Telehealth Role During the COVID-19 Pandemic: Lessons Learned from Health Care Providers in Saudi Arabia

Abstract

Background:

Coronavirus disease 2019 (COVID-19) was originally recognized in December 2019 as a case of lung infection in Wuhan, China. COVID-19 has affected the capability of health care experts to treat patients face to face. One initiative to improve the efficacy and convenience of patient care despite the physical distancing limitations has been the application of “virtual clinics” (VCs) as a treatment modality. This study was aimed to investigate the use of VCs as a tool of telehealth during the COVID-19 pandemic in Saudi Arabia.

Methods:

This study was conducted in the ambulatory care setting at King Abdullah Specialized Children Hospital in Riyadh. Respondents were selected from different groups of health care providers. The study was a hospital-based cross-sectional design using an electronic survey.

Results:

In total, 277 surveys were collected. Principal findings showed the deployment of VCs by 67.2% (n = 186) of providers. Among these providers, 54.3% were female, and only 18.8% of providers were aged >54 years. 98.1% of the respondents have started running VCs since the COVID-19 outbreak, with 47.2% of respondents running between 51 and 100 VCs per month, and the majority (74%) were spending 6–15 min per patient visit. Chronically ill patients constituted 57.7% of the patient's population served. Almost 95% of respondents used electronic prescriptions during their VCs. Most providers (98.1%) used the telephone/mobile as a means of communication with the patient during these VCs. A total of 75.5% of VCs were integrated with electronic health records such as appointment scheduling (77.9%), and 88.3% of the providers were satisfied with their VCs. The major opportunity seen by providers was reducing appointment waiting times (73.4%). The major success metric seen in VCs was increased patient satisfaction as reported by providers (67.9%). In contrast, the major challenge seen was the lack of face-to-face interaction and physical examination (86.8%).

Conclusion:

VCs are one way of centering the health system around the patient, but careful attention is needed to integrate these services with the current health care delivery system in place and ensure quality care to the patients.

Introduction

Coronavirus disease 2019 (COVID-19) was originally recognized in December 2019 as a case of lung infection in Wuhan, China, and was acknowledged by the World Health Organization as a worldwide pandemic on March 11, 2020. COVID-19 does not only bound the capability of health care experts to treat very sick patients infected with the virus but it could also impact uninfected patients with more serious chronic conditions, such as cardiac and cancer patients from receiving treatment that they would normally have during nonpandemic circumstances.¹

Health care is moving toward more technologically oriented services and facilities that ensure patients receive quality care from the comfort of their homes, without heading to clinics, or having in-person consultations.²

One initiative to improve the efficacy and convenience of patient care has been the application of virtual clinics (VCs), which use telehealth to provide an accurate assessment, monitoring, and clinical management remotely, away from the usual face-to-face clinic consultation.³ This would ultimately support the current physical distancing restrictions during the COVID-19 pandemic.

The setup and provision of a VC vary extensively depending upon the type of technology deployed, including telephone, text messaging, online web sessions, or Skype.³ Therefore, virtual care is a vital tool in backing up the clinical needs of a health system in managing the COVID-19 pandemic.

Overall, the advantages of VCs include higher patient satisfaction and more time-efficient appointments. However, there are concerns about practicality, limited technical capability, unreliable internet access, infrastructure issues, and apprehension among both patients and the medical community regarding the lack of face-to-face interaction and physical examination.⁴

Electronic health records (EHRs) have numerous functionalities that are being brought to bar during the COVID-19 pandemic. These applications are fully incorporated in VCs and can include electronic medication prescribing, ordering of laboratories and investigations, and links with patients' portals.⁵

In Saudi Arabia, there is a lack of published literature describing the proper usage and application of VCs required to effectively manage chronically ill patients during the COVID-19 pandemic (Fig. 1). International research on VC sessions is scarce as well. The literature reviewed proposes immense potential for the usage of virtual media, such as video, telephone, or other tools for virtual communication between patients and doctors. Whereas telehealth has been incorporated as an essential means to sustain VCs during the pandemic, health care representatives and policymakers at various levels have yet to consider fully how to exploit VCs in normal times.

