How Physicians in a Moroccan Tertiary Care Center Perceive Teleconsultation During COVID-19 Pandemic?

Introduction

Telemedicine encompasses the use of electronic information and communication technologies for provision of health care when distance separates patients and health care providers. Improving access to health care and cost-effectiveness are some of the key reasons that propelled interest in telemedicine over the past 30 years.¹ Rapid developments in health information and recent technological advances have led to an unprecedented proliferation of studies and investigations on telemedicine.

As the most popular form of telemedicine use, teleconsultation—whereby consultations are conducted remotely and information is exchanged between health care providers—has been shown to improve clinical outcomes mainly in psychiatric care, injury care, and chronic disease management.² Furthermore, a considerable amount of literature has been published on the effectiveness of telemedicine.

Recent investigations reported positive and high-quality clinical outcomes following the use of telemedicine in patient monitoring,³ primary care and mental health services, orthopedics, pediatrics, the management of chronic conditions such as asthma, chronic obstructive pulmonary disease, multiple myeloma, leukemia, Alzheimer’s disease and mild cognitive impairment, and diabetes.^4–7

The COVID-19 pandemic has resulted in major disruptions in routine health care service delivery around the globe. These disruptions consisted of delayed outpatient appointments and the postponement of elective operations due to overwhelming pressure on health care facilities and reluctance of patients to visit hospitals and increase their risk of contracting the novel SARS-CoV-2. These spillover effects have jointly contributed to revitalizing interest in teleconsultation and helped accelerate its adoption as an alternative modality for patient care.

It is worthy of note that teleconsultation played a pivotal role in safeguarding patient care for long-standing health problems during the COVID-19 crisis.^8,9 In fact, deployment of health communication technologies such as videoconferencing, transmission of images, and remote follow-up—otherwise known as telemonitoring—has surged during the pandemic.^10–13

Teleconsultation became increasingly popular when movement restrictions were imposed by governments, especially for routine services that do not require direct contact with patients. This provided a unique opportunity to ensure continuity of medical care while simultaneously cutting costs, preventing transmission in hospital settings, and protecting health care workers.¹⁴

Matching the rapid pace of technological advances, Morocco has incorporated telemedicine into its digital development and national health strategy.^15,16 While several constraints may have blocked the expansion of telemedicine, the COVID-19 crisis served as a remarkable catalyst to promote and accelerate implementation of telemedicine.

Evidence of the success of digital health in managing different aspects of the pandemic response, such as data processing and smart vaccination management, served as a powerful incentive to remove regulatory barriers that stood in the way of widespread telemedicine use.¹⁷ A salient example was establishment of a telemedicine commission and the subsequent amendment of legislation that guides its practice.

In fact, legislative frameworks that govern the practice of telemedicine and protection of data had already been established by Moroccan law^18,19; however, the recently revised decree included provisions to strengthen personal data protection and facilitate implementation.²⁰ Additionally, a decrease in demand on health care services during the national state of emergency gave birth to a number of telehealth solutions that aimed to improve access to health care services, the most notable of which is the digital platform, Tbib24, which bridges the gap between Moroccan patients and medical providers wherever they are.²¹

Physicians and patients are the first users of this novel modality of consultation. Therefore, their engagement is of paramount importance to make full use of the benefits that teleconsultation offers. Consequently, their perceptions and attitudes have an important influence on its success and are therefore of great importance to planners and decision-makers alike.

Several studies have evaluated perceptions and acceptance of teleconsultation by the health care workers in various medical and surgical disciplines around the world.²² This study aimed to explore knowledge, perceptions, and acceptability of teleconsultation among a group of Moroccan physicians in a tertiary care center.

Methods

This is a descriptive cross-sectional study conducted at the Cheikh Khalifa International University Hospital (HCK) of Casablanca, Morocco. The HCK is a multidisciplinary tertiary care center offering a wide range of general and specialized health care services.

All physicians working at the time of the survey in the HCK of Casablanca, including professors, specialists, general practitioners, residents, and interns, were invited to participate in this study.

The self-administered survey was developed using Google Forms. The development of the questionnaire was based on a review of literature and questionnaires used in prior similar studies.^23,24 The questionnaire was pretested among 6 physicians by an interviewer in a pilot study. The survey link was sent to participants through their professional e-mail and on a WhatsApp group on March 25, 2021. Three e-mail reminders were sent to participants after the first mailing. The survey was closed on July 3, 2021. Answers to all questions were required, which helped us avoid missing data.

