The SARS-CoV-2 pandemic has potentiated an increased uptake of telemedicine by health practitioners [1-4]. Telemedicine refers to a broad range of electronic services that obviate the need for face-to-face interactions but maintain the same patient-physician relationship [5-10].

An emerging component of telemedicine is electronic consultations (eConsults). eConsults are asynchronous clinician-to-clinician consultations via a secure web-based platform. They allow a primary care provider (PCP), such as a physician, nurse practitioner, or physician assistant, to seek nonurgent specialist advice remotely without direct contact between the patient and specialist [11]. eConsults may be used to replace an in-person consultation or ensure that an appropriate workup is completed before a face-to-face visit. They represent a well-documented, asynchronous replacement of the curbside consultation. eConsults differ from electronic triage systems that prioritize the urgency of patient-specialist consults rather than replacing them.

The entry point for the PCP into the eConsult system depends on the structure of the health service [12]. In optional-pathway services, the PCP is able to choose to refer their patient via a face-to-face pathway or via an eConsult. Conversely, in single-pathway services, the PCP must refer the patient via an eConsult, and the specialist can then decide if a subsequent face-to-face visit is necessary (Figures 1 and 2) [13-16]. Some eConsult services set clear criteria, such as mandatory investigations before lodging an eConsult. The information returned from the specialist via the eConsults provides the PCP with assistance with diagnosis, imaging interpretation, and advice on management [17]. The web-based communication platform may be a health service–specific program, or a shared electronic medical record (EMR), where the correspondence is recorded [18,19]. Outcomes include scheduling a face-to-face appointment if required or giving management advice virtually. In some cases, eConsults undergo an iterative process in which the specialist requests further information before making a decision.

eConsults address the limitations of the current medical system. From an equity perspective, disadvantaged demographics [20-23] can engage specialists, as eConsults are more economical for these groups, by bypassing social barriers and reducing travel and work expenses [24,25]. eConsults can address lengthy specialist wait times [26] to obviate specific bottlenecks in the referral pathway [27]. The lack of physical contact in eConsults means that they can still operate even within social distancing restrictions [28-31].

The feasibility of eConsults in medicine has been studied extensively [32-38]; however, their role in the surgical stream is less well-understood [39-41]. Surgical and medical eConsults differ in the variety of conditions, and those surgical conditions may require an intervention. At face value, this may imply that surgical subspecialties lend themselves less to eConsults as a face-to-face visit may be inevitable for assessment and consent [42]. Multispecialty studies have shown different patterns of eConsult use in medical and surgical conditions. For example, the eConsult requester seemed more likely to be a nurse practitioner familiar with surgical compared with medical eConsults [43]. Another study suggested that PCPs deem surgical eConsults to be of lower quality than medical eConsults [44].

The aim of this review is to build on previous systematic reviews of eConsults by focusing specifically on utility and outcomes in surgical outpatients. We synthesize our assessment using the Quadruple Aim Framework [45], which helps guide the assessment of ideal health service performance outcomes. The four components of this framework are (1) improving the health of the population, (2) enhancing patient experience of care, (3) reducing per capita cost of health care, and (4) improving the work life of health care clinicians and staff. These 4 goals are interrelated and serve to maximize the primary goal of improving population health. The role of the Quadruple Aim Framework in eConsult evaluation has been established elsewhere [12,46] and was used in a recent eConsult systematic review [40]. For the purposes of this review, we use clinicians to refer to PCPs and specialists.

This study used a narrative review with a systematic approach. We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to conduct the search strategy.

On November 4, 2021, we conducted a search of four databases (Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus). The reference lists of review articles were scanned for additional studies. Electronic referrals (eReferrals) differ slightly from eConsults in that their primary goal is to expedite a patient’s workup before an in-person specialist visit; however, terminology in this field is variable [47], and, for the purpose of this review, these terms were combined. Thus, the search terms were one for eConsults (eg, eConsult and eReferral) and one for surgical subspecialties (eg, surgery and orthopaedics; Multimedia Appendix 1). The search was limited to articles in English and those published in the past 10 years (2011-2021), given that most modern eConsult platforms were studied after 2010.

The inclusion criteria were studies on outpatient surgical eConsults, eReferrals, and store-and-forward telemedicine consults that included dedicated surgical articles and articles that included surgical eConsults as a subanalysis of a multispecialty cohort. We only included eReferral services that allowed for iterative PCP-specialist communication. We only included original studies (including observational and experimental studies) of outpatients. We excluded studies on asynchronous clinician-to-clinician communication that did not use an appropriate platform for shared patient information (eg, surgical wound images). We excluded all conference abstracts, case reports, editorials, notes, and letters.

The titles and abstracts of the obtained articles were screened by an investigator (TP) as per the inclusion criteria. Moreover, 2 investigators (TP and HT) critically appraised all the included articles independently. Disagreements regarding article inclusion were resolved through discussion between the 2 investigators.

