Effectiveness and Future Prospects of Telemedicine/Remote Health Care Management Applications in Pakistan

Medical/Health care system is spraining in Pakistan because of innovative technology, activities and services as per their financial cost (position) which is increasing day by day. This research is intended for the assessment of Telemedicine/Remote Health Care Management practices (system), which encompasses usability, acceptance and impact in public/private hospitals. To improve the existing remote health care/telemedicine practices in Pakistan by using EM (Engineering Management) based approach. It has been widely and successfully implemented and is considered as a strategic and operational tool. In the 21century due to the Technological advancements the mode of operation of service and business sector have been changed drastically. In the same way the health sectors activities also have been altered, new methods and techniques have also been devised for the treatment of the patients that were never even thought before. In the health sector Telemedicine/Remote Health Care Management is one of the development which was experienced lately. Telemedicine/Remote Health Careistaken exactly,” medicine at a distance”. Therefore, hypothetically, some procedures performed with medication which does not take place “face-to-face” and “in person” which can be considered as Telemedicine/Remote Health Care. In the industrialized world telemedicine is being used in full capacity to provide the health care services to remote and un-accessible areas. But Telemedicine/Remote Health Care Management is not very popular and admired in Pakistan; few applications are being functional presently.

Although, the incorporation of remote diagnostic function is rather a contemporary measure but the core dimensions of healthcare of as primitive as its consumers-human beings. Every consumer of remote services requires a certain level of resourcefulness, user friendliness, and service quality that can ensure the possibility of care as available in core facilities -this acquires the organization a competitive edge over its substitutes. Second concern is to increase the customer satisfaction in regards to observe, evaluate, and enhance the involvement of workforce through professionalism, knowledge ability of the services, and knowledge ability of the technology on hand, organizational rules, and after sales services. Finally, the major concern for such organizations is the lean manage the costs involved in healthcare operations because price of technology, price of infrastructure, and current financial position ofthe venture are paramount concerns so overall organization performance can be enhanced.
Medical/Health Care organizations are under tough stresses to make the improvement. Due to of the society aging, medical/healthcare services demands are increasing on the daily basis, but the medical/healthcare financial systems are not getting better in any system.
In the current millennium, medical/healthcare systems are in a continuous challenged phase, so as to be very much reasonable/accessible, safe/efficient and cost effective. Due to this reason there is a dire need forsearching outthe new, advanced and more efficient procedures to provide medical/healthcare facilities to all the people. Information security and privacy in medical/healthcare sectors is becoming a serious issue of emergent importance in these days. Due

Significance of the Study
The significance of this research extends the impact of remote diagnostic health /tele-medicines practices: in Pakistani public hospitals which are beneficial to all three stakeholders; consumer, workforce, and shareholders.
The study suggests beneficial input for public sector organizations to assist them in policy making and implementation. The paramount comprehension in this study is to formulate a design of such services to deliver them in "cheaper, better, and faster" ways.

Literature Review
As per Bashshurtelemedicineis referred as "an innovative bundle promising to achieve the threefold goal of improving access to care while limiting the rate of cost increase and maintaining quality" [3]. According to Bratton and Cody [4] another type of approach was used by the Mayo Clinic in a geriatric patient pilot study in Florida. The average of patients in the study was 77.3 years of age. The results were that 61% of the patients felt comfortable in using the system without assistance, and 72% were confident that the use of the system was giving them good care. Rogers [5] pointed out that the innovation-development procedure classify all the decisions and activities, and their impacts that take place from recognition of a need/problem, through research, development and adoption by users.
According to Fendrick and Schwartz the "technology imperative" to cure a patient is considered a major influence on the adoption of medical innovation [6].
Another important characteristic of both the physician and hospital organization is the necessity, in a very competitive market, to remain on the "cutting edge" of care in order to attract and retain patients. At the early stages, the development of the analogue telecommunication technology such as the telegraph, telephone, radio, and later on developments in digital telecommunication technology have facilitated the application of telemedicine in various medical fields [7][8].
Use of Telemedicine/Remote Health Care technology earlier to technology acquirement to promoteimproved decision making of investments [9][10][11].
By permitting the transfer of specialty knowledge to the remote community, telemedicine reduces the knowledge gap of remote physicians thereby affecting their diagnostic confidence [12]. In the medical field knowledge sharing between and among various categories of health care practitioners is an indispensable, accepted, and common practice across the world. Professional knowledge sharing among health professionals is significant to enhancing the quality and efficiency of patient care in health care facilities [13]. Additionally, it is essential that health care providers update their knowledge and expertise and keep abreast of medical advances and new medical information through reading medical books and journals, and attending morning rounds, medical lectures, conferences, and workshops [14].
In health care practices, apart from the medical knowledge, expertise, and communication skills, treatment of patients require some level of trust, confidence, and intimacy between health care providers and patients. On the one hand, telemedicine is a good solution for providing health care services to medically underserved inhabitants in rural areas, but on the other hand, it may cause emotional dissociative disorder andreduce the trust whichidentify the relationship between patients andmedical/health care providers" [15]. Likewise, Styhredescribe that "knowledge is what a certain collection of personsthink to how the world works" [16]. Knowledge sharing between various categories of health care practitioners is an indispensable, accepted, and common practice in the medical field across the world [17]. Furthermore, telemedicine, which is the application of ICT (Information and Communication Technologies) for health care delivery, and education of medical staff across distance, can play a significant role in knowledge sharing [18]. Beyond providing a connection between patients and specialized providers, telemedicine programs also promote exchange of knowledge between specialized doctors to improve decision-making by facilitating electronic transmission of patient-specific information and epidemiological information [19].
Trusting beliefs primarily from an Internet-based patient acceptance study. This research adapted the measurements from the above seminal studies. However, a field study was conducted with the subject experts from Bon Secours Baltimore Health System to strengthen the content validity and measurement applicability for the specific survey context [20]. Trusting beliefs means that one consider that the other party has one or more characteristics beneficial to oneself [21]. A new healthcare technology brings doubts about perceived self-efficacy, accessibility and support, perceived cost, and so on [22].
Research examines the factors that influence patient  with this architecture is that RHC, BHU and DHQ are usually located far away from each other thus giving rise to distance factor [38]. According to Rogove and Herbert the resistance in adoptability of novel approaches in Telemedicine like, acceptance and maintenance of robotic Telemedicine is discussed [39].
Keprovides literature review to scrutinize patient management in secondary care by doctors from multiple disciplines, primarily economic assessment was executed using Consensus on Health Economic Criteria [40]. The research sources of telemedicine database from difference sources" the role of telemedicine is most significant for the health care management applications [41].

