|Year : 2022 | Volume
| Issue : 1 | Page : 18-24
Assessment of the Saudi Arabian telemedicine experience during the COVID-19 pandemic: Dermatology-related consultations as a case
Sahar H Alsharif1, Nizar Alsharif2, Rimaz Alassiri3, Ghaidaa Khouj3, Noura Alshareef3, Anwaar Aloufi3, Arwa Hussain3
1 Department of Dermatology, King Saud University, Riyadh, Saudi Arabia
2 Department of Computer Engineering and Science, Albaha University, Al Bahah, Saudi Arabia
3 Department of Medicine and Surgery, Collage of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
|Date of Submission||26-Jul-2021|
|Date of Acceptance||16-Sep-2021|
|Date of Web Publication||30-Jun-2022|
Dr. Sahar H Alsharif
Dermatologic Surgery Fellow, Department of Dermatology, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
Background: COVID-19 is a pandemic disease that spreads rapidly. The World Health Organization recommended social distancing to prevent disease transmission. Telemedicine was one of the most important tools used during the pandemic to provide health-care services. Different clinics, including dermatology clinics, tended to use telehealth and online tools. In addition, various dermatological conditions were diagnosed and treated by family physicians using the telemedicine applications of the Saudi Ministry of Health (MOH). Purpose: The present study aimed to evaluate the efficacy of family physicians using telemedicine to diagnose and manage different dermatological conditions. Specifically, we aimed to identify the common dermatological conditions that family physicians faced during the COVID-19 pandemic, as well as the use of the various telemedicine applications launched by the Saudi MOH. We also intended to assess the need for dermatologists in the telemedicine applications of the Saudi MOH and suggest possible improvements to the telemedicine process and related Saudi MOH applications for sustainable online health care. Methods: The cross-sectional study was conducted across Saudi Arabia among family physicians and general practitioners to assess their perception of using telemedicine for dermatology-related consultations. The self-administered survey questionnaire contained 16 questions in five sections. Results: A total of 302 family medicine and general physicians completed the questionnaire. Altogether, 165 (54.6%) physicians reported that they had never used telemedicine before the COVID-19 pandemic, while 12.9% reported frequent to continuous use. During the pandemic, 86.8% of family and general physicians used telemedicine for dermatological consultations. The most used methods were phone calls (57.6%) and the SEHA application (42.7%). A total of 96.4% of participants reported that they dealt with dermatological conditions before the COVID-19 pandemic. Interestingly, about 99% of family physicians reported that they faced difficulty diagnosing dermatology-related consultations. Telemedicine was frequently used by all physicians in the central region compared with 76.7% of those in the western region (P = 0.035). Conclusion: Family physicians in Saudi Arabia increased their telemedicine practicing during the pandemic. Different telemedicine tools were used, such as phone calls, virtual clinics, and Saudi MOH applications (SEHA, TETAMMAN, TABAUD, TAWAKKALNA). The majority of family physicians faced difficulty diagnosing dermatological conditions. In addition, most reported that dermatologists should be part of health-care facilities and telemedicine centers to deal with dermatology-related consultations.
