From the ACEP 2026 Scientific Assembly: When Uncertainty Drives Overtesting, the Missing Consult Matters

For emergency department leaders, the problem is not simply that too many tests get ordered or too few specialists get called. Both can be responses to the same operational problem: uncertainty combined with uneven access to specialist input. ConsultBridge is designed to make defined questions easier to route, review, and document; any effect on testing or cost must be measured locally.

Part of the “From the ACEP 2026 Scientific Assembly” FabrixMed Insights series.

The question came into sharper focus during ACEP26’s session on the hidden hazards of overtesting in the ED. The session was not a case against diagnostic imaging. It was a reminder that emergency clinicians make decisions under pressure, often without timely access to every specialist question the case raises.

Why can uncertainty lead to both more testing and fewer documented consults?

When the clinical question is urgent but specialist access is slow or unclear, the ED team is left with an uncomfortable choice. Order another test because it is available. Call a specialist informally and hope the right information is exchanged. Wait for a callback. Transfer the patient. Or admit while the uncertainty remains unresolved.

None of these decisions can be judged without the patient’s clinical context. But the operating conditions matter. A system that makes imaging easy to order and specialist input difficult to obtain can unintentionally shape clinical behavior.

A national survey of 435 emergency physicians found that 97% said at least some of the advanced imaging they personally ordered was medically unnecessary, with a mean estimate of 22%. Respondents identified fear of missing a low-probability diagnosis and fear of litigation as the main contributors. The study describes perceptions and does not establish that a consultation pathway would have prevented those tests. Read the study in PubMed.

That distinction is important. The answer is not “replace CT with consultation.” When imaging is clinically indicated, it should be ordered. The more precise opportunity is the defensive margin: situations where uncertainty, unavailable specialist input, or an undocumented curbside conversation may influence additional testing.

What is the missing consult in this workflow?

The missing consult is not necessarily a formal bedside evaluation. It may be a defined specialist question that was never routed, a hallway recommendation that was never documented, or a callback that arrives after the patient has already been admitted, transferred, or tested further.

Informal specialist input is common. In a one-year study of an academic infectious diseases unit, 1,001 curbside consultations were recorded. The authors found that 78% were complex by their coding method and estimated that curbside work represented 17% of the unit’s clinical work value. The study was about infectious diseases, not emergency department imaging, but it demonstrates why “the specialist was asked” and “the specialist input was visible in the workflow” are not the same thing. Read the study in Clinical Infectious Diseases.

Documentation is not bureaucracy for its own sake. A useful record captures the question asked, the evidence reviewed, the specialist’s recommendation, the limits of that recommendation, and the next action owned by the treating team. That record can make a later review safer and can show where the system’s uncertainty actually came from.

Can a documented e-consult replace a CT scan?

No. A documented e-consult should not be positioned as a substitute for clinically indicated imaging, emergency evaluation, resuscitation, or bedside assessment. A stable patient with a focused question may be appropriate for asynchronous specialist review; a crashing patient or a patient whose examination cannot be deferred needs real-time or in-person care according to local policy and clinical judgment.

The useful comparison is not “consult versus CT.” It is “how does this organization answer a defined clinical question, and what happens when the answer is not available?” In some cases, specialist input may support local management or clarify that additional testing is not needed. In other cases, it may reinforce the need for imaging, admission, transfer, or immediate bedside evaluation.

What evidence supports documenting clinician-to-clinician consultation?

Recent work from Ann & Robert H. Lurie Children’s Hospital of Chicago describes implementing an interprofessional consultation program that began with infectious diseases and expanded across specialties. The study is a quality-improvement report from another organization, not FabrixMed performance evidence. Its relevance is operational: organizations can create a structured way to make clinician-to-clinician questions visible, trackable, and connected to clinical work. Read the study in PubMed.

That evidence does not prove that documentation reduces CT use. It does support a more disciplined question for health systems: how much specialist input already happens informally, where does it happen, and what would change if the question and recommendation were captured in a defined workflow?

How can ConsultBridge help without turning every case into a consult?

ConsultBridge can support a configured pathway in which the treating clinician identifies a defined question, attaches the relevant clinical context, routes it to an approved specialist or specialist group, receives a recommendation, and carries the next action forward.

The organization determines the specialties, participants, credentials, coverage windows, response expectations, escalation rules, and documentation requirements. The pathway may use the organization’s own specialists, contracted groups, FabrixMed-connected providers, or a hybrid model.

The objective is not to increase consultations indiscriminately. It is to make appropriate specialist access more consistent where an unanswered question is contributing to delay, repeat work, testing, transfer consideration, or an unclear handoff.

What should an ED pilot measure?

The first pilot should measure the workflow before claiming savings. Useful measures may include:

• Time from a complete consult request to specialist review
• Time from review to documented next action
• The proportion of requests answered within the configured response target
• Testing ordered before and after specialist review, with clinical appropriateness reviewed locally
• Transfers, admissions, and discharges associated with specialist input
• The number of informal curbside questions converted into documented encounters
• Whether face-to-face consultations remain available when clinically required
• Patient-safety events, escalations, and cases outside the asynchronous pathway

Any cost analysis must use the organization’s actual consult, imaging, staffing, and downstream-care assumptions. A generic “$50 consult versus $3,000 CT” comparison is not a reliable business case.

What does ConsultBridge not claim to solve?

ConsultBridge does not diagnose autonomously, determine whether imaging is medically necessary, guarantee a clinical outcome, replace an emergency physician, or make every specialist available at every hour. It does not eliminate the need for real-time or in-person evaluation.

It provides a workflow for a narrower problem: when an appropriate specialist question exists, the organization has qualified coverage, and the delay or ambiguity is partly caused by an inconsistent access and documentation process.

That is why the opportunity should be tested rather than advertised as a foregone conclusion. Overtesting and under-consulting may be two responses to uncertainty. A better specialist-access workflow can help make that uncertainty visible, answer the right questions earlier, and give the organization evidence about what changed.

Sources and further reading

• ACEP26: Risky Business—The Hidden Hazards of Overtesting in the ED
• Kanzaria et al., Emergency physician perceptions of medically unnecessary advanced diagnostic imaging
• Grace et al., Complexity, Relative Value, and Financial Worth of Curbside Consultations in an Academic Infectious Diseases Unit
• Li et al., Clinician-to-Clinician Interprofessional Consultations in a Freestanding Pediatric Hospital

FabrixMed and ConsultBridge support clinical workflows; they do not replace emergency evaluation, bedside care, hospital policy, specialist judgment, or local legal and regulatory requirements.