AIM: Aorta abnormalities aren't recorded in EMR half the time
Clinicians neglect to note a substantial proportion of new aortic dilations in their EMR systems, according to a respective cohort study in the July 7 issue of the Annals of Internal Medicine.

Jennifer R.S. Gordon, from the University of Iowa Carver College of Medicine and Iowa City Veterans Administration Medical Center in Iowa City, and colleagues undertook the study to examine the frequency with which CT-documented dilations of the abdominal aorta are accompanied by evidence in the EMR that a clinician recognized the abnormality.

The researchers examined patients with new dilations of the abdominal aorta detected on CT performed in 2003 at two hospitals in the Veterans Affairs Health Care System. They reviewed radiology report and EMR evidence that the radiologist notified the clinical service, aneurysm size and interval between CT and EMR recognition.

The investigators reviewed that CT scans of 4,112 patients and identified 440 (11 percent) aortic dilations, of which 91 were new findings. They found radiologists directly notified clinical teams about five new dilations.

Clinical teams did not record in the EMR recognition of 58 percent dilations within three months of the CT, and 9 percent of these dilations were 5.5 cm or larger, according to the authors.

Gordon and colleagues found that median time to recognition of aneurysm in the EMR was 237 days, and no EMR documentation existed for 16 abnormalities (29 percent of surviving patients) during a mean follow-up of 3.2 years. They noted that no evidence indicated that any of the aneurysms ruptured or that patient deaths resulted from the delayed follow-up.

The researchers acknowledged that a limitation of the study was that clinicians may have recognized some aneurysms but did not document them in the EMR.

Based on their findings, Gordon and colleagues concluded that strategies are needed to ensure that clinicians have recognized and documented abnormal test results.

The National Institutes of Health (NIH) were the primary funding source for the study.