Radiologists compose diagnostic reports through a structured workflow: they describe visual findings, summarize them into impressions, and carefully refine statements in clinically critical cases. However, most existing medical report generation (MRG) systems treat reports as flat sequences, overlooking this hierarchical organization and leading to inconsistencies between descriptive and diagnostic content. To align model behavior with real-world reporting practices, we propose RadFlow, a hierarchical workflow-guided reinforcement optimization framework that explicitly models the structured nature of clinical reporting. RadFlow introduces a clinically grounded reward hierarchy that mirrors the organization of radiological reports. At the global level, the reward integrates linguistic fluency, medical-domain correctness, and cross-sectional consistency between Finding and Impression, promoting coherent and clinically faithful narratives. At the local level, a section-specific reward emphasizes Impression quality, reflecting its central role in diagnostic accuracy. Furthermore, a critical-aware policy optimization mechanism adaptively regularizes learning for high-risk or clinically sensitive cases, emulating the cautious refinement behavior of radiologists when documenting critical findings. Together, these components translate the structured reporting paradigm into the reinforcement fine-tuning process, enabling the model to generate reports that are both linguistically consistent and clinically aligned. Experiments on chest X-ray and carotid ultrasound datasets demonstrate that RadFlow consistently improves diagnostic coherence and overall report quality compared with state-of-the-art baselines.

Radiology reports are critical for clinical decision-making but often lack a standardized format, limiting both human interpretability and machine learning (ML) applications. While large language models (LLMs) have shown strong capabilities in reformatting clinical text, their high computational requirements, lack of transparency, and data privacy concerns hinder practical deployment. To address these challenges, we explore lightweight encoder-decoder models (<300M parameters)-specifically T5 and BERT2BERT-for structuring radiology reports from the MIMIC-CXR and CheXpert Plus datasets. We benchmark these models against eight open-source LLMs (1B-70B), adapted using prefix prompting, in-context learning (ICL), and low-rank adaptation (LoRA) finetuning. Our best-performing lightweight model outperforms all LLMs adapted using prompt-based techniques on a human-annotated test set. While some LoRA-finetuned LLMs achieve modest gains over the lightweight model on the Findings section (BLEU 6.4%, ROUGE-L 4.8%, BERTScore 3.6%, F1-RadGraph 1.1%, GREEN 3.6%, and F1-SRR-BERT 4.3%), these improvements come at the cost of substantially greater computational resources. For example, LLaMA-3-70B incurred more than 400 times the inference time, cost, and carbon emissions compared to the lightweight model. These results underscore the potential of lightweight, task-specific models as sustainable and privacy-preserving solutions for structuring clinical text in resource-constrained healthcare settings.

A Pre - Purchase Evaluation and Comparative Study of Solutions from A WS, Google, Azure, John Snow Labs, and Open - Source Models on an Independent Pediatric Dataset Shruti Hegde MS, Mabon Manoj Ninan BS, Jonathan R. Dillman MD, MSc, Shireen Hayatghaibi PhD, Lynn Babcock MD, Elanchezhian Somasundaram PhD Abstract Purpose: General purpose clinical natural language processing tools are increasingly used for the automatic labeling of clinical reports to support various clinical, research and quality improvement applications. However, independent performance evaluations for specific tasks, such as labeling pediatric chest radiograph reports, remain scarce. This study aims to compare four leading commercial clinical NLP systems for entity extraction and assertion detection of clinically relevant findings in pediatric chest radiog raph reports . In addition, the study evaluates two dedicated chest radiograph report labelers, CheXpert and CheXbert, to provide a comprehensive performance comparison of the systems in extracting disease labels defined by CheXpert. Methods: A total of 95,008 pediatric chest radiograph (CXR) reports were obtained from a large academic pediatric hospital for this IRB - waived study. Clinically relevant terms were extracted using four general - purpose clinical NLP systems: Amazon Comprehend Medical (AWS), Google Healthcare NLP (GC), Azure Clinical NLP (AZ), and SparkNLP (SP) from John Snow Labs. After standardization, entities and their assertion statuses (positive, negative, uncertain) from the findings and impression sec tions were analyzed using descriptive statistics, paired t - tests, and Chi - square tests . Entities from the I mpression sections were mapped to 12 disease categories plus a No Findin gs category using a regular expression algorithm. In parallel, CheXpert and CheXbert processed the same reports to extract the same 13 categories (12 disease categories and a No Findings category) . Outputs from all six models were compared using Fleiss' Kappa across the assertion categories .

