Background
Indonesia is an archipelago country which consists of more than 17,000 islands with more than 200 million people. It faces problem caused by an uneven distribution of health professionals, and healthcare disparities due to a vast territory and transport challenges [
1,
2]. A study from the World Health Organization (WHO) showed that 18,377 doctors worked in the Java and Bali islands, whereas 15,359 doctors worked in the rest of the country, an overall rate of only 13/100,000 population [
2]. To access certain specialist physician, patients from remote areas need to travel long distances which can cause delays and high costs in accessing the health service.
To overcome this problem, Indonesia began to develop telemedicine, since it enables health professionals to communicate over long distances using the internet for the exchange of health information [
3,
4]. It is believed that telemedicine has the potential to overcome healthcare disparities and improve equitable access to healthcare by receipt of specialist’s second opinions from a distance, and could also reduce workload and professional isolation of remote healthcare workers [
4,
5].
The growth of telemedicine in Indonesia began in 1985, but unfortunately most of the telemedicine activities in Indonesia are not well evaluated and documented due to the limited number of studies [
1]. One of the most successful telemedicine systems in Indonesia is the system used in Makassar City, the capital of South Sulawesi Province. However, evidence regarding its functioning is still limited, especially regarding the clinicians’ perception.
Clinician’s perception was chosen as the research question because of the critical role they play in the health system and the functioning of telemedicine. Their acceptance is important to increase positive attitude and confidence in using telemedicine, for local sustainability and the further deployment of the technology [
6].
The driving force behind this research was the lack of studies conducted in this country on telemedicine, and the need to identify barriers and problems that could prevent wider and more effective telemedicine utilization in Indonesia.
Discussion
To the best of the author’s knowledge, this study is the first telemedicine study capturing the clinicians’ point of view and experiences in Makassar, and in Indonesia generally. Overall, the result indicated that the clinicians were satisfied with the telemedicine system, and almost all of them were interested in continuing using this system since they considered that telemedicine was beneficial for their practice.
The advantages reported in this study include getting faster diagnosis, reducing unnecessary referrals, improving health workers skill, and increasing patient’s trust. These are in line with published studies (see Additional file
3). A randomised control trial by Whited et al. on teledermatology reported that 92% of the referring clinicians and 75% of the dermatologist consultants were satisfied with the system, and 95% of the referring clinicians stated that teledermatology allowed more timely referrals for their patients [
11].
Many prior studies had shown the excitement and interest of clinicians to use telemedicine (see Additional file
3), but in many locations and disease areas this expectation had not been achieved yet. Many challenges are summarised by Kruse et al. in a systematic review about the barriers in adopting telemedicine worldwide [
12]. Technical barriers, resistance to change, licensing issues, perception of impersonal care, and information overload were the most common barriers identified by staff [
12]. In this study, we found that in the primary care clinics on the islands, grid electricity was only turned on in the evening time, so all activities during daytime had to use a generator. In addition, there are limited Base Transceiver Stations located near to these islands, which limited communication and sometimes causes outages. These factors were clearly shown to discourage use of telemedicine, particularly in remote sites that might have higher benefits from the service.
Based on the above, clinicians in this study suggested infrastructure improvement in telemedicine, such as by establishing a cooperation with some communication providers to have a stable internet network and securing the availability of electricity in the island’s area. As an alternative, using the solar energy as a low-cost way of supplying power in the day time for primary care sites could be considered.
Clinicians also made suggestions to establish coordination with many specialist doctors and the schools of medicine, to create a reporting standard, and add a supporting feature in the system to enable the clinicians to engage in direct interaction with the specialist through video consultations to improve the coordination.
Mixed methodology was used in this study to combines elements of quantitative and qualitative research to increase the breadth and depth of understanding [
13]. Tashakkori et al. defined this method as a research in which the investigator collected and analysed data, integrated the findings, and found conclusion using both qualitative and quantitative approaches [
14]. Quantitative data can support the qualitative research component by identifying outlying cases, while qualitative data can help the quantitative components to develop the conceptual model or instrument. During data analysis for this study, qualitative data was used to assist with interpreting, clarifying, describing, and validating the quantitative results [
13].
Several studies have investigated clinicians’ perceptions on the use of telemedicine. However, the majority of this research was conducted in United States, Europe and other developed countries, with a limited number of studies of this type conducted in developing countries (see Additional file
3).
Research conducted by Pasco et al. in the Philippines, a country with geographic characteristics identical to Indonesia, shows the need for better infrastructure [
15]. This result is similar to our finding, although the number of respondents is smaller. At present, there is no other data on clinicians’ perceptions of telemedicine in Indonesia. Therefore this study provides a basis for understanding the potential for wider use in this large country, and in other developing countries in areas with characteristics similar to Indonesia such as a large number of islands.
Baruffaldi et al. in a research in Bologna and Johansson et al. in Sweden found high satisfaction with video consultation [
16,
17]. Most physicians preferred to use asynchronous telemedicine since it was easily integrated in the practice, however clinicians had less confidence in their diagnosis when using this type of telemedicine [
16,
17]. This was because of the lack of real-time feedback from an expert and the poor quality of information transmitted in many cases that could affect the decision made in diagnosis and treatment. Even though real time video consultation required more complex equipment, it was clearly preferred for more for specialized cases [
16].
Periodic training was considered to be very important in order to refresh clinicians skills and maintain a proper service, as the lack of clinicians’ knowledge of telemedicine would be the greatest barrier of the implementation and adoption [
18,
19]. In a research study on 130 nurses that had been given hands-on training in telemedicine on weekly basis, Brebner et al. from the North West Regional Telehealth Resource Centre (NRTRC) in the United States proved that the level of user competence could reach 100%, as well as a high level of satisfaction [
20]. Thus, by demonstrating telemedicine capabilities and advantages, it could increase their confidence and encourage them to use this technology [
6]. Relating to the remuneration, the clinicians proposed that the local government should offer remuneration to the clinicians who provided this service and provide special funding for the operation of telemedicine. Unfortunately, they did not give recommendations on how the government should provide this fund.
There is extensive literature regarding telecardiology and teleultrasound diagnosis effectiveness. Vodicka et al. in a systematic review regarding telecardiology in Slovenia concluded that telecardiology significantly reduces the number of unnecessary referrals to a cardiologist or hospitalization, and shortens the time needed to treat patients with life-threatening conditions [
21]. Britton et al. in a systematic review showed that teleultrasound provided satisfactory quality and value for clinical diagnosis and management [
22].
Indonesia is a classic example of a country where low numbers of specialist, uneven distribution of clinician and geographic barriers frequently prevent access to specialist care. This study shows successful uptake and use of a locally developed telehealth system in both a main island and a separate island. We believe this experience should be generalizable broadly in Indonesia including (with modifications) for COVID-19 screening. As planned by the local government for the future, this telehealth platform can be expanded to other types of ultrasound and could be used for other image-based diagnosis including dermatology and ophthalmology and capture of plain x-rays using a digital camera or scanner.
This study emphasized the role of perceptions of usefulness concerning telemedicine acceptance in primary care. This result is consistent with other previous studies stating that the perception of usefulness would influence individual acceptance and use of a technology (see Additional file
3) [
23‐
26]. The significant result of this study showed that if health workers realize the usefulness of telemedicine, they will accept this system more easily and have continuous intention to use it for their daily practice. It will likely increase clinician retention in using telemedicine [
5,
26]. In addition, this study aims to inform and encourage the decision makers to make continuous efforts to improve the perception of usefulness of the system for health workers, since this would likely encourage the implementation, deployment, and sustainability of the system.
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