Telemedicine during COVID-19 Pandemic in Saudi Arabia: Oral and Maxillofacial Surgeons’ Knowledge and Implementation

Telemedicine can significantly improve health care delivery for patients with limited access to medical services. Innovative uses of this kind of technology in the provision of healthcare is increasing with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care. This study aimed to assess oral and maxillofacial surgeons' knowledge of telemedicine and its applications, and incorporation of telemedicine into their clinical practice during the COVID-19 pandemic. Methodology: This is a cross section, Questionnaire based study conducted among oral and maxillofacial surgeons in Saudi Arabia from November 2020 to January 2021. The study sample included 200 oral and maxillofacial surgeons from different regions in Saudi Arabia which has been calculated depend on reality of the Saudi health workforce during the next ten years 2018-2027 book and the total number of OMS and oral surgeons who was registered was approximately 300. Original Research Article Eltahir et al.; JPRI, 33(58A): 344-352, 2021; Article no.JPRI.78519 345 The self-administered questionnaire (which was constructed after extensive reviewing of the literature in the same context) was distributed among the selected surgeons using online platform; the components of that questionnaire were: socio demographic characteristics, knowledge of telemedicine technology, using of telemedicine before and during COVID-19 and security of telemedicine technology. A Scoring Criteria used to indicate the knowledge of OMS and oral surgeons towards the use of telemedicine technology. All statistical analyses were performed using SPSS version 21. Results: A total of 69 OM surgeons were responded, of which 52.2% were females. The knowledge of the surgeons regarding telemedicine was moderate among 43.5% (mean: 11.6; SD: 4.12, out of 20 points). Surgeons who were working in the private clinic (F=2.982; p=0.027), those who had heard of telemedicine (t=4.987; p<0.001) and those who implemented telemedicine at a current workplace before COVID-19 (t=3.873; p<0.001) had significantly better knowledge score than the rest. Conclusion: Although there was an increased implementation of telemedicine use during the covid-19 pandemic, the oral and maxillofacial surgeon’s knowledge about it seems to be low.


INTRODUCTION
Telemedicine, a term invented in the 1970s, is characterized as "the provision of healthcare services, where distance is a major consideration, by all healthcare providers using information and communication technology for the sharing of actual information for detection, care, and control of illness and injuries, study and evaluation, and education programs of health care providers, all in the service of improving the health of the people and communities" [1,2]. It refers to the use of information systems in healthcare delivery, such as smartphones, email, video conferencing, and other networking technology, to provide and facilitate clinical treatment remotely [3,4]. Telemedicine encompasses not only distant patient monitoring and diagnosis, but also elearning mechanisms for delivering education to health care staff and patients, as well as teleconsultation facilities. This could be applied to any consultation between physicians or between physician and patient that takes place over a network or video connection (e.g., Face-time, intranet, internet, Skype, etc.), as opposed to "in person" therapy, in which no Information and Communication Technology (ICT) is used to handle the contact between the patient and the practitioner [5].
Telemedicine in dentistry is referred to as "Teledentistry," and it is the method of networking, exchanging digital knowledge, providing remote consultations, workup, and examination [6]. Although, Teledentistry is still in its beginning in terms of its use by dental professionals, its inclusion in the field of medicine suits its meaning [7,8]. Teledentistry started as a military initiative in 1994 with the aim of improving healthcare services, enhancing dental education, and establishing dentist-laboratory communications [9]. Teledentistry is a form of oral healthcare that makes use of electronic media to enable dentists to communicate with one another from distance. Dental practitioners might exchange patient information using a Teledentistry network. Multiple providers might share radiographs, periodontal and hard tissue charting, treatment notes, photos, and any other required diagrams or details. Patients, especially those in need of a professional consultation, would benefit greatly from this exchange of knowledge [10]. Telemedicine in oral and maxillofacial surgery helps with differential diagnosis, care, follow-up, and disease control, and thereby improves patient care quality without needing the involvement of a maxillofacial surgeon in isolated places [11].
The current outbreak of coronavirus disease 19 (COVID-19), acoronavirus-associated respiratory conditions disease, is the third known spillover of an animal coronavirus to humans. Telemedicine has the ability to assist by allowing patients to receive compassionate treatment while limiting their proximity to other critically ill patients [12].
With the advent of the disease-causing virus COVID-19, innovative applications of this type of technology in healthcare are rising. There is an urgent need to increase the use of technology to assist people who require regular treatment. Limiting viral transmission in the population, as well as limiting exposure to other patients and workers, could help to slow the spread of the virus [13].
The Ministry of Health (MOH) newly established an e-Health system that supports the use of telemedicine which aim at improving the quality and actability of health care services among patients and healthcare providers, especially in rural areas. In order to attain the objectives of telemedicine, the Ministry of Health (MOH) initiated the Saudi Telemedicine Network (STN), a nationwide initiative encompassing all healthcare facilities, in partnership with Canada Health Infoway and the Ontario Telemedicine Network [14]. The aim of this study is to assess in general oral and maxillofacial surgeonsknowledge of telemedicine and its applications in Saudi Arabia, and specifically, during the COVID-19 pandemic, and their ability to incorporate telemedicine into their clinical practice, which can shed the light on their preperdence for any likelihood coming event.