The survey consisted of 33 questions divided into 4 sections. The first section included sociodemographic characteristics (gender, age, position, number of years in practice, and number of patients seen per week). The second section included questions related to knowledge about telemedicine and more specifically teleconsultation (practice, legislation, current definition, and need for technical training for practitioners wishing to integrate teleconsultation into their daily medical practice). The third section included questions related to perceptions about teleconsultation (benefits, barriers, and facilitators). The fourth section included questions related to acceptability, the future of teleconsultation, and its potential integration into daily medical practice.

Descriptive statistical analyses were performed using SPSS software, version 2.0. Data are presented in frequencies and percentages. To compare quantitative and qualitative variables in both groups, Student’s t test (parametric distribution) or the Mann–Whitney test (nonparametric distribution) was used for quantitative variables and the chi-square test or Fisher’s exact test was used for qualitative variables.

The study protocol was approved by the Cheikh Khalifa University Hospital in Casablanca. Participation in this study was voluntary and was not compensated. Electronic informed consent was obtained from all participants.

Results

CHARACTERISTICS OF THE STUDY POPULATION

Of 486 eligible participants, a total of 212 completed the questionnaire, resulting in a response rate of 43.62%. Among the participants, 54.7% were under 40 years old and 52.4% were female. Of the respondents, 51.4% were medical specialists and 20.8% were professors in their discipline. Approximately 25.9% had been in practice for <5 years and 23.6% had been practicing for a duration of 5–10 years. Over 56% of the physicians had a weekly activity of <50 patients (Table 1).

KNOWLEDGE ABOUT TELEMEDICINE AND TELECONSULTATION

Almost all participants (99.5%) had heard of telemedicine. Approximately 96.7% had prior knowledge of teleconsultation, 42.9% and 43.4% were aware of tele-assistance and telesurveillance, respectively. About 67% of respondents were unaware of the existence of a law regulating the practice of telemedicine in Morocco. More than half of the participants (56.1%) were aware of the existence of teleconsultation pilot projects in Morocco. Over 81.6% of respondents said they were not sufficiently informed about the practice of teleconsultation.

The majority of respondents (83.5%) knew that teleconsultation links health professionals to each other and to patients. Virtually all participants (90.1%) knew that health care professionals who wish to practice telemedicine must acquire proper training and technical skills to utilize teleconsultation devices.

Approximately 62.3% knew that a consultation that connects physicians and patients using new information and communication technologies is considered an act of telemedicine according to Moroccan legislation (Table 2).

PERCEPTIONS ABOUT TELECONSULTATION

The benefits of teleconsultation most identified by participants were reduced travel costs for patients (84.9%), preventing medical deserts (83.5%), and improved access to patient care (77.4%). The main factors facilitating the use of teleconsultation reported by participants were internet access (95.3%), data security (93.4%), and confidentiality (92.9%).

The main barriers to the use of teleconsultation identified by participants were internet access issues (98.6%), poor audio quality (96.2%), poor video quality (94.3%), and difficulty encountered by patients in expressing themselves and communicating with their physician (79.7%). The majority of respondents felt that teleconsultation is best suited for general practice (96.2%), followed by medical specialties (82.4%).

Respondents thought that teleconsultation is more suitable to chronic diseases (69.4%) and for people living in remote areas (60.4%). Almost all participants (93%) thought that teleconsultation cannot take the place of traditional physical consultation (Table 3).

ACCEPTABILITY OF TELECONSULTATION BY STUDY PARTICIPANTS

The majority of participants (91.5%) believed that teleconsultation will be an integral part of future medical practice. The majority of participants (84.4%) expressed their support for a teleconsultation project if it were to be implemented. Of the respondents, 70.8% thought that they would be able to allot time to teleconsultation in their current schedules.

Slightly over half of the respondents (55.2%) thought that their patients were not ready for this new mode of consultation yet (Table 4). Globally, more than 78% of the participants had a favorable attitude toward this new form of consultation. Our results did not show statistically significant differences of acceptability in age (80.2% for <41 years vs. 77.1% for ≥41 years; p = 0.61), gender (79.3% for females vs. 78.2% for males; p = 0.86), or experience (79.0% for <10 years vs. 78.5% for ≥10 years; p = 0.92).

Discussion

The present study explored knowledge, perceptions, and acceptability of telemedicine among Moroccan physicians. Our results showed that physicians had an overall good knowledge about telemedicine and positive perceptions about its benefits. Participants identified technical issues as the main barrier to the use of teleconsultation and fast internet connection, data protection, and security as the main facilitators. The acceptability of teleconsultation and its potential integration into the daily practice of physicians were also high.

In this study population, teleconsultation was the most popular act of telemedicine and the majority of participants understood its definition. This is consistent with findings from other studies in India²³ and Pakistan.²⁵ In contrast, studies in Libya,²⁶ Iran,²⁴ and Saudi Arabia²⁷ reported low to average knowledge among physicians.

Most participants in this study had positive perceptions about the attributes of telemedicine. This is consistent with several other investigations.^23,28,29 These findings are of paramount importance because perceived benefits such as time saving, higher productivity, improved disease management, quality of diagnosis, and clinical examination are among the main predictors for the use of telemedicine tools by health care providers.²²

Another important finding in this study was that participants identified confidentiality, data protection, and proper internet access as major facilitators of telemedicine use. These results are consistent with other studies, which indicated that lack of data protection was a major barrier to the uptake of teleconsultation among physicians and patients alike.²²

In contrast, a study among Pakistani doctors showed that only 42.9% believed that telemedicine jeopardizes the patient–doctor relationship and causes a violation of patient privacy.²⁵ Similar results were found in China and Kuwait where less than half of the physicians were concerned with privacy breach.^30,31

In Morocco, the most recently amended telemedicine law requires applicants to submit a copy of the authorization obtained from the National Commission for the Protection of Personal Data (CNDP). This is a fundamental step toward increasing demand on teleconsultation services and increasing willingness of both patients and health care providers.¹⁷ However, ignorance about these legislations may lead to skepticism about patient safety and increase physicians’ hesitancy.

From patients’ perspective, a study in Spanish households found that recommendation by a physician was a major contributor to patients’ willingness to use teleconsultation services.³² Health care providers are therefore well positioned to promote the use of teleconsultation and should be adequately informed about laws, regulations, and best practices to provide assurance to their patients.

With regard to facilitators, most participants believed that ease of use of teleconsultation tools and clinicians’ level of training have a strong impact on its uptake. This is consistent with results from previous research, which indicated that perceived ease of use of telemedicine technology by clinicians is a key factor that impacts learnability and therefore the intention to use these services.^33–35

In fact, one study in South West Ethiopia indicated that ease of use was a predictor of willingness to use telemedicine among physicians.³⁶ This calls for adequate training in digital health competencies and the integration of telehealth into health care students’ curricula to support the health care transition that emerged during COVID-19, which is likely to continue beyond it.

Previous studies showed that the importance of integrating telehealth into medical education was acknowledged by medical schools and supported by medical students³⁷; however, some barriers to its implementation were identified such as lack of support from the national health system and the overcrowding of the curricula.³⁸

These barriers might not be fully relevant to our context; therefore, further studies are needed to assess the feasibility of introducing telehealth into the Moroccan medical training curricula. Departments of medical informatics within faculties can also play a key role in increasing the willingness to use telemedicine by providing training to current and future health professionals and developing telemedicine management systems in hospital units.³⁹

On the question of barriers, this study found that lack of access to good quality teleconsultation tools is a major barrier that impedes its expansion. These findings are in line with previous research. In fact, the technical issues that may occur during teleconsultation visits not only hamper effective communication and affect the quality of clinical decision-making but may also have medicolegal implications for practitioners.⁴⁰

In addition to these findings, a study conducted among public health doctors in Pakistan indicated that in Third World countries, the main perceived barriers to the use of teleconsultation were insufficient profits and reimbursements (78.6%), poverty/lack of education (90.6%), and lack of internet connection (89.7%).²⁵ Difficulty of patient–physician communication was also identified as a major barrier in this study.

Similarly, a study among Saudi Arabian physicians found that patient–physician interaction had an influence on attitude toward the use of telemedicine. This may be linked to the challenge faced by physicians in adequately examining patients³⁰ and making adequate assessments of certain conditions such as cognitive impairment.⁴¹ From patients’ point of view, lack of patient–physician rapport and the uniqueness of direct human interaction are often used as a basis to reject video consultations.

