Teleconsultation for Clinicians Who Provide Human Immunodeficiency
Virus Care: Experience of the National HIV Telephone Consultation Service
Jessica F. Waldura, M.D., Sarah Neff, M.P.H.,
and Ronald H. Goldschmidt, M.D.
Department of Family and Community Medicine, National
HIV/AIDS Clinicians’ Consultation Center (NCCC), San Francisco
General Hospital, University of California, San Francisco,
California.
Abstract
Objective: To examine the infrastructure, successes, and challenges
of a teleconsultation service for human immunodeficiency virus
(HIV) clinicians. Materials and Methods: The HIV Warmline is a
telephone consultation service providing free, live HIV/AIDS man-
agement advice to U.S. clinicians. We present descriptive data about
callers, patients, and consultation topics gathered by electronic query
of the HIV Warmline database for 2009. Caller satisfaction survey
results for 2009 are also presented. Results: The HIV Warmline has
provided more than 37,000 consultations since its inception in
1992. The service provides consultations to clinicians from all 50
states, from a variety of professional backgrounds, and with a wide
range of HIV experience levels. The majority of call topics concern
antiretroviral therapy. Callers are generally pleased with the service,
giving a mean Likert scale rating of 4.7 on satisfaction survey
questions. Conclusion: The experience of the HIV Warmline can
serve as a model for other programs planning to develop remote
consultation systems. HIV teleconsultation has been relatively simple
to implement and can be useful for many types of clinicians. HIV
teleconsultation should continue to be evaluated as a way to improve
HIV care, especially in areas without easy access to HIV expertise.
Key words: telemedicine, distance learning, telehealth
IntroductionDistance-based clinician-to-clinician consultation (tele-
consultation) is an area of increasing interest and research.
Published reports describe successful teleconsultation sys-
tems using the telephone, Internet, and video in fields such
as dermatology, radiology, and neurology.1–4Other fields of medicine
might benefit from teleconsultation, especially those dealing with
complex clinical problems in which access to local expertise is
limited.5–11
Human immunodeficiency virus (HIV) medicine is one area in
which teleconsultation might be useful. Since HIV is a rapidly
changing field, clinicians can find it challenging to stay up to dateand could benefit from efficient access to patient-focused HIV in-
formation and advice.12,13In addition, many clinicians, especially
those providing care in rural or urban underserved areas, do not have
easy access to HIV expert assistance and need to rely on consultation
at a distance.14,15
A number of HIV teleconsultation programs have been created
globally, mostly targeting providers in the developing world.16–19We
describe here a teleconsultation p rogram for HIV care in the United
States that has provided more than 37,000 consultations over the past 18
years. This program, known as the HIV Warmline (1-800-933-3413), is a
part of the National HIV/AIDS Clini cians’ Consultation Center, a fed-
erally funded program located at San F rancisco General Hospital (SFGH)
at the University of California San Francisco (UCSF). This article details
the history and operation of the HIV Warmline and provides descriptive
data about HIV Warmline consultations to help inform future efforts in
teleconsultation.
Materials and Methods
HISTORY
The HIV Warmline was created in San Francisco in 1992 with
the goal of providing local HIV clinicians with rapid access to up-
to-date HIV information and consultation. Within a year, the HIV
Warmline expanded to become a national service with the ac-
quisition of a federal grant from th e Health Resources and Services
Administration (HRSA). Housed at SFGH in the UCSF Department
of Family and Community Medici ne, the HIV Warmline has been
in continuous operation since its inception and has since added
two additional phone services: an occupational blood-borne
pathogen exposure line (the PEPline; 1-888-448-4911) started in
1996 with supplementary funding from HRSA and the Centers for
Disease Control and Preventio n, and a national perinatal HIV
consultation service (Perinatal HIV Hotline; 1-888-448-8765)20
started in 2004. All three lines function together under the um-
brella of the National HIV/AIDS Clinicians’ Consultation Center
(NCCC), which is a part of HRSA’s AIDS Education and Training
Centers (AETC) program.
CONSULTATION SERVICES OFFERED
The HIV Warmline provides clinical information and consultation
to clinicians on all aspects of HIV/AIDS management via the tele-
phone (1-800-933-3413). The service accepts calls from clinicians
with any level of HIV-experience. It is available Monday to Friday
from 8am to 8pm EST and is free of charge to all practicing clinicians
in the United States. The service is not available to patients or the
general public.
472 TELEMEDICINE and e-HEALTH JULY/AUGUST 2011 DOI: 10.1089/tmj.2010.0210 TECHNICAL INFRASTRUCTURE
The infrastructure of the HIV Warmline is based on a telephone
system and a computer network. The Warmline is equipped with
digital group telephones connected to the SFGH trunk lines. A 1-800
number connects clinicians throughout the United States directly to
Warmline consultants. Overflow calls are transferred to the SFGH
voice mail mechanism and are returned by a Warmline consultant at
the earliest opportunity, usually within the hour. After-hours calls
are answered on the next business day. Telephone consultations are
sometimes supplemented with written materials via email or fax.
