With the introduction and wide spread use of the ACR Breast Imaging Reporting and Data System™ (BI-RADS) Lexicon, mammographers have realized the benefits of a national standard for mammography reporting. BI-RADS includes the Breast Imaging Lexicon of standardized terminology, and the Reporting System which suggests a standardized approach to the organization and wording of the breast imaging report. A fully standardized report should conform to both the BI-RADS Breast Imaging Lexicon and the BI-RADS Reporting System.

The use of computer software to collect mammography data, perform patient tracking functions and monitor quality assurance data offers many savings and benefits. The ability to use this data, once entered, to generate standardized breast imaging reports, would offer the most efficient method of mammography reporting.

However, many groups using mammography information software products that offer this capability have found that there are many barriers to automatically generating acceptable reports from this information. The reason for this is the absence in such products of an "intelligent" report translator.

The MagView AutoScribe standardized report translator is an automatic, "intelligent" software language model for standardized mammography reporting. MagView AutoScribe automatically handles each aspect of report construction and validation that allows the radiologist to quickly and reliably generate effective standardized reports for normal and abnormal, screening and diagnostic studies.

Construction
The construction of MagView reports through the AutoScribe translator includes several important features:

• The report appears the same regardless of the sequence of entry of findings and modifiers. Unlike many report generation algorithms, which add words or phrases to the report in the order in which they are selected, MagView re-generates the entire report after each selection, ensuring that all words, phrases and sentences consistently appear in the most logical sequence. This allows the radiologist to focus on the interpretation rather than the sequence in which data is selected.

• Each element of the report is context sensitive. In many cases, the way in which finding terminology is used depends on other findings which exist. For example, the presence of calcifications would be stated differently depending on whether they are the primary finding, or are associated with a mass finding. The AutoScribe translator automatically handles the translation of findings words and phrases based on finding and language context. AutoScribe also allows you to automatically generate comparison text from previously entered breast imaging and clinical exam findings.

• Sentence aggregation automatically occurs for related finding information. For reports that include many findings and modifiers, AutoScribe automatically condenses the information into a clear, succinct statement that complies with the wording and report organization sections of BI-RADS. This avoids a report construction which sounds "canned".

• Dynamic rules definition allows AutoScribe to be quickly configured and updated. AutoScribe has been designed to allow changes and updates to be made to dynamically, to allow for updates to the BI-RADS lexicon and specific enhancements requested by the end-user. This ensures that any individual requested variation may be accommodated.

Validation
Automatic validation of the standardized report is essential to the goals of standardized reporting. A well constructed, validated report offers many benefits to the patient, referring physician, radiologist and radiology group. If a mammography report includes elements which are inconsistent, redundant or inaccurate, the report may be misinterpreted, and patient care compromised.

There are several unique features of the MagView AutoScribe validation process that help ensure a clear and accurate report:

• Context based redundancy validation prevents unclear and repetitive reports. Many mammography reporting products do not validate for duplicate phrases and statements. MagView AutoScribe automatically prevents redundancy, and ensures that the mammography report is concise.

• Conflicting findings, assessments and recommendations are automatically validated. For each finding entered, MagView AutoScribe automatically validates the finding information, assessment, recommendations, and each of the other findings entered to be sure that basic BI-RADS construction rules are followed.

• Supplemental text is stored separately. With AutoScribe, any finding notes or free text which is entered for the finding is stored separately from the standardized text, and combined when the report is generated. This allows the standardized report to be re-generated at any time. It also means that there is no risk of the standardized text in the report being in conflict with the objective findings data collected for the patient. With many options for the placement of finding notes and free text comments, you can avoid the awkward displacement of related information.

• A user-defined AutoScribe Guardian™ feature allows you to ensure clinically appropriate findings and recommendations. The MagView AutoScribe Guardian allows you to create rules for the validation of breast imaging reports. Using this feature, you may warn the user or disallow any selected combination of findings, descriptors, modifiers, assessment and recommendations. For example, if the user entered a spiculated mass with an assessment of benign-negative, they could be warned or prevented from signing the report. This is a powerful tool that helps you standardize and implement the procedure and policy of your group for breast imaging reporting.

Conclusion
In order to realize the many benefits of standardized breast imaging reporting, you will need a sophisticated, effective software tool. The AutoScribe translator has the necessary construction and validation features that will allow you to effectively create standardized breast imaging reports.