Data were extracted into a Microsoft Excel spreadsheet independently by 2 investigators (TP and HT) into categories corresponding to the relevant study objectives. Extracted data included study variables (author, title, year, country, and surgical subspecialty), eConsult service design, study outcome data, and study conclusions.

A narrative synthesis was more appropriate than other synthesis methods (including meta-analysis), given the significant heterogeneity in eConsult service designs and outcome measures and the overlapping eConsult data between studies [48]. The data were synthesized by grouping together similar outcome metrics across all studies to provide a range and by grouping surgical subspecialties together to compare findings across and within different fields. The obtained narrative synthesis information was subdivided into sections using the Quadruple Aim Framework as a guide. In cases where systematic reviews were identified, we extracted key discussion points to include in our study. The findings of our narrative synthesis were depicted in tabular and schematic diagram form. Individual appraisals of study quality were not performed because of time and personnel constraints and were beyond the scope of this review.

A total of 33 studies were included (Figure 3). The characteristics of the studies analyzed are outlined in Table 1, and detailed descriptions of the studies are provided in Multimedia Appendix 2 [11,18,19,27,39,40,43,44,49-73]. Most of the included studies were published in the past 5 years (26/33, 79%), and half were from surgical journals (17/33, 52%), mainly from North America (30/33, 91%). eConsults were most represented in urology, otolaryngology, and obstetrics and gynecology.

Most of the included studies used a retrospective audit of EMR data with or without a mandatory PCP exit survey. Most of these studies used data from a single health service network, and only 1 of the studies combined surgical eConsult data from multiple hospital platforms [49]. Of the retrospective studies, 12% (4/33) were pre- versus postimplementation studies [18,27,50,51]. Approximately 3% (1/33) of the studies used feedback from post-eConsult surveys to assess the ability of the specialist to incorporate this feedback into their practice [44]. Only 15% (5/33) of the studies used a prospective design in their analysis [27,44,50,52,53]. None of these studies randomized patients to an eConsult or a face-to-face visit. Most studies assessed clinician satisfaction, with only 6% (2/33) of the studies assessing patient satisfaction with surgical eConsults [11,53].

The proportion of PCPs who rated surgical eConsults as having good or excellent value for themselves ranged from 87% to 97% [11,50,60,62-64], with an educational benefit in 60% to 89% [44,62]. A critical factor in PCP satisfaction is the quality of the specialist response. Tuot et al [44] was the only study to examine eConsultant competencies and found that a lower referral volume (<900 per year), a physician rather than nurse reviewer, and more time spent per referral (>7 minutes) were associated with higher-quality surgical and medical eConsults, as judged by the PCP. There was hope that PCP education would gradually obviate the need for future eConsults regarding the same issue; however, specialist surveys noted that PCPs often repeat questions [59]. Approximately 3% (1/33) of the studies demonstrated that a feedback session for specialists to improve their eConsult response quality resulted in a significant increase in high-quality eConsult reviews at 3 months [44]—a similar feedback session could be used for PCPs to improve their referral quality, with more frequent sessions being used to sustain long-term benefits.

eConsults undoubtedly alter the relationship between PCPs and specialists; in many cases, eConsults are replacing the informal curbside conversation. Although this traditional form of specialist consultation is still widely used, Gupte et al [59], in a survey of PCPs, found that the formal documentation of surgical eConsults was seen as a key drawcard. Indeed, although medicolegal concerns are often cited as an issue with eConsults, the permanent electronic recording of PCP-specialist consultations confers a degree of medicolegal protection when compared with undocumented curbside conversations [52]. Other features associated with eConsult uptake have been studied elsewhere [81]; a pertinent finding is that PCPs with longer practicing time are less likely to submit eConsults, which suggests that familiarity with the curbside system fosters an unwillingness to adopt new methods. It is possible that mandatory eConsults or investigations before face-to-face visits deter veteran PCPs from using eConsults; however, the specific reasons for this trend require further investigation.

Surveys of specialists noted that eConsults freed up face-to-face appointment times, and most indicated that eConsults did not increase their workload [50,59]. However, specialist satisfaction with surgical eConsults has been much more variable and more poorly studied than PCP satisfaction. Most specialists were able to respond to the eConsult within 20 minutes [44,52,56,60,63,64]. Kinberg et al [18] noted a decrease in cancellations or failure to attend face-to-face otolaryngology clinics from 38.9% (1141/2932) to 19.3% (713/3686) after eConsult implementation. One could speculate that the eConsult system allowed for triaging of patients who were anxious to seek in-person evaluation.

