Large-Scale Implementation of Structured Reporting of Adnexal Masses on Ultrasound

Abstract

Purpose: The aim of this article is to describe the development and implementation of structured reporting of adnexal mass findings on pelvic ultrasound in a large integrated health care delivery system.

Methods: A structured reporting system that includes standardized terminology for describing adnexal masses on ultrasound was developed by a multidisciplinary team of radiologists, gynecologists, and gynecologic oncologists on the basis of literature review and internal data. The system uses a reporting template that requires radiologists to assign abnormal adnexal masses to one of five possible categories on the basis of standardized criteria: category 0, 1, 2, or 3 for masses <10 cm, to reflect increasing concern for malignancy, and category X for masses >10 cm. Unique predefined hashtags were linked to each category to enable electronic data extraction, and a hard stop feature was installed that prevents reports from being finalized without a category designation. In 2014, after a 3-month pilot study, large-scale implementation was supported by an educational campaign consisting of web-based conferences, e-mail announcements, and local presentations. Clinical management recommendations on the basis of category and other clinical factors were provided in a separate practice resource for clinicians.

Results: Analysis of adherence revealed that 93% of the approximately 12,000 reports describing abnormal adnexal masses in 2016 included category designations. Feedback from referring providers via an anonymous survey indicated high levels of satisfaction with reports.

Conclusions: Multidisciplinary collaboration and leveraging of technology enabled large-scale implementation of structured reporting with high levels of adherence among radiologists and improved satisfaction among referring providers.

Keywords: Structured reporting; adnexal; mass; ultrasound.