FIG. 1.

Virtual clinic locations in Saudi Arabia.

Methods

Study Area/Setting

The study was conducted in King Abdullah Specialized Children Hospital, Riyadh, in the ambulatory care setting (clinics area). Clinic specialties were as follows: adolescent medicine, adult anesthesiology, burns and plastics, cardiac, dentistry, dermatology, employee health, endocrinology, ENT, family and community health, gastroenterology, general special clinics, genetics, hematology and oncology, hemodialysis, hepatology, home health care, immunology, infectious diseases, internal medicine, mental health clinic, nephrology, neurology, obstetrics and gynecology, ophthalmology, palliative care, pain management, pediatrics, pulmonology, rheumatology, surgery, and urology.

Study Subjects

Respondents were selected from different groups of health care providers including physicians, nurses, clinical coordinators, pharmacists, and patient educators who work in the ambulatory care center in National Guard Health Affairs, Riyadh. The participation of such a group was selected intentionally as they are directly involved in providing clinical services through VCs for patients and it would ensure a balanced opinion of the respondents as well as the generalizability of the research results.

Study Design

This study was a hospital-based cross-sectional design to investigate the importance of the role of telehealth during the COVID-19 pandemic crisis and the efficient use of VCs with the help of EHRs in the effective management of patients. The purpose behind selecting the study design as cross-sectional is because it is relatively faster to conduct. This would be the best option during the COVID-19 pandemic. Moreover, this type of observational research can be used to gather preliminary data on the use of VCs to support further research and experimentation. One of the advantages of cross-sectional studies is that since data are collected all at once, it is less likely that respondents will quit the study before data are fully collected.

Sample Size

The researcher estimated representative sample size is 252 respondents, where the population size of the selected health care providers working in the ambulatory care center is 728, with a confidence interval of 95% and an estimated margin of error 5%.

Sampling Technique

Convenience sampling used that relies on data collection from population members who are conveniently available to participate in the study.

Data Collection Methods

Data collection was done by the principal investigator. The data collection tool was an electronic survey (e-survey). The purpose of selecting e-survey as the data collection tool was because of the current situation of COVID-19. It would be the best suitable tool at present given the restrictions practiced now in the health care organization including physical distancing that limits using other tools such as in-depth interviews and face-to-face questionnaires. Health care providers are currently overwhelmed with their clinical schedules trying to meet the increased clinical tasks assigned to them at this time. An e-survey would increase response rates by reaching the target audience quickly and effectively. It would further provide great real-time results for quick and easy analysis. Moreover, respondents can pick the best suitable time for them to answer an online survey rather than doing this by scheduled telephone interviews, and they are expected to answer e-surveys more honestly.

The tool was adapted from an online accessible survey that was conducted in 2018 by the Zipnosis Healthcare Group, a group of specialists in virtual care and telehealth. Their survey, titled 2018 On-Demand Virtual Care Benchmark Survey, was focused on how health systems are deploying and using virtual care (see Appendix). After tailoring the e-survey, it has been tested for reliability and validity through pilot testing. Twenty e-surveys were distributed to different health care providers including nurse specialists, clinical coordinators, physicians, a pharmacist, and patient educators. The answers were consistent. The language used and the flow of questions were clear to all respondents. No skewed answers were seen. All coefficients for the questions were between 0.685 and 0.722, which indicates that there was a strong correlation between the questions for each factor and the whole questionnaire. The full process of data collection began after obtaining the approval of the hospital research center ethical committee. The distribution of the survey was done through distributive e-mails and social media platforms such as Whatsapp.

The e-survey has focused on three dimensions: virtual care operations, technology, and clinical aspects. Areas of interest in virtual care operations will be reflected in how virtual care is set up and supported in Saudi health care organizations. Topics include patient populations and utilization, strategy and operational responsibility, goals, challenges, and plans. The technology section looks at the technology used for virtual care demand, as well as how virtual care fits into the digital health landscape. Topics include modalities and integration of other telehealth technologies. The clinical section delves into clinical uses and outcomes from virtual care programs. Topics include staffing and efficiency, and conditions treated.

