Purpose or Case Report: Clinical decision support (CDS) may positively affect patient care in radiology by encouraging high-value imaging, usually via society guidelines. Given recent national initiatives for high-value imaging, imaging-related CDS was deployed by many hospital systems. Existing studies show modest reduction in low-utility imaging following CDS implementation. With the adoption of pediatric-specific imaging guidelines at our institution, we seek to evaluate the direct impact of CDS on clinician orders, particularly in the emergency department (ED).
Methods & Materials: This study was conducted for quality improvement and is exempt from IRB. A pediatric-specific CDS system was deployed in our large, urban, tertiary pediatric academic medical center, with over 10,000 ED visits per month. CDS alerts for radiologic exam related criteria were acquired from August 2024 through September 2025 using Slicer-Dicer (EPIC). CDS responses were grouped into “action taken” and “no action taken” categories, corresponding to consideration and dismissal of CDS recommendations respectively. Subgroup analysis was performed, including assessing alerts from the ED.
Results: Over the 14-month period, there were on average 1160 monthly radiologic CDS activations. Of these, 14% (2329/16234) of alerts originated from the ED, while encompassing 22% of all diagnostic imaging ordered. In total, 86% of all alerts in the system led to an “action taken” assignment (14112/16234). However, alerts from the ED represent on average 38% of those with “no action taken” designation, but only 10% of “action taken” (p < 0.001). Of note, residents activate CDS alerts proportionally 3-4 times more frequently within the ED as compared to outside the ED, unlike other provider groups, and have a higher rate of “no action taken” alert designation when ordering from the ED.
Conclusions: Data show that CDS alerts arise in the ED in proportion to total imaging volumes and generally lead to positive consideration of CDS guidance. However, there is disproportionate dismissal of CDS alerts within the ED. Reasons for this may include, for example, CDS alerts not accurately capturing when imaging is indicated due to broader differential diagnoses. Evaluation of these data will ideally contribute to the evolution of more accurate and effective CDS alerts, more robust clinical practice pathways, and targeted clinician education within our institution.