The Structured Report and PACS

Abstract

The structured report presupposes evaluation of its two constituent elements: the digital report and diagnostic-image management, that is, management of the “native” images and/or of their processing.

• 1. Digital report: in Europe, the digital report is regulated by several codified regulations. For example we report Italian low 59/97 states: “Records, data and documents produced by the public administration and private parties by computerized means ... their electronic storage and transmission, are valid and relevant to all effects of the law...” and “In all computer documents, the manual signature is replaced by the digital signature”. Legislative Decree 82/2005, Article 22, states: “Documents produced by computerized means, computerized data and documents produced by public administrations constitute primary and original information...” This means that the written and signed digital report is an original, unique document and that, if the radiologist writes two reports, they are two originals and all others are copies. The report, once validated and digitally signed, is available online and may be accessed and consulted only by those so authorized (the user, the family physician, the consultant).

• 2. Diagnostic-image management: There are at least a few aspects of diagnostic-image management that are connected to the structured report. Firstly, the technological/computerized evolution of image diagnostics, thanks particularly to multi-image procedures (such as multislice CT), This requires automated, computerized systems able to rapidly transmit and make available to the radiologist, almost in real time, the necessary data and at the same time obliges the radiologist to transmit his or her own data rapidly and efficiently. Secondly, the introduction of new diagnostic elements — such as bidimensional and tridimensional processing and reconstruction or elements deriving from assisted diagnosis or virtual reality (Fig. 61) — that must be made part of the reporting process.