METHODOLOGY
A cross-sectional Questionnaire based study was carried out in Saudi Arabia, from November 2020 to January 2021.

Study Participants
The study sample included 200 oral and maxillofacial surgeons from different regions in Saudi Arabia, who worked in hospitals, private clinics, and universities, with consecutive sampling method. The only inclusion criterion was any oral and maxillofacial surgeon in Saudi Arabia, who was able to contact during the data collection period. Thus, the current study involved professionals such as consultants, specialists, registrar, and residents. The present study questionnaire consisted of the demographic data, knowledge of telemedicine technology, use of telemedicine before and during COVID-19 and security of telemedicine technology. The questionnaire was constructed after extensive reviewing of the literature, and revising another constructing questionnaire in the same context. The authors used the reality of the Saudi health workforce during the next ten years 2018-2027 book to calculate the sample size. The total number of OMS and oral surgeons who were registered was approximately 300 which considered as total population and then the formula was used to calculate the sample size at confidence level of 95% and confidence interval 5, which resulted in sample size of 168. The questionnaire was sent to 200 OM surgeons to cover the drop out responses.

Scoring Criteria
The knowledge towards the use of telemedicine technology was drawn from 4 questions discussed in Fig. 1 with 5-point Likert scale categories ranging from "very low" coded as 1 to "very high" coded as 5. The total score was calculated by adding 4 questions. The scores generated has a minimum of 4 points and a maximum of 20 points, which indicates that the higher the score the higher the knowledge towards the use of telemedicine technology. By using 50% and 75% of the total score points to determine the level of knowledge respondents were classified as poor knowledge by the score range of 4 -10 points, >10 to 15 points were moderate and >15 to 20 points were considered as good knowledge level.

Statistical Analysis
The data were shown as frequency, percentage, mean and standard deviation, whenever appropriate. Between comparisons, Mann Whitney U test or Kruskal Wallis test were applied. Normality distribution was performed by using Kolmogorov-Smirnov test and Shapiro Wilk test. Data followed abnormal distribution. Thus, non-parametric tests were applied. All statistical analyses were performed using the (SPSS) software. P values <0.05 were considered statistically significant.

RESULTS
This study enrolled 69 OM surgeons to measure their knowledge about telemedicine before and during COVID-19. More than half were females (52.2%) and nearly two-third were Saudis (63.8%). With regards to educational level, 55.1% had a PhD degree. With respect to their position, 56.5% were specialists with 40.6% had 1 -5 years of experience. Furthermore, 46.4% were working at University hospital and one third of them were in Qassim Region. In addition, 73.9% had heard about the word "telemedicine" (Table 1).
Following the results, the knowledge of surgeons was high to very high in a question related to "To what extent is continuous training in the use of telemedicine necessary for doctors?" However, they showed poor knowledge related to the questions of "To what extent are you familiar with telemedicine tools" and "To what extent are your familiar with dental applications of telemedicine technology" (Fig. 1).
It could be seen that the implementation of medicine increased from 59.4% before pandemic to 75.4% during the pandemic. With regards to the type of communication used for telemedicine, WhatsApp was the most commonly used application before (63.4%) and during (69.2%) COVID-19 pandemic, followed by video conference application (before: 34.1% vs during: 42.3%). The most commonly mentioned providing services when using telemedicine was for follow up (before 70.7% vs during: 71.9%), followed by consultation (before: 58.5% vs during: 57.9%). In could be further noticed that the patients benefitted from telemedicine increases on the cases of more than 20 patients (before: 26.8% vs 35.1%). Furthermore, nearly all (94.2%) thought that there was an increased rate of telemedicine used during the pandemic ( Table 2).
It was revealed that the surgeons rated high to very high for the question of "To what extent does telemedicine technology require a formulated and clear framework for access to medical information?", followed by "To what extent are security policies and guidelines and necessary for the use of telemedicine technology?" and "To what extent does telemedicine technology require legal clarification for patients?" (Fig. 2).
Based on the results, the mean knowledge score was 11.6 (SD 4.12) out of 20 points with poor, moderate and good knowledge has been detected among 40.6%, 43.5% and 15.9%, respectively (Table 3).  When measuring the association between the knowledge score and the socio demographic characteristics of surgeons, it was found that surgeons who were working at private clinic (F=2.982; p=0.027), those who have heard about telemedicine (t=4.987; p<0.001), and those who implemented telemedicine at a current workplace before COVID-19 (t=3.873; p<0.001) showed significantly more knowledge than the other groups. Other socio demographic characteristics did not show significant effect when compared to the knowledge score including, gender, nationality, educational level, position, years of experience, work region and implemented telemedicine at a current workplace during COVID-19 (all p>0.05) ( Table 4).

