EHR in nuclear stress testing

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Electronic Health Record As An Important Tool for Nuclear Stress Testing

OVERVIEW Nuclear stress testing is a useful tool in the diagnosis of coronary disease. It requires coordination of services among several departments and accounts for a loss of resources when a patient arrives for the testing unprepared. Total time for this test can involve 2-3 hours and several personnel from the stress lab, a clinician and the nuclear medicine staff, along with the cost of the isotopes which were specifically ordered for this exam. By utilizing the EHR as a tool in the process we can hopefully eliminate stumbling blocks to the successful completion of the study. An order field within the EHR can eliminate a host of recurring problems which can hinder the successful completion of a study and proper reimbursement for it.

Following a progressive algorithm from the initial order in the EHR through the electronic signature can facilitate correct practices from the very beginning through the procedure and reimbursement process. Mandatory fields must be populated prior to advancing through the order process to the electronic signature of the ordering clinician.

The Society of Nuclear Medicine, as well as, the American Society of Nuclear Cardiology have both developed standards and recommendations which can assist ordering physicians. They have also compiled a comprehensive list of absolute contraindications for nuclear stress testing. These are fields which can be easily added to the CPOE software while in the development phase. By alerting ordering clinicians to both of these the possibility of improper scheduling or unprepared patients can be reduced. This will have the result of improving patient care and at the same time reducing wasted resources, personal, isotopes and also decrease the wait time for others needing the same exams. These fields should be highlighted with a warning sign and use of a color alert for ease of use. While this process may take a bit more time initially the end results will save valuable resources hereafter. As soon as the CPOE has been signed by the ordering clinician a paper copy of the patient preparation can be automatically generated at the secretary’s station and be handed to him on his way out avoiding the need to mail instructions. While this works well with nuclear cardiology it can also be successfully applied to all other diagnostic nuclear medicine studies by making adjustments for the type of study being ordered. We propose the following method for this concept.


1. Order is written from a dropdown list containing CPT codes by the clinician in the EHR. The CPT prompts a question asking the patient weight. This will determine if the study will be a 1 or 2 day protocol since there is a weight limit for 1 day protocols. This in turn will allow the proper instructions to be generated for the patient. The patient instructions will contain required preparation as directed by the Society of Nuclear Medicine1 and The American Society of Nuclear Cardiology2

2. Correct diagnosis for the exam selected from the ICD-10-CM list. This will generate an alert of absolute contraindications for the test which must be acknowledged by the ordering clinician (Henzlova, 2009; Strauss, 2002). In addition, the selection of a proper ICD-10-CM code is imperative as many insurance carriers require prior authorization before a test can be performed.

3. On the patient demographic form in the EHR the insurance carrier will be listed. This can alert the ordering clinician if prior authorization is required. In a perfect world the insurance company will be interfaced with the patient EHR and the process of preauthorization can begin as soon as the order is electronically signed.

4. The current medication list will alert the clinician if medications need to be held for the exam (Henzlova, 2009; Strauss, 2002).

5. Upon the electronic signature of the CPOE an alert is transmitted enabling the printed instructions to be generated and a preauthorization request sent to the insurance company. By presetting default values for a specific insurance carrier in the EHR all necessary patient information will be automatically captured by the carrier.

6. The patient is instructed to stop at the reception desk where the study will be scheduled. The patient will be handed a copy of the printed instructions with specific directions to be followed including fasting, medicines to discontinue, clothing to wear and any other preparation for the exam.

7. After completion of the study with a click of a button a bill can be generated and automatically sent to the billing department or in a perfect world, directly to the insurance carrier.

CONCLUSION Time spent during the start- up phase of an EHR is essential when all stakeholders directly involved in the design of the finished product are consulted prior to implementation. This input is a valuable asset which cannot be overstated. By meeting the challenges initially the resulting product will be an EHR designed to enhance patient care and increase productivity.

Although I use the example of a Nuclear Cardiology Stress Test, this method can be easily adopted to any type of diagnostic imaging study by changing a few of the question fields within the order page.


Henzlova, M. J., Cerqueria, M.D., Hansen, C.L, Taillefer, R. & Yao, S. (2009). Stress Protocols and tracers. American Society of Nuclear Cardiology.

Strauss, H. W., Miller, D.D., Wittry, M.D., Cerqueria, M.D., Garcia, E.V., Iskandrian, A.S., Schelbert, H.R., Wackers, F.J., Balon, H.R., Lang, O., & Machac, J., (2002). Society of Nuclear Medicine Procedure Guideline for Myocardial Perfusion Imaging. Society of Nuclear Medicine Procedure Guidelines Manual.

Submitted by Michele Chappell