Data Management and Analysis Plan

The collected data were analyzed using Microsoft Excel Statistical Features. In the analysis, the study employed descriptive statistics and inferential statistics where various variables were described and compared. Descriptive statistics involved measures of central tendency such as the mean and median and measures of dispersion such as the standard deviation. Inferential statistics involved measures of association where the study tested whether there exists an association between two categorical variables.

Ethical Considerations

Ethical approval to conduct the study was obtained from the institutional review board of the involving hospital. Respondents were informed that they were free to join the study and their participation was voluntary. Confidentiality was maintained through the data collection process. All data was safeguarded and protected from unauthorized access. Access to the used computer was protected by a personal password. Individual respondents were not identified in the report.

Results

Principal findings showed the deployment of VCs as follows: a sizeable number of providers were running VCs (n = 186, 67.2%). Among these, 54.3% were females. Saudi and non-Saudis were similarly likely to be running VCs, but there was a visible age slope, with only 18.8% of providers aged 54 years and above running VCs. The study also sought to compare the respondents by their years of experience. It was concluded that 35.7% of the respondents had between 10 and 15 years of experience. Those who had between 5 and 10 years of experience were constituted to 25.6% of the total, and 21.3% had an experience between 0 and 5 years. Those who had >15 years of experience were 17.35% of the total.

The majority of the respondents, 141 (50.9%), were nurses, whereas 88 (31.7%) were physicians. Clinical coordinators and patient educators were both 13, each constituting 4.69%. Pharmacists were 7 (2.53%), whereas the other functional areas constituted 5.42% of the total respondents to the survey. 98.1% of the respondents had started running VCs since the COVID-19 outbreak, with 47.2% running between 51 and 100 VCs per month, and the majority (74%) spent 6–15 min per patient visit.

Chronically ill patients constituted 57.7% of the total population served. Simple common conditions along with medication refills were the top conditions (74.5% and 65.2%, respectively) treated. Almost 95% of the respondents used electronic prescriptions during their VCs. It was noted that 23.4% of the clinics had physicians only who were internally sourced, whereas 70.9% of the clinics had a mixture of physicians, nurses, and coordinators who were also internally sourced. To add on, 4.32% of the clinics had nurses only who were internally sourced. Two clinics outsourced staff through their technology provider, whereas none of the clinics outsourced their staff through a third party.

Most providers (98.1%) used the phone as a means of communication with the patient during virtual consultations. In total, 4.9% of the clinics used videos, 1.24% used chats, 36.02% used texts, and 15.53% used e-mails, while 0.62% used other modalities in their VCs. In total, 75.5% of VCs were integrated with EHRs and patient portals such as appointment scheduling (77.9%). Of interest is that 65.6% of VCs were not supported by a designated virtual care department within the hospital. Out of 55 VCs, 34.5% had a telemedicine division. To add on, 45.4% had ambulatory care division while 1.82% had urgency care division, whereas 1.8% had steering committee divisions and 3.6% had information technology divisions.

This study was also interested in the degree of satisfaction of those involved in VCs. Out of the 160 respondents, 50% indicated that they were very satisfied with the VCs they were involved in, 38.7% indicated that they were satisfied while 9.3% indicated that they were neither satisfied nor dissatisfied. The remaining 1.25% and 0.63% indicated that they were dissatisfied and very dissatisfied, respectively. Furthermore, 13.3% were planning to launch VCs in the next 3 months, 0.9% were planning to launch one in the next 12 months, whereas 7.3% were planning to launch one but did not have a set time limit. However, 11.5% said they had no plans to launch a VC.

Moreover, 82.2% of the respondents indicated that they were planning to expand their VCs, whereas 17.5% indicated that they are not planning to expand after the COVID-19 pandemic. The study also pursued the opinion of the respondents in terms of their idea of the best way to expand their VCs. It was concluded that out of 158 who responded, 80.3% said that adding modes of care such as chat and video would be the best ways to expand. In contrast, 70.8% said that increasing the number of providers would be a strong means to expand, whereas 62.0% said that increasing their capacity for more patients will be the best way to expand.

