Background: Deep vein thrombosis (DVT) is typically diagnosed from ultrasound (US) Doppler evaluation and anticoagulation therapy is the standard treatment to prevent life threatening pulmonary embolism (PE). In our hospital, the treating provider is alerted to the positive test result by phone and/or text in the imaging result. There is an absence of clinical decision support (CDS) in this arena because the electronic health record (EHR) cannot discretely “understand” the imaging result. The Structured Reporting initiative standardizes report formatting and content which can create a framework for electronic consumption of the interpretive result. This becomes the basis for radiology result driven CDS in the EHR providing a safety-net for prompt initiation of appropriate therapy.

Purpose: This innovation leverages structured reporting of US exams for suspected DVT allowing the EHR to identify positive test results, which trigger interruptive alerts for providers if anticoagulation medications are not ordered or active within a set time-frame.

Description: The radiology department implemented system structured templates with a fixed pick list impression field. When used, the discrete impression populates smart data elements in the EHR as well as readable text in the imaging report. Utilizing this unique value, a Best Practice Alert (BPA) was created for patients in the hospital. The alert fires two hours after a positive DVT imaging result, if:1) The patient does not have therapeutic anticoagulation prescribed, and
2) The patient does not have an INR (international normalized ratio) greater than two.

The BPA displays the imaging result, pertinent lab values, links to orders for anticoagulation, and acknowledgement buttons.
In the first 6 months of 2018, an average of 53.2 US exams were performed per week for suspected DVT with an average of 98.4% reported using the structured reporting system. The average rate for positive structured reports was 6.7 per week. The BPA triggered on an average of 3.7 patients per week. Of those patients, an average of 2.6 patients/week (69.7%) went on to receive anticoagulation. (See Figure 1.)

Conclusions: Identification of and prompt treatment for DVT is important in the prevention of life threatening pulmonary embolism. Utilizing structured radiology reports and EHR CDS, effective safety systems can be created to alert the treatment team when apparent delays in therapy initiation occur. This innovation describes the successful implementation of CDS fueled by structured reporting in radiology to assist physicians in providing timely, quality care. This concept can be replicated, creating countless opportunities to expand structured reporting in radiology to improve patient care.

IMAGE 1: Figure 1: Patients with DVT and BPA Firing