Keywords: COVID-19, dermatologist, family physician, Saudi Ministry of Health, SEHA application, telehealth, telemedicine
|How to cite this article:|
Alsharif SH, Alsharif N, Alassiri R, Khouj G, Alshareef N, Aloufi A, Hussain A. Assessment of the Saudi Arabian telemedicine experience during the COVID-19 pandemic: Dermatology-related consultations as a case. J Dermatol Dermatol Surg 2022;26:18-24
|How to cite this URL:|
Alsharif SH, Alsharif N, Alassiri R, Khouj G, Alshareef N, Aloufi A, Hussain A. Assessment of the Saudi Arabian telemedicine experience during the COVID-19 pandemic: Dermatology-related consultations as a case. J Dermatol Dermatol Surg [serial online] 2022 [cited 2022 Oct 6];26:18-24. Available from: https://www.jddsjournal.org/text.asp?2022/26/1/18/349433
| Introduction|| |
Late in 2019, the global novel coronavirus disease (COVID-19) began to spread rapidly, which led to a reclassification of the disease as a pandemic disease in 2020. The World Health Organization guidelines recommended social distancing to prevent disease transmission. Subsequently, this forced physicians to provide health-care services using online tools to minimize and contain the spread of the virus., One of the most important tools is telemedicine, which is using computer applications to deliver clinical services by remote diagnosis and treating patients through telecommunication technologies.,,, Using online applications for different services including health-care services was one of the most effective solutions for controlling the spread of the virus. During the quarantine period, the Saudi government, represented by the Ministry of Health (MOH), closed nonessential clinics, including dermatology clinics, except for life-threatening and COVID-19-related cases. As a consequence, dermatological conditions were diagnosed and treated by family physicians using the telemedicine applications of the MOH. However, dealing with dermatological cases was a challenge since dermatology training is inadequate in the undergraduate medical curriculum and dermatologists are always needed. Previous studies have shown poor congruence between family physicians and dermatologists in the diagnosis of multiple skin diseases. A study conducted in Abha, Saudi Arabia, reported that 69.5% of family physicians lacked knowledge on common dermatological disorders. Other studies in Riyadh suggest that knowledge of topical corticosteroids among family physicians was inadequate. Until now, no studies in Saudi Arabia have shown the perception of family physicians using telemedicine to deal with dermatological conditions. Therefore, this study assesses family physicians' perception of using telemedicine for dermatology-related consultations. First, we study the process of telemedicine for the application of current MOH telemedicine. Then, we evaluate its efficiency for diagnosing and managing different dermatological conditions and identify the common dermatological conditions during the pandemic. Finally, we suggest possible improvements in the telemedicine process and related MOH applications for sustainable online health care.
| Ministry of Health Telemedicine during the COVID-19 Pandemic|| |
During the unexpected shutdown of most clinics and urgent move to telemediation due to the COVID-19 pandemic, the MOH has used its traditional call center services, called the 937 call center, to provide 24/7 medical consultations through physicians as well as its developed smartphone application, SEHA, to promote health care and telemedicine. SEHA is one of many apps launched by the MOH and used during the pandemic and its related curfew and preventative measures; other apps include TETAMMAN (an app that reinforces the commitment of all people directed to isolation and follow-up their cases), TABAUD (an app to assure social distancing and track the contacts of infected individuals), and TAWAKKALNA (an app that facilitates the issuance of movement permits based on COVID-19 infection and vaccination status). These apps are an important part of the success of Saudi Arabia's management of the pandemic, which has been widely recognized around the world. However, these apps, the technology behind them, and their national deployment were not a new environment developed in response to the pandemic. In fact, Saudi Arabia, with its ambitious strategic framework formed in 2016, vision 2030, has been moving steadily toward digital transformation and e-government. One of the most important government agencies formed in Saudi Arabia, which enables many e-government programs, is the Saudi Data and Artificial Intelligence Authority.
Both the 937 call center and the SEHA app deploy telecommunication technologies for telemedicine. In the SEHA app, online medical consultation services are enabled through chat, voice, and video calls between patients and the MOH's accredited doctors. Essential patient information is registered in the app's database and the user (patient) describes the case in words and/or delivers his/her condition using images/video. Consultations are carried out case by case, and the user has to reenter his/her health history and information on health condition when a consultation is required again. Only family physicians participate in the app, and there is no technically controlled medical supervision on consultations. Moreover, patient-to-physician assignment occurs when an arbitrarily decided doctor accepts the case after reading a brief description. Moreover, no comprehensive information is retrieved from a national data center or centralized data center that considers other aspects of the patient's information such as full health history as well as demographic and geographic considerations.
| Ministry of Health Telemediation Assessment for Dermatological Conditions|| |
A cross-sectional study was conducted across Saudi Arabia among 302 family physicians and general practitioners to assess family physicians' perception of using telemedicine for dermatology-related consultations. This study was approved by the Institutional Review Board of the Saudi MOH. A validated online questionnaire was used to collect the data. It contained 16 questions in five sections. The first section asked about personal and sociodemographic data such as sex, age, nationality, region, level of education, and number of years practicing. The second section contained three questions about telemedicine, including the use of telemedicine before and during the COVID-19 pandemic and what kind of tool was used. The third section estimated the frequency of dermatological conditions before and during COVID-19. The fourth section assessed the most common dermatological conditions during COVID-19. It also determined any difficulties in diagnosing and managing dermatology-related consultations as well as what actions were taken in response to any difficulties. The fifth section aimed to find whether there was a need for dermatologists to handle dermatological cases in MOH telemedicine. Data entry was carried out in Microsoft Excel 2019 and statistical analysis was performed by SPSS version 22. An appropriate statistical test was used to examine the relations between the categorical variables.