Most participants in this study believed that teleconsultation is most suitable for general practice and management of chronic diseases. Likewise, a study conducted among physicians during the COVID-19 pandemic in France identified teleconsultation as a fundamental tool for management of patients with “chronic, but under control,” conditions.⁴²

Another study conducted in Lagos also reported a high desirability for using telemedicine in emergency and chronic medical conditions.⁴³ In this study, physicians believed that teleconsultation is more suitable for health care practice in remote areas, which is also consistent with other studies.^23,25 However, a study conducted in India reported that physicians disagreed with the statement that teleconsultation only benefits the urban community.²³

Most participants in this study had a favorable attitude toward teleconsultation. This finding is important because acceptability of teleconsultation services by clinicians is a major factor that affects sustainability.⁴⁴ Similar studies indicated that health care providers had an overall positive attitude toward telemedicine^23,24; however, dental practitioners were less positive about the advantages of telemedicine compared with nurses, general physicians, and specialists.²⁴

A study in Kuwait indicated that 89% of physicians were willing to integrate teleconsultation into their practice. The same study showed that the more physicians used technology during their daily practice the more favorable they were toward this modality of consultation.³¹ This suggests that teleconsultation should be progressively blended into medical practice in Morocco for it to become pervasive.

Barriers to the expansion of telemedicine vary between countries due to the difference in support from national health systems, adequate reimbursement schemes, and sustainable financial support. In Morocco, the expansion of teleconsultation will help respond to unmet health care needs in remote areas. Additionally, it is a powerful tool to increase patients’ adherence to the treatment regimen of long-standing health issues such as tuberculosis and facilitate the monitoring of patients with prevalent conditions such as diabetes and cardiovascular conditions.

More importantly, it could alleviate the shortage in the health care workforce by speeding up the process of taking expert advice and promoting interprofessional collaboration between health care providers.⁴⁵ However, the lack of widespread availability of communication technology may accentuate existing inequalities in access to health care services.

To the best of our knowledge, this is the first study to investigate knowledge, perceptions, and acceptability of teleconsultation among the Moroccan health care workforce.

However, this study has some limitations. First, this study is monocentric and only includes practicing physicians in hospital settings; this leaves abundant room for investigating knowledge and perceptions about teleconsultation among other health care workers. Second, this study is conducted in a teaching hospital and the results should not be generalized to primary and secondary health care facilities. Third, the number of questions in the survey was high, which may have affected the response rate. Finally, this study does not investigate patient perceptions about the use of teleconsultation, which exert an equally powerful influence on the uptake of teleconsultation services.

The results of this study are useful to inform decision-makers about the state of knowledge on teleconsultation and barriers to the uptake of telemedicine tools. Our findings should be used to design interventions and policies aimed at promoting the use of teleconsultation by Moroccan physicians to cut the costs of health care provision and reduce inequities in access to care.

Conclusions

Based on the results of this study, overall acceptance of teleconsultation was high among Moroccan physicians and technical issues were the main barriers to its use. Additionally, knowledge about the legislative frameworks that govern the practice of telemedicine in Morocco and national pilot projects among physicians was average. Provision of adequate training and improved internet access will therefore encourage the use of teleconsultation services by health care providers.

Furthermore, this study has thrown up many questions for future research such as identifying the predictors, barriers, and facilitators of teleconsultation use by Moroccan patients in rural and urban settings. Adequate understanding of these perceptions will assist public health leaders in leveraging telemedicine to help advance health care coverage, promote patient-centered quality care, and ensure continuity of care beyond the COVID-19 pandemic.

Authors’ Contributions

Conceptualization was done by M.J., M.K., and C.N.; methodology was done by M.J. and M.K.; validation was done by M.J., M.K., and C.N.; formal analysis was done by I.B and M.K.; investigation was done by K.B.; data curation was done by K.B.; writing—original draft preparation—was done by M.J.; writing—review and editing—was done by M.J., Z.S., O.B., and M.K; visualization was done by M.J.; and supervision was done by M.J. and C.N.

All authors have read and agreed to the published version of the article.

Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

This research did not receive any specific grant from funding bodies.