Approximately 6% (2/33) of the studies noted an unanticipated use of eConsults by clinicians. Gupte et al [59] found that 73.3% (487/664) of orthopedic eConsults were initiated by an orthopedic clinician using the eConsult system for ease of generating a preoperative chart review. Frequent spot checks to ensure the PCP is not the same as the specialist should be performed in all eConsult services to ensure this practice is not taking place. Parikh et al [49] noted that neurosurgeons electronically contacted 12% (8/69) of patients directly; however, this may represent a more well-rounded eConsult and does not mean that the guidelines were being deliberately disregarded. Direct patient contact may reduce time delays arising from obtaining patient information secondhand through the PCP and should be encouraged when it is being used to supplement, and not replace, the eConsult. Furthermore, details of contact between the patient and specialist need to be accessible to the PCP to ensure that they remain informed of the patient’s case and maintain their educational benefit.

All cost-saving analyses found that surgical eConsults were associated with reduced costs to patients and health services [43,50,51,58,60]. Some studies drew similar conclusions on indirect outcomes, such as differences in specialist payments [53,54]. Approximately 6% (2/33) of the studies found that savings were because of reduced outpatient rather than inpatient costs, possibly from a reduction in diagnostic tests and procedures and more rapid initiation of treatment [51,58]. Anderson et al [51] also found that health service cost savings were greater in orthopedics than in the 3 medical specialties, possibly because orthopedic visits involve more costly procedures, which yield greater savings when avoided.

The caveat to these results is that all studies were limited in their ability to estimate cost savings because of the large number of variables that cannot be accounted for, such as costs incurred outside a given health service. Furthermore, the longest comprehensive cost analysis was 3 years.

A summary of the findings of this review within the Quadruple Aim Framework (Table 2 and Figure 4) shows that surgical eConsults have benefits at every step of the referral pathway. We found that surgical eConsults showed significant benefits in time and cost savings, reducing surgical outpatient wait times and increasing access to surgical care in underserved patient populations. Although the uptake in surgical subspecialties has been less enthusiastic than in medical subspecialties, the broad outcomes are similar in the 2 fields. Although many concerns common to medical and surgical eConsults (such as workload increases, medicolegal protection, and reimbursement) were found to be unfounded or surmountable, specific surgical concerns (eg, the erosion of the patient-surgeon relationship before surgery) could still be addressed.

This paper builds on 2 recent systematic reviews of combined medical and surgical eConsults [39,40,82,83]. The 2019 review by Vimalananda et al [39] included 63 studies in their analysis, most of which were observational, which is similar to our findings. They were able to identify 2 studies on medical subspecialties (nephrology and endocrinology) that compared the clinical outcomes of eConsult patients with face-to-face referrals, whereas we could identify no such studies on patients of surgery. Liddy et al [40] included 43 studies in their analysis and were notably able to show cost savings because of eConsult use. Our finding on cost savings is also consistent with a scoping review that suggested target key areas where money can be saved using telehealth (eg, mitigating the need for expensive, unnecessary procedures) [84]. This and our overall findings should be reassuring to health services looking to implement surgical eConsults into their workflow. The most common barriers to eConsult implementation that we identified—namely, medicolegal, workload, and reimbursement concerns—are very similar to recent articles dedicated to this topic [81,85-88] and, therefore, were not discussed in this paper.

Limitations include that the studies were from a limited cohort from 3 well-established eConsult services, and only 3% (1/33) of the studies were performed in a low socioeconomic status country [71]. There is a significant overrepresentation of some subspecialties, and all data were observational, which raises the possibility of unknown factors causing the outcomes described in this review. Randomization has been used in medical eConsult studies [89,90]; however, this may not be reflective of real-world conditions. At this stage, it would be advisable for further work to shift its focus from well-established markers of eConsult benefits to analyzing pitfalls and safety concerns. We did not conduct individual appraisals of study quality. Furthermore, it was impossible to include all the multispecialty studies where surgery was a subanalysis of the broader population, given that our search strategy missed studies that did not include a surgical term in the title or abstract. Our exclusion of non-English articles may also have missed other studies from low socioeconomic status countries. Concerns such as medicolegal issues and management responsibilities were raised in the discussion sections of some papers but could not be included in the data.

There are some important understudied components of surgical eConsults. An example is the effect of differing patient-surgeon relationships before a major operation on patient satisfaction with a virtual platform. Furthermore, we identified factors associated with a high-quality eConsult response, and this can be leveraged in future work that can explore these features, such as prior telemedicine training, to optimize the quality of responses. Other work can confirm the economical use of diagnostic investigations within the eConsult system. Finally, assessment of eConsult outcomes in specific surgical subspecialties (eg, cardiothoracic surgery) may show benefits associated with eConsults for a specific specialty.

In conclusion, eConsults represent a safe and advantageous alternative to face-to-face consultations in surgical clinics. Specific surgical subspecialties and conditions appear to benefit more from eConsults, although, even in cases where an in-person visit is needed, eConsults serve to expedite the patient’s workup. For most outcomes, surgical eConsults performed similarly to medical eConsults. Most limitations of surgical eConsults are system-level issues that can be addressed by appropriate implementation protocols, including clinician training and automatic safeguards. Future work on surgical eConsults should further elucidate long-term safety considerations, patient perspectives, and the effects of evolving practices during the COVID-19 pandemic.