After data were collected, they were modified, coded, and entered into SPSS version 22 (SPSS, Inc., Chicago, IL, USA). All the statistical analyses were conducted using two-tailed tests. A P value below 0.05 was considered to be statistically significant. A descriptive analysis based on frequency and percentage distribution was carried out for all the variables including the residential area, demographic data, history of using telemedicine before and during the COVID-19 pandemic including methods used, dermatological assessment with types of covered cases, and attitude toward using telemedicine of family medicine and general physicians. Cross-tabulation was used to test for the distribution of the telemedicine experience during COVID-19 using physicians' demographic data and history of using telemedicine before the pandemic. The Pearson Chi-square test was used to test for the relation's significance.
| Results|| |
A total of 302 family medicine and general physicians completed the study questionnaire. Of these, 159 (52.6%) were in the western region, 65 (21.5%) in the southern region, 62 (20.5%) in the eastern region, and the remainder in the central and northern regions. Participants ages ranged from 20 to 59 years old with a mean age of 39.1 ± 10.8 years. In total, 176 (58.3%) participants were women and 288 (95.4%) were Saudis. As for job level, 128 (42.4%) were residents, 85 (28.1%) were consultants, and 75 (24.8%) were specialists. Considering years of experience, 107 (35.4%) had experience of 1–5 years and 47 (15.6%) had experience of more than 10 years [Table 1].
|Table 1: Personal data of sampled family medicine physicians in Saudi Arabia|
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Results show that 165 (54.6%) physicians never used telemedicine before the COVID-19 pandemic while 39 (12.9%) of them reported frequent to continuous use. During the pandemic, 86.8% of the family and general physicians used telemedicine for dermatological assessment, which was frequent to continuous among 60.2% of them. The most used methods were phone calls (57.6%), followed by the SEHA application (42.7%), virtual clinics (27.5%), social media (21.4%), and 937 call centers (8.8%). A total of 239 (79.1%) of the respondent physicians agreed on the need to employ dermatologists to deal with dermatological cases in MOH telemedicine modalities [Table 2].
|Table 2: Practice and perception of telemedicine use by family medicine physicians before and during coronavirus disease-2019 pandemic in Saudi Arabia|
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A total of 96.4% of the study participants reported that they dealt with dermatological conditions before the COVID-19 pandemic. During the pandemic, 92.4% reported that they dealt with eczema/dermatitis (87.1%), hair disorders (52%), infective skin disorders (27.8%), and pigmentary disorders (21.9%), while the least reported conditions were sexually transmitted infections (14.6%), vascular lesions (5%), and acne (2.3%). Interestingly, about 99% of the family physicians reported that they faced difficulty diagnosing dermatology-related consultations, which was frequently or usually among 24.5% of them. Regarding the action they took when facing difficulties, 57% asked a dermatology expert, 56.7% asked their colleagues (family physicians), 53.7% referred the case to a dermatologist, 46.7% consulted their seniors (family physicians), and 37% did their best to diagnose and manage the case [Table 3].
|Table 3: Dermatological practice by family medicine physicians before and during coronavirus disease-2019 pandemic in Saudi Arabia|
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Telemedicine was frequently used by all the physicians in the central region compared with 76.7% of those in the western region (P = 0.035). A total of 90.6% of the consultants used telemedicine during the COVID-19 pandemic compared with 50% of the GPs and 78.9% of the family medicine residents (P = 0.002). In addition, 91.5% of the family medicine physicians with more than 10 years of experience frequently used telemedicine during the pandemic in comparison to 73.8% of those who had experience <1 year [P = 0.030; [Table 4]].