We present a novel approach to Chest X-ray (CXR) Visual Question Answering (VQA), addressing both single-image image-difference questions. Single-image questions focus on abnormalities within a specific CXR ("What abnormalities are seen in image X?"), while image-difference questions compare two longitudinal CXRs acquired at different time points ("What are the differences between image X and Y?"). We further explore how the integration of radiology reports can enhance the performance of VQA models. While previous approaches have demonstrated the utility of radiology reports during the pre-training phase, we extend this idea by showing that the reports can also be leveraged as additional input to improve the VQA model's predicted answers. First, we propose a unified method that handles both types of questions and auto-regressively generates the answers. For single-image questions, the model is provided with a single CXR. For image-difference questions, the model is provided with two CXRs from the same patient, captured at different time points, enabling the model to detect and describe temporal changes. Taking inspiration from 'Chain-of-Thought reasoning', we demonstrate that performance on the CXR VQA task can be improved by grounding the answer generator module with a radiology report predicted for the same CXR. In our approach, the VQA model is divided into two steps: i) Report Generation (RG) and ii) Answer Generation (AG). Our results demonstrate that incorporating predicted radiology reports as evidence to the AG model enhances performance on both single-image and image-difference questions, achieving state-of-the-art results on the Medical-Diff-VQA dataset.

We introduce a radiology-focused visual language model designed to generate radiology reports from chest X-rays. Building on previous findings that large language models (LLMs) can acquire multimodal capabilities when aligned with pretrained vision encoders, we demonstrate similar potential with chest X-ray images. This integration enhances the ability of model to understand and describe chest X-ray images. Our model combines an image encoder with a fine-tuned LLM based on the Vicuna-7B architecture, enabling it to generate different sections of a radiology report with notable accuracy. The training process involves a two-stage approach: (i) initial alignment of chest X-ray features with the LLM (ii) followed by fine-tuning for radiology report generation.

Recent advances in deep learning have enabled researchers to explore tasks at the intersection of computer vision and natural language processing, such as image captioning, visual question answering, visual dialogue, and visual language navigation. Taking inspiration from image captioning, the task of radiology report generation aims at automatically generating radiology reports by having a comprehensive understanding of medical images. However, automatically generating radiology reports from medical images is a challenging task due to the complexity, diversity, and nature of medical images. In this paper, we outline the design of a robust radiology report generation system by integrating different modules and highlighting best practices drawing upon lessons from our past work and also from relevant studies in the literature. We also discuss the impact of integrating different components to form a single integrated system. We believe that these best practices, when implemented, could improve automatic radiology report generation, augment radiologists in decision making, and expedite diagnostic workflow, in turn improve healthcare and save human lives.

Recent advances in generative vision-language models (VLMs) have exciting potential implications for AI in radiology, yet VLMs are also known to produce hallucinations, nonsensical text, and other unwanted behaviors that can waste clinicians' time and cause patient harm. Drawing on recent work on direct preference optimization (DPO), we propose a simple method for modifying the behavior of pretrained VLMs performing radiology report generation by suppressing unwanted types of generations. We apply our method to the prevention of hallucinations of prior exams, addressing a long-established problem behavior in models performing chest X-ray report generation. Across our experiments, we find that DPO fine-tuning achieves a 3.2-4.8x reduction in lines hallucinating prior exams while maintaining model performance on clinical accuracy metrics. Our work is, to the best of our knowledge, the first work to apply DPO to medical VLMs, providing a data- and compute- efficient way to suppress problem behaviors while maintaining overall clinical accuracy.

Radiology report analysis provides valuable information that can aid with public health initiatives, and has been attracting increasing attention from the research community. In this work, we present a novel insight that the structure of a radiology report (namely, the Findings and Impression sections) offers different views of a radiology scan. Based on this intuition, we further propose a co-training approach, where two machine learning models are built upon the Findings and Impression sections, respectively, and use each other's information to boost performance with massive unlabeled data in a semi-supervised manner. We conducted experiments in a public health surveillance study, and results show that our co-training approach is able to improve performance using the dual views and surpass competing supervised and semi-supervised methods.