Integrity of clinical information in radiology reports documenting pulmonary nodules

Abstract

Objective: Quantify the integrity, measured as completeness and concordance with a thoracic radiologist, of documenting pulmonary nodule characteristics in CT reports and assess impact on making follow-up recommendations.

Materials and methods: This Institutional Review Board-approved, retrospective cohort study was performed at an academic medical center. Natural language processing was performed on radiology reports of CT scans of chest, abdomen, or spine completed in 2016 to assess presence of pulmonary nodules, excluding patients with lung cancer, of which 300 reports were randomly sampled to form the study cohort. Documentation of nodule characteristics were manually extracted from reports by 2 authors with 20% overlap. CT images corresponding to 60 randomly selected reports were further reviewed by a thoracic radiologist to record nodule characteristics. Documentation completeness for all characteristics were reported in percentage and compared using χ2 analysis. Concordance with a thoracic radiologist was reported as percentage agreement; impact on making follow-up recommendations was assessed using kappa.

Results: Documentation completeness for pulmonary nodule characteristics differed across variables (range = 2%-90%, P < .001). Concordance with a thoracic radiologist was 75% for documenting nodule laterality and 29% for size. Follow-up recommendations were in agreement in 67% and 49% of reports when there was lack of completeness and concordance in documenting nodule size, respectively.

Discussion: Essential pulmonary nodule characteristics were under-reported, potentially impacting recommendations for pulmonary nodule follow-up.

Conclusion: Lack of documentation of pulmonary nodule characteristics in radiology reports is common, with potential for compromising patient care and clinical decision support tools.

Keywords: diagnostic imaging; electronic medical records, solitary pulmonary nodule; health information technology; patient safety.