## 3 Results and Discussion
### Access to Knowledge  
Access to a second opinion at the hospital is organized with a second call on duty 24 hours a day. During the day, the physician is in the hospital. During evenings and nights the second call is not at the hospital, but within a specified time limit near the hospital.  
_\"The treatment of a stroke is in principle the same regardless of time of day or night. We have our routines: we examine, take blood tests, CT, is the standard examination... it happens regardless of what time. Everyone knows it, or should know (...). Both interns and us [physicians]\" A: Referring hospital._  
Here the physician describes how routines are a way of managing the treatment. Even though the knowledge is organized across departments, the routines constitute the practice. Both interns and physicians follow standard rules for treatment. If the intern decides on thrombol treatment, the treatment is discussed with the second on-call specialist. As physician D explains, the physicians may not have worked specifically with stroke patients before. Since the referring hospital does not have a neurologist, they need to contact the specialist hospital in all cases when considering thrombol treatment.  
_\"When it comes to thrombol treatment, the second call night duty is always involved. We do not have a neurologist here. It is chief physicians on duty, stand-ins, who do not do stroke treatment in the hospitals where they come from. Therefore, we think there should be a neurologist involved in our discussion.\" D: Referring hospital._  
The need for access to knowledge is first searched for locally, defining the need for further knowledge by evaluating standardized rules for stroke treatment. Secondly, if thrombol treatment is an option, neurologists at the specialist hospital are contacted.  
Even though the specialist hospital has its own neurological department, with physicians who are specialists in their field, they have also been organized in a way that they have interns on duty during nights and evenings. They also have their second on-call duty specialist located within a specific time limit from the hospital. The interns at the specialist hospital call up their second on-call specialist on duty if they cannot handle the question from the smaller hospitals. They do not decide on thrombol treatment without discussing it with their second on-call specialist on duty. Hence the VC equipment is only used when the specialists are staying in the specialist hospital.  
_\"After 19.30 on week days, we cannot use videoconferencing. Not after 13.00 Saturdays and not Sundays.\" A: Referring hospital._  
_Interviewer: So, if the service had been there 24 hours a day, could it have been more helpful?_  
_\"If there had been more routines on it; it would have been used more often.\" G: Specialist hospital._  
Having stroke patients arriving 24 hours a day requires access to competence at all times. As the service is only available from 7:00 in the morning to 7:30 in the evening, most of the informants indicated that it would have been better, easier with the same routines 24/7, and that they would have been feeling safer if they were able to use the VC equipment whenever a difficult case came in during day/night. Most of the specialists were positive about a 24/7 service, but some of the more experienced ones did not think it was a good idea. They indicated that in the evenings they will only meet a less experienced doctor who has to contact the \"on-call\" duty specialist for backup when they get inquiries regarding stroke patients, and they will only have the phone. Otherwise the specialist has to come to the hospital to participate in the VC consultation, which could delay the treatment of the patient. The traditional use of the telephones gives access to knowledge regardless of the time, as the second callson duty in the specialist hospital may be contacted at their homes and do not have to travel to the hospital to access the VC equipment.