The major opportunity seen by providers during the COVID-19 pandemic was the reduction of appointment waiting times (73.5%) and the reduction of the costs of delivering care for risk-based populations by lessening the utilization of high-cost care alternatives (65.1%). The major success metric found in VCs was increased patient satisfaction (67.9%).

In contrast, it was noticed that the major challenge faced by providers when running VCs was the lack of face-to-face interaction and physical examination (86.98%). Other challenges were fitting virtual care into provider workflow (46.98%), integrating with existing technology such as electronic medical record (EMR) (43.72%), gaining provider's acceptance (31.6%), and driving patient utilization (28.84%).

Discussion

Virtual care has been well defined as any type of remote communication between patients and/or their providers, utilizing health information technology to ensure the quality and efficiency of patient care.

Respondent Demographics

Our findings on the role of telehealth during the COVID-19 pandemic reflect certain contextual aspects, such as the high rate of use by female providers (54.3%) to ensure the respect for the cultural and social considerations and the comfort of female patients who may be reluctant to conduct a video consult with a male physician, and vice versa. This is what has been concluded in a study that was conducted in Germany on how men differ from women when it comes to the virtual patient–physician relationship.⁶

Saudi and non-Saudis were similarly likely to be offering VCs, but there was a visible age slope, with only 18.8% of providers of age ≥54 years running VCs. This may be partly clarified by the fact that the older age group may be less acquainted with technology and telehealth and unwilling to shift from the traditional clinics as confirmed by previous literature.⁷ This matches our findings on the distribution of deployment of VCs as per years of experience. It was clear that providers who have 10–15 years of experience are those most likely to run VCs, which may reflect that those younger age providers are those most readily implementing this novel technology (Table 1).

Table 1.

Distribution of Usage of Virtual Clinics According to Years of Experience

YEARS OF EXPERIENCE	0–5 YEARS	5–10 YEARS	10–15 YEARS	>15 YEARS	TOTAL
No. using virtual clinic	31	51	72	32	186
Percentage	16.67	27.42	38.71	17.20

Virtual Care Deployment and Operation

Among health organizations and providers, virtual care is growing. Although challenges to implement virtual care still exist, health care systems are progressively launching virtual services.⁴ Research and investigation on how virtual care is implemented in the Saudi health system is an area of opportunity for the health care industry. The respondents consistently showed intentions and expected growth for VCs in the organization.

Our results show that providers in Saudi Arabia have recently begun implementing VCs. The majority (98.2%) of respondents initiated VCs in a 6-month period during the COVID-19 outbreak. There is an opportunity resulting from the COVID-19 pandemic, as the study findings have revealed that 50% of providers running VCs were very satisfied and 38.75% were satisfied, and 82.5% were planning to expand their VC utilization. However, only 20% of providers who were not already running VCs were planning to launch such services in the future with ∼7% of them planning to launch but had no set time frame.

A likely challenge that must be considered with VCs is the essential role of the physical examination in the doctor–patient relationship.⁴ Remarkably, in this study, it was found that 86.9% of providers agreed that physical examination was vital during a clinic session and that this was the main challenge that they faced when conducting the VCs.

Moreover, the major challenge perceived by providers who run VCs and those who do not is the lack of face-to-face interaction (72.4% and 60%, respectively) (Fig. 2). Therefore, they must be deployed cautiously to select patient population such as with chronic conditions and simple conditions in which providers can sufficiently rely on the clinical history of the patient as results show (Tables 2 and 3).

FIG. 2.

Comparison of responses between those who are involved in virtual clinics and those who are not according to its opportunities.

Table 2.

Total Number of Physicians That Have Chosen Chronically Ill Patients

FUNCTIONAL AREA	ONLY CHRONICALLY ILL PATIENTS
Clinical coordinator	2
Nurse	16
Other (please specify)	6
Patient educator	0
Pharmacist	1
Physician	68
Total	93

Table 3.

