title: Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program.
abstract: OBJECTIVE
  Screening for abdominal aortic aneurysms (AAAs) reduces aneurysm-related mortality and has been recommended by the U.S. Preventive Services Task Force and American Heart Association since 2005. Medicare has covered a one-time screening ultrasound for new male enrollees with a familial or smoking history since 2007. Nevertheless, in the U.S., screening has remained underutilized. Review of patients with ruptured AAA in our system in 2007 showed the majority were undiagnosed, yet met U.S. Preventive Services Task Force and American Heart Association screening guidelines. To reduce the number of preventable AAA ruptures and deaths in our patients, we implemented an AAA screening program using our electronic medical record (EMR). This study describes the design, implementation, and early results of that screening program.
  
  
  METHODS
  Between March 2012 and June 2013, men aged 65 to 75 years with any history of smoking were targeted for screening. Medical records were reviewed electronically to exclude patients with abdominal imaging studies within 10 years that would have diagnosed an AAA. Best practice alerts (BPA) were created in the EMR so when an appropriate patient is seen, office staff and providers are prompted to order an aortic ultrasound. AAA was defined as aortic diameter ≥3.0 cm or greater, and ultrasound reports contained a standard template providing guidance for patient management when an aneurysm was identified. Newly identified AAAs were triaged for vascular surgery consultation or follow-up with their primary physician. The number of eligible patients, unscreened patients, and AAAs identified were tabulated by our Regional Outpatient Safety Net Program.
  
  
  RESULTS
  In a population of 3.6 million, 55,610 patients initially met screening criteria, and 26,837 (48.26%) were excluded from the BPA because of prior abdominal imaging studies. After 15 months, there were 68,164 patients who met screening criteria, 54,356 (79.74%) of whom had undergone an abdominal imaging study. Thus, 27,519 patients underwent an imaging study after the BPA was activated. During the study period, 731 new AAAs were diagnosed, 165 over 4.0 cm in diameter. Screening rates have increased at all medical centers where the BPA was activated, and the percentage of unscreened patients has been reduced from 51.74% to 20.26% system-wide.
  
  
  CONCLUSIONS
  In an integrated health care system using an EMR, AAA screening can be implemented with a dramatic reduction in unscreened patients. Further analysis is required to assess the impact of the screening program on AAA rupture rate and cost-effectiveness in our system.
authors: Department of Vascular Surgery, Southern California Kaiser Permanente, San Diego, Calif. Electronic address: robert.j.hye@kp.org.
authors: Robert J
authors: RJ
authors: Hye
authors: Regional Outpatient Safety Net, Southern California Kaiser Permanente, Pasadena, Calif.
authors: Andrea E
authors: AE
authors: Smith
authors: Department of Population Care Management, Southern California Kaiser Permanente, Fontana, Calif.
authors: Gary H
authors: GH
authors: Wong
authors: Department of Pharmacy Analytical Services, Southern California Kaiser Permanente, Downey, Calif.
authors: Southida S
authors: SS
authors: Vansomphone
authors: Department of Lipidology and Family Medicine, Southern California Kaiser Permanente, West Los Angeles, Calif.
authors: Ronald D
authors: RD
authors: Scott
authors: Department of Quality and Clinical Analysis, Administration, Southern California Kaiser Permanente, Pasadena, Calif.
authors: Michael H
authors: MH
authors: Kanter
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery; D057286:Electronic Health Records / Q000592:standards*; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000379:methods*; D017410:Practice Guidelines as Topic; D015397:Program Evaluation; D012017:Referral and Consultation; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures