Perception of telemedicine among medical practitioners in Malaysia during COVID-19

The novel Coronavirus Disease 2019 (COVID-19) has brought unprecedented changes in the way conventional health care is delivered. This study examined if clinicians’ perceptions regarding telemedicine and its barriers to implementation in Malaysia have changed during this pandemic. A cross-sectional survey was conducted among Malaysian medical doctors of various specialties in four urban healthcare facilities between June 2020 and July 2020. A total of 146 (41.7%) out of 350 responses were obtained. 62% of doctors reported a reduction greater than 50% in outpatient visits during the COVID-19 pandemic. The majority of doctors either found telemedicine useful in situations similar to COVID-19 (34.2%) or that it is essential to their daily practice (42.5%). However, only 22% reported using telemedicine for consultation during the COVID-19 pandemic. 74% of doctors felt that telemedicine would only benefit up to 30% of their patient population. Significantly more female doctors (80%) felt that telemedicine would benefit their patients compared to male doctors (45.8%) (P=0.03). Physicians (51.3%) were more inclined to adopt telemedicine in comparison to surgeons (32.4%) (P=0.03). The majority cited medico-legal issues and consent (80.6%), billing and charges (66.7%) and insurance reimbursement (62.5%), technical difficulties (62.5%) as their barrier to the adoption of telemedicine. Female doctors and physicians were more willing to adopt telemedicine when compared to male doctors and surgeons. Although the COVID-19 pandemic appeared to improve the perception, significant barriers should be resolved before many can incorporate it into their practice.


INTRODUCTION
The novel Coronavirus Disease 2019 (COVID-19) first emerged as a series of severe pneumonia of unknown etiology in Wuhan, Hubei Province of China on 31 December 2019. The causative agent, known as Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2), was isolated on 7 January 2020. Since then, many countries have enforced social isolation or social distancing through

Objectives
The objectives of the study were to: • Investigate the perception of telemedicine before and during the COVID-19 pandemic; • Determine the willingness of doctors to adopt telemedicine; • Explore the barriers to the implementation of telemedicine in Malaysian healthcare.

Study design and ethics approval
This was a cross-sectional survey in which a self-administered online questionnaire entitled "Is telemedicine relevant in your practice?" was conducted among Malaysian medical practitioners between June 2020 and July 2020. Before the commencement of the study, full ethical approval was obtained from the Research and Innovation Centre of KPJ Healthcare University College. (Approval no: KPJUC/ RMC/EC/2020/283)

Study population
The questionnaire was distributed to 350 doctors in four private hospitals covering four states, namely KPJ Ampang Puteri Specialist Hospital, KPJ Seremban Specialist Hospital, KPJ Damansara Specialist Hospital and KPJ Penang Specialist Hospital. The participants were from private urban healthcare centers involving consultants from various specialties. Nurses and other allied healthcare professionals were excluded.

Preparation of questionnaire
The survey was an online questionnaire distributed via e-mail through a Google document format. It was a 16-question self-administered survey.
It was designed and modified based on previously published research articles [15]. A group of two-member experts with experience in the field of telemedicine evaluated the modified questionnaire. The questions were either dichotomous (yes/no) responses or multiple-choice questions.

Statistical analysis
Statistical analyses will be performed using the Statistical Package for the Social Sciences (SPSS) software (Version 24.0, IBM Corp., Armonk, NY). Descriptive statistics were used in the form of frequencies and percentages for categorical variables. The Chi-squared test was used to measure the association between some of the variables in the study. A p-value ≤0.05 was considered statistically significant.

RESULTS
There were 146 respondents out of the 350 invitations sent (41.7%). The majority of the respondents were male (65.75%), with more than 20 years of experience working as a healthcare professional (64.4%). The source of knowledge and awareness regarding telemedicine came mainly from social media and news (69.9%). There were still 4% of the respondents who reported no knowledge of telemedicine at all (Table 1).
During the COVID-19 pandemic, 62% of respondents felt that there was a reduction greater than 50% in outpatient visits and the majority (63%) of them felt that the situation would only improve in one to two years.
Almost all (91.8%) of the respondents were already using an electronic patient record management system at the survey time. Unfortunately, only 22% of respondents reported using telemedicine for consultations during the COVID-19 pandemic. In regards to what percentage of patients would benefit from telemedicine, the majority (42.5%) agreed that less than 10% would benefit from it, 31.5% responded between 10-30%, 15% responded between 30 to 50%, and 9.6% responded above 50%.
When questioned about the future of telemedicine, 34.2% of doctors found telemedicine useful in situations similar to COVID-19, 42.5% of doctors found it useful regardless of the occasion and thought it should be integrated as a normal part of clinical practice and 23.3% of doctors felt that telemedicine was not relevant to their practice. The majority (67.1%) agreed that telemedicine was best suited for follow-up cases.
Awareness of the organizational readiness in implementing telemedicine is essential. Unfortunately, 39.7% had no knowledge of the drug delivery services available at their respective hospital.
In 1997, the Malaysian government implemented the Telemedicine Act as a guideline and proposed a protocol for clinicians to practice telemedicine. Unfortunately, 43.8% had no knowledge of the act and this proved to be a significant barrier in the implementation of telemedicine in the Malaysian healthcare system. Table 2 shows the comparison of responses between male and female respondents. 80% of female respondents answered that at least 10% or more of their patients would benefit from telemedicine compared to 45.8% of male respondents (P=0.03). Other questions about the impact of COVID-19 on healthcare economics, intention and willingness to use telemedicine, knowledge and awareness of telemedicine, and organization readiness showed no statistically significant differences between male and female responses. Table 3 shows the comparison of responses between surgical specialties and non-surgical specialties. The reduction of outpatient volume during COVID-19 was observed equally in both surgical (61.8%) and non-surgical practices (61.5%), with the vast majority (61.6%) of respondents seeing 50% or fewer than their typical volume of patients. Significant differences (P=0.03) were recorded regarding the intention and willingness to use telemedicine, as 51.3% of non-surgeons agreed that telemedicine was useful and should be part of their daily practice compared to 32.4% in the group of surgeons. In the group of surgical specialties, 50% of doctors answered JOURNAL of MEDICINE and LIFE telemedicine was only useful in situations similar to COVID-19 compared to 20.5% in the non-surgical group. There were significant differences (P=0.01) in terms of knowledge and awareness of the 1997 Malaysian act of telemedicine, with 59% of doctors from non-surgical specialties reporting no knowledge on the existence of the act compared to 26.5% of surgeons. Table 4 shows the comparison of responses between different medical disciplines. There were significant differences (P= 0.01) in the reduction of outpatient volume between different disciplines. Internal medicine physicians (89.9%), emergency physicians (66.7%), pediatricians (66.7%) and Ear, Nose and Throat (ENT) surgeons (64.3%) reported a reduction greater than 50% in the outpatient volume. However, doctors in obstetrics and gynecology (60%) observed a 10 to 20% reduction in the outpatient volume. Table 5 shows the comparison of responses between those that adopted telemedicine before and after the COVID-19 pandemic. There were no statistical differences noted in the responses between the two groups. However, doctors that adopted telemedicine after COVID-19 reported a higher acceptance of the technology (88.9%). Another notable difference between the two groups was related to the types of patients suitable for the practice of telemedicine. 85.7% of those that adopted telemedicine earlier felt that the technology is best suited for follow-up patients only. On the contrary, the majority of those who adopted telemedicine after COVID-19 reported that both new and follow-up patients are suitable for telemedicine (55.6%).
A variety of different reasons were cited by respondents as barriers against the use of telemedicine, including medico-legal aspect and consent (80.6%), billing and charges for such services (66.7%), insurance reimbursement/payment for such services (62.5%), technical difficulties including the setup and availability of technology (62.5%), patients willingness to adopt telemedicine (55.6%), time consumption and reduction in productivity (38.9%) and prescription of a medical certificate (40.3%) ( Figure 1).

Interpretation of the main findings
In this study, 34.2% of doctors agreed telemedicine was useful in situations similar to the pandemic of COVID-19, and the majority felt that it should be integrated as a normal part of clinical practice (42.5%). There was still a minority (23%) of doctors who felt that telemedicine was not relevant to their practice. These findings were similar to the study conducted by Ibrahim et al. in 2010, where almost 80% of doctors were in favor of the idea of remote communication with their patients [16].
Despite the majority (62%) of the doctors experiencing a reduction greater than 50% in outpatient visits during the COVID-19 pandemic, there was no significant increase in doctors practicing telemedicine when compared to before the pandemic. Only a handful of doctors (14%) practiced telemedicine before the COVID-19 pandemic, and it increased to 12% after the pandemic began. This was partly due to the negative perception of Malaysian doctors, as the majority (74%) felt that telemedicine would only benefit up to 30% of their patients. The majority of the surgeons (67.7%) felt that telemedicine was only essential during a pandemic such as COVID-19. This corresponds to a previous study in Malaysia that shows 67.5% of clinicians were unwilling to accept a reduction in face-to-face consultations [16], probably due to the poor knowledge of doctors in practicing telemedicine and the unpreparedness of the organization of the respective hospital in implementing the system.
Age of the doctors and seniority in practice may be another explanation for the poor acceptance of telemedicine. In this study, the majority of doctors were senior clinicians (64%) who have practiced medicine for more than 20 years. A similar study conducted by

5-10 years 16 11
Less than 5 years -- Table 1. Demographic profile of doctors who responded to the questionnaire.
ENT -ear, nose and throat.

JOURNAL of MEDICINE and LIFE
Gaggioli et al. in Milan found that senior male doctors were more reluctant to adopt telemedicine for a variety of reasons [17]. This could also explain our findings in a subgroup analysis where female doctors (80% vs. 45.8%) were more optimistic than their male counterparts. In our study, most female respondents were in the younger age group, with 48% practicing for less than 20 years. Our findings differed from previous studies, which stated that male doctors were more likely to adopt telemedicine [17,18].
This study also showed that physicians (51.3%) are more willing to adopt telemedicine than doctors from surgical specialties (32.4%). Surgical subspecialties are usually a barrier for telemedicine due to their procedural component [19]. Ophthalmologists, for example,        may find that telemedicine is limiting their patients' eye physical examination with an ophthalmoscope or slit lamp that would be required to reach a diagnosis or progress of the disease. Unfortunately, this is not valid in all surgical specialties. Telemedicine is still beneficial, especially during the preoperative and postoperative assessment, thus minimizing the attendance of patients to the hospital, which has a significant impact on the cost of patient care [20]. For example, there was increasing concern about the safety of various endoscopic and laparoscopic procedures during the COVID-19 pandemic in general surgery and colorectal surgery. There appears to be a potential of virus spread with the utilization of laparoscopy, mainly due to aerosolization of bodily fluids and vapor formed by heat-generating cautery devices [21,22]. Various studies have been published to encourage a conservative approach in managing such cases, with endoscopy and proctological procedures performed selectively [23]. Telemedicine has been suggested as a tool for consultation and screening; only those who are deemed not deferrable are attended physically in the hospital [23].
Besides the role in patient teleconsultation, telemedicine is also playing an increasingly important role as a tool to obtain clinical guidelines and communications among team members. A survey done by Benítez et al. concluded that social media and video conferences were the most popular options utilized during the COVID-19 pandemic for such purpose while maintaining social distancing [24].
Another notable mention is the role of telemedicine in the field of psychiatry and mental health. Among the various impacts of COVID-19, fear of infection and uncertainty about the disease can precipitate various psychiatric disorders; those with predisposing mental illness may experience more worry, anxiety, and suicidal ideation and develop other mental illnesses in comparison to healthy controls [25]. Telepsychiatry and smartphone-based cognitive therapy has been demonstrated to be an effective option where psychiatric patients tend to overestimate the risk of contracting COVID- 19 [26].

Tehnical difficulties -IT equipment and infrastructure
Time-consuming and reduced productivity

Medico-legal aspects and consent
Billing and charges to such services

Medical certificate prescription
Insurance reimbursement/payment for such services Patient education and willingness to participate in telemedicine services