Total Number of Providers That Have Chosen Simple Common Conditions

FUNCTIONAL AREA	SIMPLE COMMON CONDITIONS
Clinical coordinator	4
Nurse	45
Other (please specify)	4
Patient educator	4
Pharmacist	1
Physician	63
Total	121

As to provider perceptions, the most common advantages of VCs were that it reduced patient travel costs (52.5%), reduced appointment waiting times (73.4%), and offered on-demand convenient virtual care (53.4%). It was notable to mention that although VC was not appropriate for all patients (as video clinics may be unsuitable for very elderly patients without access or capability of the essential technology), it indirectly supported them with their follow-up by reduced waiting times for appointments and facilitated regular appointment bookings as needed and enhanced access by reducing geographical distance.⁸

Patient experience is an important objective and measure of success in any health care organization.⁹ Our results showed that 67.9% of all respondents considered patient satisfaction a major success metric of the VC program. A total of 57.8% of providers who were running VCs agreed with this success metric (Table 4). If VCs were to become sustainable and the standard for routine follow-up care, we expect an increase in the total number of patients examined daily.

Table 4.

Comparison of Responses Between Those Who Are Involved in Virtual Clinics and Those Who Are Not According to Success Metrics

SUCCESS METRICS	NO VIRTUAL CLINIC (%)	YES VIRTUAL CLINIC (%)
Increased patient satisfaction	43.33	57.84
New patient acquisition	14.44	32.97
Reduce clinical work time	37.78	50.81
Ensuring care quality	31.11	43.78
Offering electronic prescription rates	26.67	45.41
Increased provider satisfaction	30.00	48.11

Technology

EMR is still a challenge, with 13.5% of respondents asserting that their VCs did not integrate with the EMR yet, especially as virtual care delivered in clinics is a component of the expanding telehealth strategy. Of those clinics that were integrated with EHRs, 98% of the VCs were done through the phone wherein providers can simultaneously view the EMR of the patient, order laboratories, and book further appointments, and the patients can follow-up on their laboratory tests and reports through the patient portal.

This would confirm what was suggested in the literature about the importance of having a departmental operation strategy plan and a focus on strong leadership in driving virtual care and launching VCs by providing all the necessary components, including technology and building the capacity of the infrastructure to facilitate workflow in virtual consults.⁹ Having a dedicated virtual care operational unit is essential within the organizational structure as respondents stated that only 34.6% of their VCs have designated a VC department responsible for day-to-day operations.

The technology to provide virtual visits is widely available and creates a full-featured workstation, yet, many software options are notoriously unreliable and too difficult for all patients to navigate.¹⁰ System integration was found to be the third challenge as reported by the health care providers (43.27%). The selected software must be made available on any device and integrate with the workflow. Accessible technical support and work flow configurability are key to a successful virtual care program, thus, EMRs used when running VCs must openly support third party software integrations.¹⁰

Hospitals are deploying VCs and utilizing the technology to meet the needs of their varied patient populations and conditions and ensure quality patient care.⁹ VCs are becoming more and more multimodal, with 69 VCs using two modes of communication, and 10 clinics using three modes, and 80% of the providers were planning to add modes of care such as chat and video calls. These are strong findings that offer insights on providers' strategies and confirm that the expansion of VCs is valuable.

Clinical Aspect

Considering how the clinical functions of virtual consultations work in a health care organization and the patient outcomes is vital.¹¹ Our results showed that VCs are allowing providers to shorten patient visits considerably, as most VCs (74%) took between 6 and 15 min, allowing for administrative duties in between patient consultations.

Quality reporting has always been challenging for providers.¹¹ In total, 70.9% of respondents reported that their clinics were internally staffed by physicians, nurses, and/or coordinators. Only 1.2% said that the clinics were staffed by an outsourced technology provider. This raises a question on the quality of communication delivered as well as system integration. For instance, a technology provider might be of importance when it comes to offering a reporting and analytics solution.¹¹

We noted that providers identified as working on less critical cases such as simple conditions were more likely to be offering VCs (n = 121) than those dealing with critical conditions such as acute illness (n = 10). This shows the potential to expand virtual walk-in clinics and virtual consultations. This is consistent with previous literature on how VCs can balance out current patterns of care such as traditional clinics and decrease primary and urgent care visits for patients.¹¹

As much as VCs have the potential to grow during the COVID-19 pandemic, there are still challenges to the deployment as our results show that 47.2% of providers conduct at least 51–100 VCs per month since the beginning of the COVID-19 pandemic.