DISCUSSION
Although emergence of telemedicine is four decades from now, sudden emerging of covid-19 necessitates its virtual presence and usage to keep social distancing in the medical field. Oral and maxillofacial surgery like other specialties is affected strongly during this pandemic. The presence of telemedicine in the form of OM surgeon to patient, surgeon to surgeon communications, and delivering of knowledge through continuous education could play important role in this difficult time.
The purpose of the present study was to evaluate the knowledge of the oral and maxillofacial surgeons regarding telemedicine (TM) technology and its implementation during COVID-19 pandemic in Saudi Arabia. The level of knowledge toward the use of TM technology is moderate which was among 43.5% of the oral and maxillofacial surgeons while 40.6% were classified as poor knowledge and only 15.9% had good knowledge level. The mean knowledge score was 11.6 (SD 4.12) out of 20 points. These results are consistent with the paper of Albarrak et al. [14] as they reported that 46.1% physicians had average knowledge about TM and most of them showed positive perception about it and were willing to adopt it in their clinical practice. This had also been documented by Shoman et al. [15] where they accounted 50.5% health workers were aware of the telehealth. On the other hand, Biruk and Abetu, [16] reported that health professionals in North West Ethiopia demonstrated better knowledge toward TM. Results indicated that, 37.6% of the health professionals exhibited good knowledge whereas in the current paper only 15.9% were classified as good knowledge level, which was lower than the previous report. Furthermore, we noted that being a private clinic oral and maxillofacial surgeon, being aware of telemedicine and being a telemedicine initiator before the pandemic were the factors associated with increased knowledge [17].
In relation to the implementation of TM at the current workplace, current result noted an increase of TM usage before and during the pandemic. Before the pandemic, it was noticed that there were 59.4% of the practitioners who implemented TM in the form of diagnosis, consultations, follow up, treatment and others. Whereas during the pandemic it rose up to 75.4%. Other literatures did not demonstrate comparisons of TM use before and during the pandemic whilst, in a paper of Kalidayan et al. [18] they indicated that there were 58.1% of the physicians who used some form of TM during the COVID-19 pandemic [19,20]. WhatsApp has been one of the favorite public applications since 2009 [21][22][23][24]. And moreover, according to this study one more additional characteristic could be added to this application, as this study showed that WhatsApp is the most commonly used application related to TM before and during the pandemic (before: 63.4% vs during: 69.2%), followed by video conference application (before 34.1% vs during: 42.3%). These results are consistent with the paper of Kaliyadan et al. [18] based on their accounts, the most frequently used application during TM was WhatsApp, followed by Zoom meeting and Microsoft Teams. Likewise, in a paper of Helou and colleagues, [21] they reported that physicians in Lebanon had used WhatsApp for telehealth before and during the pandemic which was comparable with the current results. In USA, [19] clinicians used Google hangouts as well as zoom application for TM which was also compatible with previous reports. It could be further noted that the most commonly mentioned services in using TM before and during the pandemic was follow up, followed consultation and most of the surgeons agreed that there was an increased in need of TM during the pandemic.
Oral and Maxillofacial surgeons who participated in this study were rated high to very high that TM technology require a formulated and clear framework for access to medical care and they were also agreed that the security policies and guidelines are necessary for the use of TM technology. On the other hand, surgeons showed moderate perception that TM technology reduce the efficiency of patient's care, authorized access necessary for the implementation of TM.

CONCLUSION AND RECOMMENDA-TION
Although there was a rise in the use of telemedicine during the COVID-19 pandemic, oral and maxillofacial surgeons' knowledge of the technology appears to be little. Surgeons who were works in the private clinic, those who implemented telemedicine in their workplace before the pandemic and those who have heard about it were likely to have better knowledge about telemedicine technology than the other surgeons. It is very important to address the gaps in the knowledge toward telemedicine technology.OM Surgeons who have sufficient knowledge about TM, are more than ready to bring telemedicine forward and help create institutional change. Thus, this study warrants further researches to validate the knowledge of OM surgeons regarding telemedicine use and evaluate the factors associated with it.

LIMITATIONS
The small number of Study Participants.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
Ethical clearance number (SRPSSC approval/F-2020-5005) has been taken from Qassim University, college of Dentistry, ethical research committee.