Enhancing the expressiveness of structured reporting systems

The overall goal of this research is to build a structured reporting system that reduces the cost, delays, and inconvenience associated with conventio nal dictation and speech recognition systems. We have implemented such a st ructured reporting system for radiology that replaces current dictation and transcription processes by allowing radiologists and other imaging profess ionals to select imaging findings from a medical lexicon. The system uses a n imaging-specific information model, called a "description set,' to organi ze selected terms in a relational database. Unique features of the knowledg e representation that enhance its expressiveness include its ability to cod ify uncertainty about an imaging observation and to represent explicitly th e logical relationships among imaging findings. In addition, the system doe s not require the user to fill in "blanks' in a static text template. Inste ad, it allows entry of terms in arbitrary order and uses automated text-gen eration techniques to create a text report that referring physicians are ac customed to receiving. In parallel, the system also produces a multimedia r eport that the referring physician can use as a quick reference. Unlike the results of conventional dictation or speech recognition, each finding is c oded in a relational database for later information processing. Thus, the s tructured report database can be used to index images by content, to provid e real-time decision support, to enhance radiologists' performance, to cond uct exploratory clinical research, and to transmit imaging report data to c omputer-based patient record systems. Copyright (C) 2000 by W.B. Saunders C ompany.