CDS won't replace radiologists in pediatric emergency cases

Pediatric emergency department physicians (PEDPs) value assistance from radiologists in making imaging decisions and won’t stop consulting them about these decisions once software-based clinical decision support mechanisms have been implemented at their institutions.

That’s the word from PEDPs who participated in a study conducted at The University of Pennsylvania Children’s Hospital in Philadelphia and reported online Oct. 10 in the JACR.

For the study, James Hogan, MD and colleagues sought PEDPs’ perspective on radiologist consultations and how “software-based clinical decision support mechanisms (CDSMs)” might be integrated with existing imaging clinical decision support (ICDS) methodologies to optimize imaging utilization within the hospital. Potential participants were recruited from the institution’s emergency department, which has a staff of 60 PEDPs and sees more than 90,00 children annually.

Thirty 20- to 30-minute interviews were audio-recorded, transcribed verbatim, and de-identified by an independent third party. Using third-party software that facilitates the organization of qualitative data for coding and analysis, responses from 30 transcripts were then assigned thematic codes developed in two ways: a priori (informed by the literature and an interview guide) and through line-by-line reading of a subsample of interviews. Coded data were divided into three categories: common influences on the imaging decision process, radiology consultation experience and PEDPs’ perspective on CDSMs, including how the implementation of a CDSM at their institution might affect clinical practice.

On the common influences front, PEDPs were found to first consider patient factors like presentation, stability, and differential diagnoses when choosing an imaging path. The data also revealed that PEDPs think a consultation with a radiologist necessary when they are uncertain about which potential diagnoses are most urgent and in instances where they are considering the benefits and harms of potential imaging studies.

Other influences on the imaging decision process included PEDPs’ own experience. One respondent explained that the more experience PEDPs have with imaging, the more they are aware of what they do not know and are unafraid to admit it.

The study also revealed a belief among PEDPs that radiologist consultation is helpful in treating complex patients who defy predetermined decision algorithms, and that the reciprocal exchange of ideas between radiologists and PEDPs is superior to other forms of ICDS. According to the authors, PEDPs interviewed pointed out that while literature may not correspond to specific clinical scenarios, radiologist consultation allows tailored imaging recommendations. Radiologist consultation was also deemed helpful when access to certain advanced imaging modalities is limited.

Moreover, the study brought to bear radiologists' belief that while CDSMs may potentially improve workflow, radiologist consultation would still be beneficial for complex cases. PEDPs envision the optimal CDSM interface as providing increased opportunities for consultative interaction with the radiology department, researchers noted, adding that radiologists “have the opportunity to facilitate effective implementation of CDSMs by listening to the perspectives of referring physicians, providing education on AUC, and reconciling conflicts with clinical practice.”


Hogan and colleagues acknowledged in the study that some of these results may be difficult to “transfer to other practices” because their research had been limited to one hospital and had been conducted at a tertiary pediatric medical center. Additionally, they noted that the CDSM had not yet been completely implemented at their institution when the study was conducted and that further research on the perspectives of ordering physicians once this had occurred would yield further insight into the topics discussed.

“As radiologists spearheaded the study and conducted many of the interviews, PEDPs’ responses may have been subject to social desirability bias,” the authors wrote. “Finally, there are inherent limitations in self-reported data that stem from various social and psychological factors.”

Despite these limitations, the authors concluded, the study clearly indicates that PEDPs will continue to make consultations with radiologists a key component of imaging clinical decision support after software-based CDS solutions have been instituted. “In particular, our results highlight the limitations of purely evidence-based appropriate use criteria (AUC) and the irreplaceable function of radiologists as the thinking, understanding, creative human counterbalance to the standardized uniformity of CDSMs,” they concluded. “Through efforts such as those discussed here, radiologists have an opportunity to promote value-based imaging care, which may potentially contribute to improved health outcomes.”