Health care systems continuously evolve. At this point, a health care system’s efficiency is a measure of its ability to rapidly collect, store, and analyze information and make it accessible in real time to a wide range of health care providers to optimize patient care. A key component of these systems is the use of technology to allow health care providers to easily consult and securely share patient information with other providers. The World Health Organization (WHO) promotes this use of information communication technology (called eHealth) in support of health care services and training. In a 2016 survey, the WHO reported that 58% of responding member states had eHealth strategies, and 62% of member states had a consultation service using mobile information communication technology between health care practitioners or between health care practitioners and patients [1].

This ubiquitous use of technology in health care is reflected in published literature, and the benefits of these systems to care processes have been well documented. A systematic review by Deldar et al [2] found 174 publications examining the role of teleconsultations. Another systematic review by Saliba et al [3] identified 94 studies evaluating the facilitators and barriers of various telemedicine services. The delivery of such eHealth solutions is substantial. Teleconsultations in dermatology [4] and psychiatry [5], for example, may come in different modalities and be provided using videoconferencing and store-and-forward systems (ie, sending images and text information). Teleradiology, which has been around for decades, allows for the transmission, storage, and retrieval of images between radiologists and other professionals [6]. Many other technologies may be used to serve as a means of accessible electronic medical records, mobile telephone symptom recordings, and dedicated support lines, as used, for example, in palliative care [7].

In Alberta, Canada, physicians have access to telephone consultations with specialists through a 24/7 call center called RAAPID (Referral, Access, Advice, Placement, Information, and Destination). RAAPID ensures that physicians have quick access to other physicians (often specialists) for advice, allowing patients to be cared for by the calling physician in their local setting. However, if patients require transfer to other institutions for care, RAAPID also facilitates these transfers [8]. One component of the RAAPID system that has been increasingly utilized is telephone consultation with Otolaryngology–Head and Neck Surgery (OHNS). As part of a quality assurance study to evaluate RAAPID’s telephone consults with OHNS, we conducted an environmental scan of similar programs in other parts of the world, searching for program characteristics and outcomes associated with similar physician-to-physician telephone consultation programs.

We used a combination of formal literature searches and internet searches based on methods adapted for the conduct of an environmental scan [9]. Other published environmental scans have also used internet searches for gathering data [10,11]. Since the RAAPID program provides consultation using only phones between physicians, we limited our search to programs that included physician-to-physician consultation with telephone as the main technology.

An information technologist (author TC) performed the literature search. The search was done on the following databases: Ovid MEDLINE(R), Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, CINAHL, and Web of Science Core Collection. The search was limited to English publications in the 10-year range of 2007-2017 to ensure that identified articles reflected more contemporary practice in the field. To identify Canadian programs, the literature search was supplemented with an additional internet search (by author PT) using the following search terms in Google: (Physician or Doctor) AND (Telephone Consultation or Phone Consultation). Then we reviewed potentially relevant search results and websites. The internet search results were limited to the first 10 search result pages (~100 results).

Three authors (PT, TC, SA) screened the search results for programs providing access to specialists through telephone consultations. For the results from the literature search, a 2-step screening was performed: title-abstract screening and full-text review to identify relevant studies. The title-abstract screening was performed independently by 2 authors (PT and TC; PT and SA). Then, full-text screening was independently reviewed by 2 authors (PT and SA). Disagreements in the screening decisions were resolved by discussion. Only consultation programs that used the telephone as the main technology were included, as well as studies that used telephones for initial consultations before using other technologies at a later time. However, consultation programs that used the telephone in combination with other technologies (such as fax, video platform, electronic communication, mobile messaging, and web-based platforms) were excluded.

One author (PT) extracted the data, and the data were verified by a second author (SA). The following data were extracted from the publications and the internet search results: the name of the program, the country within which the program operates, a description of the program, who the program is available to, the scheduled times and specialty areas in which the service is available, reported measures (ie, the volume of calls, response times), disposition after consultation (ie, sent home, sent to the emergency department or hospital, elective consultation in a specialty clinic), satisfaction with the calls, and potential costs or cost avoidance. For the supplemental internet search, one author (PT) reviewed the search results and extracted the data.

Our environmental scan identified 17 studies on telephone consultation programs between health care practitioners, and 13 programs across Canada. Programs were widely dispersed across a wide range of specialties and disease states. Overall, the most common model for accessing care was having the physician connect directly with the specialist or consultant rather than using a routing system or call-back procedure. The majority of programs were for physicians; however, many were supportive of calls from other members of the care team.

Interestingly, less than half of the publications evaluated outcomes related to patients’ dispositions or costs. In the few studies that evaluated health care utilization, all reported an avoidance in either emergency department visits or hospitalizations. As expected, this translated into major cost savings for the programs. However, it is relatively unclear what the overall net savings and costs of these programs were, as few (if any) analyses accounted for the input costs of operating and maintaining these programs. Indeed, British Columbia’s RACE program [27] has a low operating cost. It provides a hotline system that directly pages a specialist who, in turn, calls the referring physician. RACE reports a cost of only $120/month for the telephone system support and an administrative support cost for 1 day per month. Costs savings and some costs occurrence to the system would be expected; however, the benefits to patients in terms of timely medical advice and indirect cost savings (eg, travel to the emergency department, time away from work) would likely offset any cost occurrences. Coupled with reduced pressure on the emergency department and hospital system reported by the programs, the benefits are likely substantial.

RAAPID’s 24/7 call center shares some similarities to other telephone programs, but also notable differences. Unlike most programs that involve direct calling to specialists, physicians call a hotline and the call center connects them to specialists, if needed. The call center provides extensive support. At the consultation level, the call center triages the call to specialists, ascertains that the consultation occurred, and provides logistical support during and after the consultation. At a system level, the call center, when required, coordinates the transfer of patients to appropriate centers, with due consideration to bed management. However, this labor-intensive process impacts the operating cost (ie, the cost from 24/7 staffing).

Although more expensive to implement, the RAAPID program has previously reported that from November 2014 to October 2015, of 51,171 telephone consultations, 36% were not referred to the emergency department (29.1% resulted in the provision of advice and 6.9% were referred to a specialist clinic) [29]. This coincides with the figures observed in other programs reported in this paper. British Columbia’s RACE reported a 32% prevention rate in emergency department visits [27]. Wegner’s study [17] on pediatric subspecialist consultations reported that 52% avoided emergency department visits, specialty visits, and hospital transfers and admissions. Zanaboni’s study [24] on consultation calls to cardiology, dermatology, and diabetology reported that 77% avoided emergency department visits, hospitalizations, or in-clinic consults.

This environmental scan is the first narrative review of telephone consultation programs. We have reviewed the published literature and performed a supplemental internet search. However, the heterogeneity of programs and outcome measures limited comparison across programs. Moreover, limitations in resources have precluded a systematic review and a more extensive review of internet searches. The pervasive use of technology in health care consultations was evident in the literature search and internet search. The use of phones for consultations was minor compared to the use of more recent technologies like videoconferencing, mobile messaging, and other electronic and web-based platforms.