The Warmline has a secure network of computers and servers
managed by the UCSF/SFGH Information Technology department.
Consultants at each workstation use direct input software to record
caller demographic information, de-identified patient information
(consistent with HIPAA guidelines), and consultation notes that serve
as an electronic medical record. The database of caller, patient, and
consultation topic information can be searched for reporting, con-
tinuous quality improvement, and research purposes.
The HIV Warmline Web site is a part of the larger NCCC Web site
(www.nccc.ucsf.edu) that includes the PEPline and Perinatal HIV
Hotline Web sites. The site contains information about the NCCC
telephone consultation services and provides access to clinical re-
sources created by the NCCC, along with links to outside training and
technical assistance resources, educational resources, and guidelines.
CONSULTANTS
The HIV Warmline is staffed by a multidisciplinary team of ap-
proximately 15 UCSF clinical consultants, including family physi-
cians, internists, infectious disease specialists, obstetrician/
gynecologists, and clinical pharmacists. New consultants are selected
after a comprehensive review process and undergo supervised
training before working as principal consultants. In addition to ex-
tensive clinical experience and academic proficiency, consultants
should have excellent communication and teaching skills. Con-
sultants vary in the amount of time they spend answering telephone
calls at the HIV Warmline, varying from 10% to 70% effort. Most
consultants also maintain active HIV clinical practices or engage in
HIV-related research or other academic activities.
CONSULTATION METHODOLOGY
During business hours, between two and five consultants are
usually available to answer calls. Consultants work together onsite at
the Warmline call center to facilitate multidisciplinary collaborative
discussions of complex cases and to encourage ongoing peer review
of consultations. Consultants use the information contained in fed-
eral HIV practice guidelines (Department of Health and Human
Services Guidelines for the Use of Antiretroviral Agents in HIV-1-
Infected Adults and Adolescents at http:/ /aidsinfo.nih.gov) as the
basis for clinical recommendations. Clinical questions relating to
emerging issues or clinical ‘‘grey areas’’ that are not adequately de-
scribed in the federal guidelines are addressed using research find-
ings and/or expert opinion. Complex cases are generally discussed
impromptu among a group of HIV Warmline consultants beforemanagement options are presented to the caller. Cases involving HIV
drug resistance may also be discussed at a monthly resistance panel,
staffed by HIV Warmline consultants and other UCSF HIV resistance
experts. Recommendations from the resistance panels are presented
to the caller and posted for public viewing on the NCCC Web site.
When clinical questions arise that require the input of sub-specialists,
such as oncologists, nephrologists, or neurologists, HIV experts on
the UCSF faculty from the respective specialty departments are
consulted.
QUALITY ASSURANCE
Maintaining state-of-the-art expertise in HIV care requires fre-
quent updates, ongoing dialog with experts, and review of articles,
guidelines, and conference findings. HIV Warmline consultants are
expected to participate in monthly peer-led internal training sessions
and resistance panel discussions. Individual level HIV-specific con-
tinuing medical education is also expected, including attendance at
HIV conferences and ongoing review of the HIV literature.
The quality of consultations is continuously monitored. Formal
peer-review occurs quarterly with each consultant being assigned to
review a set of randomly chosen and de-identified consultations from
their colleagues. In addition, informal quality control occurs spon-
taneously as consultants discuss cases with each other and receive
input and feedback from colleagues in real time.
Customer satisfaction surveys are mailed quarterly to a random
sample of callers from that quarter. Results are shared with clinicians,
and feedback is integrated into quality improvement sessions.
OUTREACH AND PROMOTION
The HIV Warmline’s outreach plan includes promotion through
conference attendance, materials distribution, and targeted mailings.
The HIV Warmline staffs a booth with outreach materials in the ex-
hibitor area at an average of eight conferences a year, especially
those attended by clinicians caring for large numbers of underserved
and minority patients. In addition, many regional and national
organizations list the HIV Warmline as a resource for clinicians.
A large number of callers hear about the HIV Warmline from col-
leagues who have used the service.
LEGAL
As a UCSF program, the university accepts legal responsibility for
all NCCC consultations.
FUNDING
The HIV Warmline is funded entirely by the HRSA AETC program.
The HIV Warmline and its faculty members accept no funding from
the industry, avoiding any appearance of commercial bias.
DATA REVIEWED FOR THIS STUDY
This study reviews information available from database query and
caller satisfaction surveys for the year 2009. A one-time evaluation of
time spent on the telephone per consultation, performed by an inde-
pendent observer during May and June of 2006, is also presented.TELECONSULTATION FOR HIV CLINICIANS
ªMARY ANN LIEBERT, INC. /C15VOL. 17 NO. 6 /C15JULY/AUGUST 2011 TELEMEDICINE and e-HEALTH 473
