By Bill Bunker, Executive Vice President, SCI Solutions
As personal medical records become more accessible, patients often find themselves confused – what does the information within their own record actually mean? Even physicians from one medical specialty to another find difficulty translating specific medical terminology and phrasing. The Wall Street Journal notes a growing trend of certain medical specialties, such as radiology, are pushing to change the way medical reports are written so their findings are clearer to both patients and physicians.
Conveying Key Clinical Information
We’ve all been patients at one time or another – imagine this scenario. Say you’re experiencing a mysterious pain in your right upper abdomen, so you are referred to a radiologist to make sure it isn’t something serious. What write-up would you rather read in your medical record?
- Report One: “A too-small-to characterize lesion of the liver, kidney, etc.”
- Report Two: “Liver: several lesions that are too small to characterize are likely simple cysts.
The majority of patients would choose Report Two. It’s not only easier to understand, it also puts you at ease to know the likely prognosis. In the age where medical libraries like WebMD are accessible at one’s fingertips, patients often agonize over self-diagnosing themselves with having a condition much worse than reality. Therefore, it is beneficial for doctors to give insight, when appropriate, on a likely prognosis to save the patient from unnecessary worry.
It Takes Templates and Technology
The American College of Radiology reports some radiology organizations have created new report templates that emphasize brevity, simplicity, and careful word choice to avoid ambiguity. When these templates are supported by the hospital or practice’s referral management system, the benefits substantially increase. At Clarity Health, our cloud-based platform labels key information that a radiologist needs to effectively run an imaging test – clear diagnosis of what the referring provider is trying to find or rule out, clear body part and modality to be screened, any patient allergies, etc. By marrying better report templates with technology, we can improve communication for both patients and physicians, enabling better care coordination for the healthcare system as a whole.