Fitting virtual care into the provider's practice workflow may be challenging as noticed in the study (46.98%). For virtual visits to be effective, providers must determine how to integrate them into their practice workflow. When setting a schedule to accommodate virtual visits, two key variables must be considered: the range of problems assessed and the number of patient encounters booked well in advance.¹⁰ For example, a community family practice dealing with a wide range of problems and many same day bookings would have to mix virtual visits with in-person encounters. In comparison, a mental health practice could potentially make all their visits virtual.

One of the keys of applying VCs will be increasing providers' acceptance. Organization leaders must first establish their goals for adopting virtual health, asking themselves about the unique value VCs will bring to the care encounter.¹⁰ It is very important for health care leaders to identify what resources the organization will need, and which patients should be targeted. From there, organizations must consider how patient engagement technology will impact providers. Assessing providers' readiness and engagement, technology infrastructure, operations and workflow, and care model design will help organization leadership to cater technology implementation to provider needs and preferences.

From the most technologically savvy to the least technologically savvy health care consumers, interest in telehealth far outpaces utilization in confounding ways. This was reflected in our study as one of the challenges was driving patient's utilization (28.84%). This might be due to the lack of information, access, and a high-quality patient's experience required during these VCs as reported in previous literature.¹⁰

Difference in VC Utilization among the Kingdom

In response to the elevated risk level from the COVID-19 pandemic, various hospitals in Saudi Arabia have accelerated telemedicine health services, offering secure and virtual face-to-face interactions with doctors. Individuals can book their appointments with their hospital's doctors using various communication channels, including mobile applications.¹² However, there is no published articles on the use of VCs in these hospitals up till now.

Johns Hopkins Aramco Healthcare, Dhahran (JHAH), has accelerated the launch of primary care and psychiatric video consultations. Since March, JHAH's primary care physician, Dr. Nisar Ul-Islam Yaseen, and Chief of Psychiatry and Mental Health Services Dr. Abdulsamad Al-Jishi have been connecting with patients using MyChart, the patient portal that is part of the hospital's EMR.¹²

Dr. Yaseen stated: “I found that video visits, when compared to the alternative of a telephone appointment, offer a valuable extra communication modality. By being able to see the patient, you can improve the quality of the clinical assessment. For example, when a patient complained their asthma symptoms were currently troublesome, without being able to see him, I would have asked him to come to the clinic for a fuller physical assessment.”

“But with the video visit, I could see that the patient wasn't in any respiratory distress, looked well and had no difficulty breathing, so I could make a better judgment and develop a more appropriate management plan, which did not require him to attend the hospital.” He added: “Our personal experience so far is very positive, but we will need some time to fully assess the benefit in Saudi culture. With that said, I think it is very promising; I am optimistic that it will be an important option for our patient psychiatric care in the future.”¹²

Furthermore, in line with the precautionary measures to prevent the spread of the novel COVID-19, Bisha Health Affairs has activated the VCs at the developmental and behavioral disorders centers of the Maternity and Children Hospital. The VCs provide psychological counseling, re-dispensing of medicines and video calling. The center, which benefited 80 persons, includes five clinics: developmental disorder diagnostic clinic, speech-language clinic, psychologist clinic, physiotherapy clinic, and occupational therapy clinic.¹³

Implications for Policy and Practice

There were several recommendations for health care organizations to establish an action plan to maintain the efficiency and sustainability of the VCs. Our first recommendation is to encourage the usage of VCs across all ambulatory care clinics during the pandemic to meet the increased demand of patients and cope with the shortages in providers.

Second, we recommend that each specialty or department offers at least 10% of its clinic bookings through VCs to sustain the utilization of VCs even after the pandemic, and maintain the desired standard of clinical care, linking with electronic prescribing of medication, laboratory test ordering, and appointment booking.

Third, it is recommended that health administrators strongly support the deployment of VCs by adding modes of communication especially video calls. This would improve the efficiency of the care delivered and resolve the challenge of the lack of face-to-face interaction.

