Utilization of Telemedicine by the Lebanese Physicians During Time of Pandemic

Introduction

About once in a generation, a global pandemic invades the world and places health care systems in many countries into chaos. The fact that an epidemic is not dealt with as often as other diseases limits the experience of how a health care system would handle it. Today, the world faces the outbreak of the coronavirus disease 2019 (COVID-19) as the third documented spread of an animal coronavirus to humans, causing a major epidemic in the past two decades. By the end of 2019, coronavirus was identified as the cause of the spread of a respiratory distress syndrome in Wuhan city of the Hubei Province of China.¹ The virus rapidly spread across China and then across the whole world, including Lebanon, which reported the first case of COVID-19 on February 21, 2020,^1,2 until the World Health Organization (WHO) announced it a global pandemic on March 11, 2020.^3,4

In Lebanon, the public health care sector was highly affected during the civil war (1975–1990), and thus, the government was forced to rely more on the private sector to provide health care services to the Lebanese people. This was shown by the proportion of the budget of the Ministry of Public Health (MOPH) that was spent on the private sector, increasing drastically from 10% in 1970 to 80% in the late 1990s; therefore, forcing the private sector to record a growth of almost 60% after the war.⁵ Currently, the public sector is formed of 28 hospitals all over Lebanon with more than 2,500 beds, whereas the private sector is formed of more than 100 hospitals representing more than 70% of the health care force in Lebanon.⁶ Together, both public and private components of the Lebanese health care sector sum up to a rate of 2.7 beds per 1,000 population.⁷ As for Lebanese physicians, the physician-to-population ratio is 22.71 physicians to 10,000 population as per the latest statistics released in 2020 by the MOPH.⁸ However, these statistics will probably decrease significantly in 2021 due to the increased immigration of physicians from Lebanon as a result of the economic and political crisis facing the country, especially after the Beirut port explosion.⁹ Moreover, regarding the common illnesses that are faced by the health care system in Lebanon, statistics show that more than 60% of the chronic conditions of Lebanese patients are cardiovascular diseases and diabetes.¹⁰

Reporting the first case of COVID-19 and the start of its spread in Lebanon, announced the start of the fight against the pandemic by the government and the MOPH. The health care system was not ready to deal with a large number of COVID-19 cases on top of around 8,000 cases the hospitals—both private and public—take on a daily basis. Furthermore, at the start of the pandemic, Lebanon only had 750 functional ventilators, of which only 250 were dedicated to COVID-19 cases.¹¹ MOPH tried to increase the number of intensive care unit (ICU) beds and ventilators mainly in public hospitals, yet only about 500 ICU beds are dedicated to COVID-19 cases with an almost 90% occupation rate.¹² This high occupation rate and the rapid spread of the pandemic among the population forced the government to declare a state of national health emergency in March 15, 2020, and multiple lockdowns that summed up to a total of more than 10 weeks where schools, universities, and most of the institutions were completely closed.¹³

The nature of the spread of the novel coronavirus by respiratory droplets has set constraints on daily communication between people, including physicians and their patients.¹⁴ The recommendations that were announced by the WHO concerning the concept of “physical distancing” and limiting contact with others have created challenges for physicians practicing medicine during their everyday life.¹⁵ These challenges have forced physicians to search for new tools. One of these tools, currently being piloted, is telemedicine.¹⁶

Telemedicine is defined as supplying remote medical services by utilizing telecommunication technologies for diagnosis, assessment, and medical education. It is a continuously evolving field that accommodates the emerging health demands of different communities by implementing the latest information and communication technologies. Although telemedicine and telehealth are often used interchangeably, it should be noted that “telehealth” is considered by some to be a broader concept that incorporates the health care resources provided by any of the health care professionals. In contrast, the former is confined to the health services offered by physicians.¹⁷

The use of technology in the medical field has been rising rapidly and offering, in many cases, an alternative to traditional ways of practicing medicine, especially when remote medical services are required.¹⁸ Physicians are progressively embracing telemedicine and many of its tools as a method of maintaining the health care needs of their patients.¹⁹ Also, the growing demand for health care services and the inadequate medical resources to cover these needs have concentrated efforts on expanding the use of telemedicine.²⁰ The latter has already been effectively utilized in acute care settings, including virtual ICU, and is now aptly seen to be a useful tool for disaster management, specifically COVID-19.¹⁸