JOURNAL of MEDICINE and LIFE
There were multiple concerns regarding the implementation of telemedicine and why it would benefit a minority of patients in this study. Primarily, the doctors were concerned about the medico-legal, security and privacy implications of telemedicine (80.6%). Medico-legally, doctors are at risk, as there is a lack of rules, legislation, and updated protocols for telemedicine, unlike its more traditional face-to-face counterpart [27]. For example, when a misdiagnosis occurs during a virtual consultation, the fault may lie with the technology, doctor, or patient. Therefore, the legal processes to overcome it are far more complicated than a similar error occurring during a face-to-face consultation where the law is standardized and universal.
The Malaysian Medical Council (MMC) advisory on telemedicine during the COVID-19 pandemic states that medical practitioners must possess adequate training, require valid informed consent, confirm the identity of patients, patient approval on other parties present and make sure that the technology used complies with legal requirements regarding privacy and security. However, the biggest drawback to the advisory was the requirement for doctors to reserve the practice of telemedicine solely for patients under their care. This may be a limitation of telemedicine in the COVID-19 era as it prevents doctors from conducting telemedicine consults on new patients who have no access to the hospital during the pandemic [28]. The Malaysian Code of Professional Conduct states that physical examination is mandatory for a patient consult. However, the advisory on telemedicine has given a leeway for non-physical telemedicine applied during the pandemic and not after.
The second concern was reimbursement or bill payments for telemedicine services. Questions arise if consultation fees via telemedicine should be based on current guidelines of face-face consultations or if they should be reduced as no physical examination is performed. However, this does not resolve the fact that the doctor is still consulting, interpreting results, and providing professional advice during telemedicine via audio-only phone calls, video calls, text chat, or e-mails.
Currently, in Malaysia, online health providers cite a fee of about 20 Ringgit Malaysia (RM) (4.70 USD) for a consult with a general practitioner and 40 RM (9.40 USD) for a consult with a specialist [29]. These charges are much lower than a face-to-face consultation at private clinics or hospitals. Hence, they may not be financially viable given the substantial initial investment of telemedicine. This could negatively affect the income of clinicians if traditional fee-for-service payment methods continue to be followed.
The third concern in implementing telemedicine was the technical difficulties. Doctors felt that the current environment lacked the adequate infrastructure for telemedicine (62.5%). This included Internet bandwidth, network issues, proper video conferencing applications, and reliable data storage. This corresponded to a study in Saudi Arabia where only 33.3% of clinicians were actually implementing telemedicine in hospitals that adopted it. Reasons cited were technical issues, insufficient training for doctors, and poor response from patients who preferred face-to-face consultations [18]. In terms of security and privacy issues, doctors were skeptical that the current systems available were safe and secured (i.e., not easily hacked or spied on). During the COVID-19 pandemic, there have been issues regarding patient privacy intrusions through the use of tools such as the Zoom Communication Inc. application for video conferencing [30]. These tools are simple, inexpensive, and easy to use by healthcare providers and patients alike. However, they lead to issues such as hacking intrusions and non-secure storage of video data. In the USA, doctors risk facing lawsuits or state actions for patient privacy violations despite acting in "good faith" to provide telemedicine services during the COVID-19 pandemic [30]. Therefore the concern for data privacy and security is critical.
The other concerns include patient education and willingness to participate (55.6%). This agreed with a recent study conducted in an urban city in Malaysia where less than half of its 4504 respondents found that the role of the Internet or a mobile health application was beneficial to them [31]. The authors indicated that this was due to most respondents having limited knowledge regarding the use of online health applications and the cost of embracing such technology [31]. Even in the neighboring country of Singapore, an urban center with one of the highest penetration of information technology globally, a recent study found that only 52.5% of their population was willing to use telemedicine [32]. Deterrents to telemedicine included age, ethnicity, patients' beliefs, cost and privacy [32].
Finally, doctors were also concerned over the legality of online medical certificate (MC) prescription (40.4%). This concern stems from an age-old tradition where MCs were required to be stamped with a doctor's Medical Council stamp in order for employers to verify its validity and authenticity [33]. In our study, the majority of doctors were comfortable with online MC prescriptions.

Limitations
The response rate of 41.7% was considered low, but it would be understandable as many are struggling to cope with the unprecedented changes in their daily practice. This study had participants mainly from a private healthcare system where most doctors were senior consultants, with many having above 20 years of experience. It is possible that the sampling method may have led to a self-selecting bias, in which doctors who were particularly willing and able to practice telemedicine did not participate. This study only targets a niche population in urban private institutions covering four neighboring states in West Malaysia. An inclusive study should include the states of East Malaysia (i.e., Sabah and Sarawak) with a larger rural community and doctors from public hospitals where healthcare accessibility and patient congestion represent an issue.
This study had participants mainly from disciplines that require an in-person physical examination and may be underrepresented by those from disciplines where telemedicine is more suited.