|Table 4: Determinates of telemedicine experience during coronavirus disease-2019 pandemic among family physicians, Saudi Arabia|
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| Discussion|| |
Primary care physicians are the health-care system's backbone. Understanding and finding the gaps in the management of dermatological conditions can help the health-care system become more effective. In Saudi Arabia, telemedicine is primarily used to raise the quality and accessibility of the health-care system for patients, particularly those in rural and isolated locations. This study assessed telemedicine use and the perception of physicians before and during the COVID-19 pandemic. The use of telemedicine before COVID-19 was 54.6%, while the frequency increased to 86.8% during COVID-19. These results may be related to the variety of obstacles and challenges that telemedicine adoption and implementation before COVID-19 may have faced. The main barriers were the availability of adequate/sustainable funding from outside the health-care facility (e.g., from the Saudi Arabian government) followed by the availability of adequate financial resources in the health-care facility to implement, operate, and maintain telemedicine, as reported in a study conducted in Saudi Arabia. According to our research, phone calls and the SEHA application were the preferred modes for teleconsultations during the pandemic. Our results agree with a study conducted in western China. Another study suggests the use of WhatsApp, which allows users to send pictures or video, as this provides sufficient material for diagnosis, management, and follow-up.
In our study, primary care physicians reported that eczema/dermatitis was the most frequent disease (87.1%). Similar findings were reported by a study in Abha. This could be explained by the fact that the frequency of handwashing and using hand sanitizer increased during COVID-19. According to our results, about 99% of the family physicians faced difficulty diagnosing dermatology-related consultations. Different studies agree with this finding., Regarding the action they took to deal with difficulties, 57% tended to ask dermatology experts, while 56.7% asked their colleagues (family physicians) and 53.7% referred the case to a dermatologist. A previous study found that 72% of patients with skin conditions were referred to a dermatologist by primary care physicians. The rationale behind this could be the lack of dermatology teaching at the postgraduate level and inadequate education at medical school., Therefore, we suggest teaching primary care physicians to recognize common and serious dermatological diseases.
Several studies conducted in the United States have assessed the diagnosis and treatment of skin disease, finding that primary care physicians are inferior to dermatologists. Altogether, 79.1% of the primary physicians in our study believed that dermatologists should deal with dermatological diseases. This emphasizes the need for dermatologists to be employed in health-care facilities and telemedicine centers.
| Ministry of Health Telemedicine: Improvement Proposal|| |
As shown in Section 3, there is a pressing need and a wide space for improving telemedicine as well as promising supporting capabilities. The current model of the MOH telemedicine represented by the SEHA app uses the limited available information and does not involve dermatologists or other specialists from majors other than family physicians [Figure 1]. Transferring a case to dermatologists cannot occur technically within the system while physicians consult dermatologists informally outside the system as well.
Based on the doctor contacting patients, there are two possible models to involve dermatologists and other specialists in the current telemedicine system. One easy way is to allow other specialists to participate in the existing SEHA app. Doctors check patients' cases and accept what is related to their specialism. A navigation page could be added to the patient page to choose the specialty that best fits its case to reduce overheads; case transfer is also required within the system.
The second model is to maintain family physicians as the first-line contacts for patients while having a second (hidden) layer of other specialties. The case physician follows up the case and patient and makes the intra-consultations if needed. Intraconsultations are the official communication between the case physician and other specialists within the system, which grants access to patients' records.
With the existence of well-established governmental agencies such as the Saudi Data and Artificial Intelligence Authority and strong support for e-government to accelerate digital solutions and integration nationally, telemedicine can be improved to become leading worldwide. Systems integration with other agencies would not only improve the end user's experience for patients but also provide high-quality data storage, management, and analysis as well as assure patients' data privacy. A huge, centralized database of residents' data could accelerate research in all directions, which could be reflected in telemedicine. [Figure 2] shows an example of a possible SEHA structure that includes the participation of physicians from other specialties as well as the integration of a national data center.
| Conclusion|| |
During the COVID-19 pandemic, family physicians in Saudi Arabia increased their telemedicine practicing. Different telemedicine tools were used including phone calls, virtual clinics, and Saudi MOH applications. The majority of family physicians faced difficulty diagnosing dermatological conditions. Consequently, most of them suggested that dermatologists should be a part of health-care facilities and telemedicine centers to deal with dermatology-related consultations. Here, we provide recommendations for health information technology developers to ensure that telehealth services are widely adopted and used after the COVID-19 pandemic. Since the beginning of the pandemic, the MOH in Saudi Arabia has been developing the field of telehealth, as it has launched various applications (TETAMMAN, TABAUD, TAWAKKALNA) that have improved the quality of using telemedicine activities and facilitated all health services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pak HS. Teledermatology and teledermatopathology. Semin Cutan Med Surg 2002;21:179-89.