Amid the H1N1 outbreak in California, telemedicine played a significant role in controlling the spread of the disease, laboratory and diagnostic support, and patient consultations.²¹ As for the current COVID-19 pandemic, it is of great concern that cases will overwhelm the capacity of medical facilities’ unless the proper containment precautions are effectively implemented.²² This is already overshadowing the management of other life-threatening conditions that require rapid medical intervention, such as strokes, pulmonary embolisms, myocardial infarctions, among others.^23,24

This background has laid the foundation for telemedicine to play a role in controlling the current COVID-19 pandemic.²⁵ Telemedicine has the potential to allow the facilitation of providing the necessary medical care to patients without exposing them to contact with other patients or the general population.^23,25 Furthermore, telemedicine is being utilized to track suspected cases in quarantine, advise on quarantine precautions, answer questions related to COVID-19, check for test results, and triage clinical needs.²⁶ Moreover, the critical role of telemedicine during this crisis has been represented by physicians who are under quarantine themselves, but still able to provide care for their patients.²⁶

Based on the above, this study aims to assess the utilization of telemedicine among Lebanese physicians during the COVID-19 pandemic and investigate the patterns of this use.

Materials and Methods

Study Design and Settings

This is an online cross-sectional study that was conducted using LimeSurvey^® statistical survey web application. Questionnaires were sent via e-mail to Lebanese physicians registered in the Lebanese Order of Physicians (LOP) of Beirut and Tripoli. Data collection was done from June 2020 till August 2020. The University institutional review board (IRB) approved this study.

Recruitment and Participants

Physicians were invited to participate through e-mails sent via the LimeSurvey online platform. A list of all registered Lebanese physicians’ names was obtained from both LOP of Beirut and LOP of Tripoli. The list contained 6,964 e-mails, and 2,191 other e-mails were added from hospitals’ websites. Thus, a total of 9,155 e-mail addresses were collected, and e-mails were sent between June 2020 and August 2020 with an invitation link embedded at the end along with an attached consent form. A total of 7,330 e-mails were successfully sent, while 1,825 e-mails were bounced back. Three reminders were sent to nonrespondents within 2, 4, and 6 weeks of sending the invitation e-mail. The identity of all participants was kept anonymous, and the analysis of the data was done collectively to protect the privacy of the participants.

Questionnaire

The questionnaire was constructed by the authors based on concerns frequently tackled during the pandemic regarding the use of telemedicine by physicians after a thorough literature review. It included three sections tackling the following: sociodemographics, telemedicine practice during COVID-19 pandemic, and attitude toward telemedicine use during COVID-19 pandemic. The survey was provided in both Arabic and English languages. The questionnaire was initially piloted on 15 physicians to check for clarity, question-wording, the time needed to fill the survey, and to validate the established questions, and then, adjustments to the questionnaire were carried out accordingly.

Sample Size

The number of physicians registered in the LOP of Beirut and LOP of Tripoli was 13,468 physicians when the study was conducted. For a power of 80%, a margin of error of 5%, and—due to the lack of data from the literature—an estimated proportion of Lebanese physicians who utilize telemedicine of 50%, the calculated sample size was 374 respondents with a confidence level of 95%.

Statistical Analyses

Statistical significance was set at a p-value <0.05. All analyses were performed with SPSS 22.0 software (SPSS, Chicago, IL).

Results

Participants’ Demographics

Four hundred one (N = 401) physicians completed the survey resulting in a response rate of 5.85%. The mean age of respondents was 45.5 years (±12.2). Physicians were almost equally distributed between different age groups where 26.9% were younger than 35 years, 26.7% were aged between 36 and 45 years, 22.7% were aged between 46 and 55 years, and 23.7% were older than 55 years. Most of the responding physicians were males (64.3%). The majority (91%) were attending physicians, and 61% had more than 10 years of experience. Medical subspecialties represented 32.9% of the respondents, while surgical subspecialties formed 18.7%, and general practitioners and family physicians formed 12.7%. More than half of the physicians reported being consulted by an average of 5–10 patients per day (Table 1).