H1:
There is a significant impact of adoption of innovation on remote health care management system.

H2:
There is a significant impact of available speciality knowledge on remote health care management system.

H3:
There is a significant impact of trusting beliefs and self-efficacy on remote health care management system.

H4:
There is a significant impact of perceived ease of use on remote health care management system.

H5:
There is a significant impact of cost of technology on remote health care management system.

H6:
There is a significant impact of financial feasibility on remote health care management system.

H7:
There is a significant impact of patient acceptance on remote health care management system.

RESULTS AND DISCUSSION
The range of the "alpha coefficient" lies from 0-1 which could be used to explain the reliability of factors taken out from dichotomous i.e. questions asked having two possible options of answers or multi-point designed questionnaires/scales. The rating of the questions is 1 for Strongly Agree and 5 for Strongly Disagree as shown in Table 1. There were seven independent variables along with one dependent variables based on the literature review which was used for the calculation of the relationship between independent variables and dependent variables as shown in Fig. 1.
Cronbach's Alpha value for overall reliability is 0.665 which proves that the data is reliables variables as shown in Table 2. Descriptive statistics deal with the concepts and methods concerned with summarization and explanation of the important aspects of the statistical data.
The results presented in Table2 are from the two normality standard tests i.e. Kolmogorov-Smirnov and the Shapiro-Wilk Testas shown in Table 3

Research Model
Regression model is presented as follows: Where X1= V1, X2 = V2, X3= V3, X4= V4, X5 = V6, X6= V6, X7= V7 and ε = error term R: 74.5% correlation coefficient between all the predictors (independent variables) and the dependent variable. R2: 55.5% proportion of variance in the dependent variable predictable by The predictable variables adjusted R2: 55.1% dependent on the number of variables used in the equationas shown in Table 5.   Telemedicine does hold a good future in Pakistan as indicated by the data, but it will not gain popularity in near future. It will take some time for the activities to develop and be common. This is so because telemedicine was recently introduced in Pakistan unlike other developing nations who adopted it in late 1990's. In Pakistan the practice started almost a decade later in 2008.
After that investments will be attracted and only then can the subject prevail in its true sense. However potentially it is a very strong area with a number of benefits supporting the idea.

RECOMMENDATIONS
A lot needs to be done for telemedicine in Pakistan. A number of shortcomings were identified by the study and for them some solutions have been recommended. For a successful future of telemedicine these recommendations need to be implemented. Some of the suggestions can only be implemented by the government.  s  t  n  e  i  c  i  f  f  e  o  C  d  e  z  i  d  r  a  d  n  a  t  s  n  U  s  t  n  e  i  c  i  f  f  e  o  C  d  e  z  i  d  r  a  d  n  a  t  S  T  t  n  a  c  i  f  i  n  g  i  S  B  r  o  r  r  E  d  r  a  d  n  a  t  S  a  t  training to all the personnel who participate in telemedicine activity. This will help raise the level of aptitude of the staff and will also reduce the reluctance that doctors have in accepting the impending change.
(ii) Alternate energy sources shall be provided to the existing remote stations. It is difficult and expensive to do so, thus smaller sources may be provided that can only power the ICT equipment so that tele-medical consultations may take place uninterrupted.
(iii) Awareness shall be spread regarding the subject.
General public as well as businessmen, doctors and students shall be introduced with the idea.
This will create a need and pathways will be developed for the business. Also, innovations will be made by those who are related to the