110 reporting templates created as part of the Radiological Society of North America reporting initiative. We evaluated how well this approach addressed the project's goals. The RELAX NG schema language expressed the cardinality and hierarchical relationships of reporting concepts, and allowed reporting elements to be mapped to terms in controlled medical vocabularies, such as RadLex®, Systematized Nomenclature of Medicine Clinical Terms®, and Logical Observation Identifiers Names and Codes®. The approach provided extensibility and accommodated the addition of new features. Overall, the approach has proven to be useful and will form the basis for a supplement to the Digital Imaging and Communication in Medicine Standard. © 2011 Society for Imaging Informatics in Medicine.