Patterns of Telemedicine Use Among Respondents

The majority of the physicians (N = 401, 88.3%) reported practicing medicine in their workplace during the COVID-19 pandemic. However, most of the respondents (N = 401, 75.8%) also reported using telemedicine to provide health care services to patients without in-person visits during the pandemic. Among those using telemedicine (N = 304), around 40% reported that they started using it during the COVID-19 pandemic, and 47.2% reported using it with patients they already know and with new patients as well. WhatsApp Messenger and regular phone calls were among the most common telemedicine tools used. Also, voice calls, voice messages, text messages, and media were all among features of different telemedicine tools used by most physicians (Table 2).

When asked about the purpose of their telemedicine use, 97% of participating physicians reported using it for checking laboratory or radiological results, 85.8% reported using it for ordering laboratory and radiological investigations, 85.1% reported using it for history taking, 83.4% reported using it for prescribing medications, 77.2% reported using it to diagnose consulting patients, and 68.9% reported using it for inspecting patients using photos or videos (Fig. 1). Most of the respondents using telemedicine (N = 304, 57.8%) reported spending an average of fewer than 15 min per consultation completed via telemedicine. Almost half of the responding physicians answered that the percentage of patients consulting them via telemedicine was less than 25% compared with their load of patients in the clinic before the COVID-19 pandemic. Moreover, 20.5% answered that they could reach a definitive diagnosis in more than 75% of all telemedicine consultations. In contrast, a majority of 86.8% stated that they had received consultations that could not be completed via telemedicine.

Furthermore, when physicians who do use telemedicine were asked about barriers to telemedicine use, 91.7% answered that the inability to perform an adequate physical examination was one barrier, whereas 75.8% and 74.2% agreed that patients’ abuse of telemedicine consultations and poor internet connection were, respectively, other barriers (Fig. 2). Around 60% stated that they kept medical information obtained via telemedicine consultations in patients’ medical records. Only 16.2% reported doing a consultation via telemedicine in the presence of someone who could listen to the conversation. Also, 30.8% confirmed attending any educational activity that aims at training physicians on the use of telemedicine technology during the COVID-19 pandemic. Regarding physicians’ financial income, a vast majority of 93% of participating physicians reported that their income was affected during the COVID-19 pandemic, whereas only 16.9% of those who do use telemedicine revealed getting paid for any of their telemedicine consultations.

Discussion

As a result of the COVID-19 pandemic, the use of telemedicine to provide health care services to patients became more popular to prevent the spread of the virus.²⁷ Many studies were recently conducted, implying the wide and beneficial use of telemedicine to manage many of the patients’ health care problems. Management of multiple myeloma, chronic myeloid leukemia, and pediatric infectious diseases were all health care problems where telemedicine was successfully used to provide health care services to patients during the pandemic.^28–30 Our study focuses on the utilization of telemedicine by Lebanese physicians during the pandemic and the patterns of this use.

A previous study conducted in Lebanon showed that the use of telemedicine by Lebanese physicians increased after the onset of the COVID-19 pandemic.³¹ The results of our study were consistent with the previously mentioned as it showed that 40% of the Lebanese physicians using telemedicine started their use during the pandemic. This reveals that the already rising use of telemedicine in health care has been accelerated by the outbreak of the COVID-19 pandemic. The current study also showed that WhatsApp Messenger was the telemedicine tool used by a vast majority of the Lebanese physicians, which is in agreement with another study conducted in Lebanon proving the popularity of WhatsApp use among Lebanese physicians for interprofessional consultation.³² This widespread use of telemedicine and WhatsApp among Lebanese physicians provides evidence of the potential of WhatsApp as a telemedicine tool that can be implemented and integrated into the health care system in Lebanon, especially in the context of a future pandemic. Moreover, almost 60% of physicians reported spending less than 15 min on a consultation completed via telemedicine. In contrast, the literature states that the average time of an in-person clinic consultation is more than 15 min.³³ This implies that telemedicine can play a role in saving physicians’ time; this conclusion is supported by other studies that consider telemedicine a time-saving method of providing health care services.³⁴ However, since physicians are not being paid for their telemedicine consultations, they might not be putting in the same effort.

