Table 2.

Themes/Sub-themes and Representative Quotes from Focus Group Participants

Theme	Exemplar Quotes
Intrinsic Barriers
Ability/Self-Efficacy	“to be perfectly honest, I never feel horribly comfortable with heart screening” “I feel reasonably comfortable, though I’m always in pursuit of learning more”
Training	“Radiologists that just come out of practice are not comfortable with fetal hearts.” “All you really do during residency is try biometry and assess how big is the baby..”
Attitude/Usefulness	“look at the huge debate over mammography …stating that screening really isn’t changing outcomes. Has anybody looked at screening in fetal echoes?” “It’s never been a lack of awareness that doing a screen on the heart was important” “it might be that it we are just stuck at the moment with a crummy screening test or one that has several significant deficits”
Extrinsic Barriers
Expectations	“a lot of patients think their ultrasound is to see their baby and get the gender. But they need to go to high-quality places, and they don’t …demand better quality.”
Feedback	“I’ve been doing this for a long time, but I have really no sense of how many I’ve missed. I could be..missing a lot” “I would also mention that getting the feedback from my referrals would increase my knowledge, … hearing back, really was valuable. So that communication between us… and those we refer to is really important”
Organizational Barriers
System-level	“with initial prenatal detection, ultrasound is done in thousands of different offices, by physicians doing low volume and low risk… “locations with much less resources you’re not going to have the access to the specialists, to have the resources to refer to them.” “I do not think you get the same ability to look at something that you want to see better … reading a scan from home.” “I did rely on the ultrasonographer, you know, I just looked at the pictures. She was the one that told me if something was weird”
Process Implementation	“So how do we get that implemented as a requirement? How do we get that implemented across the nation?” “..at the end of the day financial incentives and disincentives at the level of the organization will be what ultimately pushes change across the board”
Policy/Quality Control	“Standardize the terminology and make sure everybody uses the same thing to prevent this kind of hedgy-ness“ “We are taking on certification for nuchal translucencies and cervical length, but yet for cardiac images, a basic 4-chamber and outflow tracts views, there is practically no accreditation system”