Evidence-Linked Radiology Reporting: A Human-Supervised Reference Architecture for Structured Imaging Intelligence

Imaging demand is growing faster than the radiology workforce can expand, and reporting backlogs cannot be resolved through training and recruitment alone. The most direct opportunity is reducing the time and effort radiologists spend producing reports, a task that requires interpreting images, integrating clinical history and prior studies, and drafting structured findings. We present Harrison.Rad 1.5 (HR1.5), a radiology-specific multimodal large language model that accepts interleaved text and visual inputs and generates structured and unstructured text across plain-film radiology, spanning computed radiography, chest, musculoskeletal, abdominal, spine, and pelvic x-rays, and mammography. HR1.5 is trained through a three-stage pipeline: domain adaptation of a base language model on radiology reports, contrastive vision-encoder training with curriculum-based hard negatives on ~6 million image-report instances, and visual-question-answering fine-tuning on multi-turn conversations. We evaluate it with a Findings-Diagnosis scoring framework that extends RadGraph-XL entity extraction with ontology-based synonym matching and polarity-contradiction detection, benchmarked on RadBench, a simulated FRCR 2B Short Case examination scored against Angoff-method thresholds, ReXGradient, and internal multi-modality datasets. HR1.5 is the only system evaluated to meet the simulated FRCR passing standard and achieves the highest accuracy on closed-format clinical questions, across anatomical regions, on internal multi-body-part and mammography reporting, and on the primary clinically-aligned score for public chest reporting. We further examine explainability and model behaviour, including question-sensitive Grad-CAM heatmaps, attention analysis, and confidence estimation, to support responsible future evaluation toward clinical use, and a framework for clinically grounded assessment of report quality.

Radiology report evaluation is essential for advancing automated report generation. Natural language generation metrics have limited clinical relevance. Clinical efficacy (CE) metrics evaluate important medical findings, but focus mainly on presence and cover only a limited set of entities. Due to heavy reliance on manual annotations, it is difficult for CE metrics to extend clinical entities or attributes. In clinical practice, radiology reports serve as a medium for information transfer. Clinicians use them to perform downstream diagnostic tasks without directly inspecting images. Based on this insight, we propose ReportQA, a clinical-related and flexible radiology report evaluation framework, supporting detailed quantitative analysis of radiology report generation systems. We first collect datasets covering multiple imaging modalities and anatomical regions. We then construct knowledge trees of clinical entities and attributes with radiologist guidance, and use large language models (LLMs) to extract structured information from raw reports. Next, we generate QA pairs from predefined templates and apply quality control through self-filtering and report-based filtering. During evaluation, the report is treated as context, and an LLM acts as a judge model to answer the QA pairs. Based on the resulting QA accuracy, we introduce QAScore metric. Compared with existing metrics, QAScore shows better alignment with radiologist judgments. Experiments on multiple state-of-the-art vision-language models reveal that current report-based inference paradigms struggle to learn fine-grained clinical representations and exhibit strong negative prior biases. In contrast, question-driven inference provides a more effective alternative. For reproducibility and extensibility, we release the knowledge trees, structured reports, and QA pairs, along with the pipeline code for QA construction and evaluation.

Radiologists follow heterogeneous reporting practices. Two radiologists examining the same image and identifying the same clinical findings might nevertheless compose superficially distinct reports, varying in terminology, shorthand, formatting, and level of detail. These variations in reporting norms represent an under-appreciated obstacle in efforts to evaluate AI-based radiology report generation (RRG) models, where machine-generated reports are typically assessed based on their concordance with human-generated references. In this paper, we quantify the sensitivity of established evaluation metrics to variations in reporting practices, revealing impacts large enough to alter the rankings of models. We introduce a radiologist-informed taxonomy of variations in radiology reporting practice and a method (ReRef) that rewrites reference reports along the axes of our taxonomy while preserving clinical interpretation. For instance, when comparing the performance of nine RRG models on MIMIC-CXR using RadCliQ-v1, condensing the discussion of normal findings in the reference reports causes Libra to drop from first to second place while CheXOne rises from third to first. Our results suggest that many current metrics fail to decouple clinical interpretation from conformity to reporting practices and that choosing the ``right'' references that accurately reflect the desired reporting practices can be important in practice. To support future research, we release MIMIC-CXR-Ext-ReRef, a radiologist-validated dataset of 120 (original, alternative) reference report pairs derived from MIMIC-CXR.