Helou S, El Helou E, Abou-Khalil V, Wakim J, El Helou J, Daher A, et al.
The effect of the COVID-19 pandemic on physicians' use and perception of telehealth: The case of Lebanon. Int J Environ Res Public Health 2020;17:4866.
Danis J, Forczek E, Bari F. The use of telemedicine in dermatology: Teledermatology. Orv Hetil 2016;157:363-9.
Charalambides M, Singh S. The place of technology in dermatology: Pros and cons. Br J Hosp Med (Lond) 2018;79:664-5.
World Health Organization. Telemedicine: Opportunities and Developments in Member States. Report on the Second Global Survey on eHealth. Korea: World Health Organization; 2010.
Trinidad J, Kroshinsky D, Kaffenberger BH, Rojek NW. Telemedicine for inpatient dermatology consultations in response to the COVID-19 pandemic. J Am Acad Dermatol 2020;83:e69-71.
Trettel A, Eissing L, Augustin M. Telemedicine in dermatology: Findings and experiences worldwide – A systematic literature review. J Eur Acad Dermatol Venereol 2018;32:215-24.
Kidholm K, Ekeland AG, Jensen LK, Rasmussen J, Pedersen CD, Bowes A, et al
. A model for assessment of telemedicine applications: Mast. Int J Technol Assess Health Care 2012;28:44-51.
Alshaikhi SA, Assiri AS, Alshaikh AA, Alshaikhi SA, Assiri HA, Alshaiki OA, et al
. Knowledge, attitude and practice of primary care physicians regarding colon cancer in Abha City, Saudi Arabia. Middle East J Fam Med 2021;19:68-80.
Marchell R, Locatis C, Burgess G, Maisiak R, Liu WL, Ackerman M. Patient and provider satisfaction with teledermatology. Telemed J E Health 2017;23:684-90.
Thakkar SH, Chavda PD, Mehta KG. Do primary care physicians require training in core clinical dermatology? A cross sectional needs assessment study from Western India. Indian J Dermatol Venereol Leprol 2019;85:380-7.
] [Full text]
Albarrak AI, Mohammed R, Almarshoud N, Almujalli L, Aljaeed R, Altuwaijiri S, et al.
Assessment of physician's knowledge, perception and willingness of telemedicine in Riyadh region, Saudi Arabia. J Infect Public Health 2021;14:97-102.
Alaboudi A, Atkins A, Sharp B, Balkhair A, Alzahrani M, Sunbul T. Barriers and challenges in adopting Saudi telemedicine network: The perceptions of decision makers of healthcare facilities in Saudi Arabia. J Infect Public Health 2016;9:725-33.
Hong Z, Li N, Li D, Li J, Li B, Xiong W, et al.
Telemedicine during the COVID-19 pandemic: Experiences from Western China. J Med Internet Res 2020;22:e19577.
Jakhar D, Kaul S, Kaur I. WhatsApp messenger as a teledermatology tool during coronavirus disease (COVID-19): From bedside to phone-side. Clin Exp Dermatol 2020;45:739-40.
Alsaidan MS, Abuyassin AH, Alsaeed ZH, Alshmmari SH, Bindaaj TF, Alhababi AA. The prevalence and determinants of hand and face dermatitis during COVID-19 pandemic: A population-based survey. Dermatol Res Pract 2020;2020:6627472.
Al-Hoqail IA, Gad A, Crawford RI. Dermatology practice in primary health care services: Where do we stand in the Middle East? Int J Dermatol 2002;41:4-7.
Federman DG, Kirsner RS. The abilities of primary care physicians in dermatology: Implications for quality of care. Am J Manag Care 1997;3:1487-92.
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[Table 1], [Table 2], [Table 3], [Table 4]