The literature has been discussing the need for further investigation of the implications of telemedicine on patients’ confidentiality.^32,35,36 Our study tried to tackle this topic in many aspects. Only 16% of physicians stated that they would do a telemedicine consultation in the presence of someone who could listen to the conversation; this shows that physicians using telemedicine do try to preserve patients’ privacy. However, 60% of physicians stated that they would keep medical information they acquired via telemedicine in patients’ medical records. This raises questions that are already raised by the literature about the extent of respect of patients’ confidentiality when telemedicine is used for keeping medical records.³⁶

Nonetheless, these results can also be seen as evidence that keeping medical records while using telemedicine is not a problem as most of the physicians do it, yet the literature expresses concerns on the lack of consistency in the process of keeping medical records by physicians using telemedicine considering it the latter’s “weakest link.”³⁷ Therefore, the need for guidelines tackling these ethical concerns and governing the use of telemedicine has become increasingly necessary to offer both physicians and patients a safe environment while using telemedicine. Previous studies have already mentioned and recommended developing such guidelines repeatedly.^31,32

However, our results showed that physicians are still questioning the efficiency of telemedicine in health care. More than 85% of physicians stated that they were unable to reach a diagnosis when providing a telemedicine consultation. This is probably due to the fact that a consultation lacking a complete physical examination is considered by physicians an inadequate consultation. Our results confirmed this assumption as more than 90% of physicians considered the inability to complete a physical examination one barrier coming between them and the adoption of telemedicine. Two other studies conducted in Lebanon were also in agreement with this assumption.^31,32 This implies that it might be wrong to consider telemedicine a service that can completely replace the current face-to-face dominated health care services and provide the same quality of health care. Instead, telemedicine may be integrated into the health care system as a service that can be used for following up with patients rather than for a complete consultation, especially during a pandemic, to minimize unnecessary increased contact with patients, consumption of protective equipment, and patient load in health care facilities.^38,39

Previous studies highlighted the financial concerns raised by physicians in association with their use of telemedicine.^31,40,41 Our study tackled this issue when we asked the physicians about their patient load during the COVID-19 pandemic. In Lebanon, the LOP recommended physicians use telemedicine to provide health care services for their patients during the pandemic. However, the results showed that the load of patients consulting via telemedicine is less than 25% of the load of in-clinic consultations before the pandemic, as reported by more than half of the physicians. Also, a substantial majority of almost 95% of physicians stated that their income was affected during the COVID-19 pandemic, whereas only 16% reported getting paid for any telemedicine consultation. These results present another barrier facing the broad integration of telemedicine with the health care system as physicians will not be encouraged to depend on telemedicine in providing health care services if it affects their financial income and consequently their quality of life. Thus, the presence of a payment method that compensates physicians for the health care services they provide via telemedicine should be a priority in any plan aiming to implement telemedicine in the health care system.

Limitations

Our study still had some limitations. First, a total of 9,155 e-mails were obtained of 13,468 registered physicians. Among sent e-mails, 1,825 were bounced back since e-mails received from LOP of Beirut and LOP of Tripoli were outdated. Second, in the process of investigating the utilization of telemedicine among Lebanese physicians, we used e-mail to collect our data. This may represent a sampling bias because an e-mail is an online tool and that a vast part of telemedicine depends on online tools, one of which is e-mail.

Conclusions

In conclusion, our study indicated that telemedicine is used by most Lebanese physicians and that this use has been accelerated by the COVID-19 pandemic. Our results showed that telemedicine does have a potential that can allow it to be integrated in the health care system and implemented on a national organized level. The advantages of telemedicine use do encourage this approach primarily as a part of a governmental plan prepared to deal with any future pandemic. However, ensuring the acceptance of the implementation of telemedicine in the health care system still needs work from policymakers. Physicians seem to think that the path toward the adoption of telemedicine in the health care system still lacks the development of guidelines tackling controversial topics raised by the use of telemedicine, and policies governing this use, and setting rules that standardize medical practice provided through this service.

Authors’ Contributions

All authors participated in concept and design, writing the article, and approving the final version of the article.

Acknowledgments

We would like to express our gratitude to all individuals who made this work see the light, especially study participants.

Disclosure Statement

No competing financial interests exist.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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