The fourth recommendation is that organizations set up a designated VC department that would be responsible for the day-to-day operations during VCs and respond promptly to technical issues that providers may face during the VCs such as connection problems and integration with EHRs. VCs should be staffed internally, and the technology provider outsourced to facilitate older age health care providers' acceptance and utilization of telehealth tools.

Conclusions

As the COVID-19 pandemic continues to rage on, the use of telehealth tools is increasingly relevant to meet the increased pressure being placed on health care systems. Telehealth in general and VCs in particular are likely to address many of the challenges to delivering safe quality care during the COVID-19 pandemic. VCs can be a viable solution to avoid direct physical contact and reduce the risk of COVID-19 transmission.

Although patient demand and the need to improve access will guarantee that virtual care will become more common across the Saudi health care system, as such a framework is needed to establish excellence in VCs and consults, and that will sustain quality health service delivery and ensure continuity of care.

Footnotes

Authors' Contributions

The first author designed the study, sought ethical approvals from the relevant entities, developed the data collection instrument in consultation with experts, and collected and analyzed the study data. The second author advised on conceptualization, supervised the analysis of the data, and cowrote the article for submission.

Acknowledgments

The authors acknowledge the support of King Abdullah International Medical Research Center and King Saud Bin Abdul-Aziz University for Health Sciences.

Ethical Statement

The authors declare that they have obtained the required ethical approvals for this body of work, including consent for publication.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Appendix

References

Portnoy

, Waller

, Elliott

. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract, 2020; 8:1489–1491.

Kruse

, Krowski

, Rodriguez

, Tran

, Vela

, Brooks

. Telehealth and patient satisfaction: A systematic review and narrative analysis. BMJ Open, 2017; 7:e016242.

Jones

, Brennan

, Jacques

, Wood

, Dixon

, Radley

. Evaluating the impact of a ‘virtual clinic’ on patient experience, personal and provider costs of care in urinary incontinence: A randomised controlled trial. PLoS One, 2018; 13:e0189174.

Rutherford

, Noray

, Ó HEarráin

, Quinlan

, Hegarty

, Ekpotu

, Arize

, Fabamwo

, Alrubaiaan

, Bhupalan

, Alshehhi

, Power

, Hill

ADK

. Potential benefits and drawbacks of virtual clinics in general surgery: Pilot cross-sectional questionnaire study. JMIR Perioper Med, 2020; 3:e12491.

Bashshur

, Doarn

, Frenk

, Kvedar

, Woolliscroft

. Telemedicine and the COVID-19 pandemic, lessons for the future. Telemed J E Health, 2020; 26:571–573.

Bidmon

, Terlutter

. Gender differences in searching for health information on the internet and the virtual patient-physician relationship in Germany: Exploratory results on how men and women differ and why. J Med Internet Res, 2015; 17:e156.

McGrail

, Ahuja

, Leaver

. Virtual visits and patient-centered care: results of a patient survey and observational study. J Med Internet Res, 2017; 19:e177.

Parish

, Ratnaraj

, Ahmed

. Virtual clinics in the present—a predictor for the future?. Future Healthc J, 2019; 6(Suppl 2):37.

Palen

, Price

, Shetterly

, Wallace

. Comparing virtual consults to traditional consults using an electronic health record: An observational case-control study. BMC Med Inform Decis Mak, 2012; 12:65.

10.

Bokolo Anthony Jnr. Use of telemedicine and virtual care for remote treatment in response to COVID-19 pandemic. J Med Syst, 2020; 44:132.

11.

Webster

. Virtual health care in the era of COVID-19. Lancet, 2020; 395:1180–1181.

12.

Hassan Rashid. Telemedicine on the rise in Saudi Arabia amid pandemic. 2020 . https://www.arabnews.com/node/1666576/saudi-arabia (last accessed January 10, 2020 ).

13.

MOH News—Bisha: Virtual clinics at centers for developmental and behavioral disorders activated. 2020. https://www.moh.gov.sa/en/Ministry/MediaCenter/News/Pages/News-2020-06-04-002.aspx (last accessed December 8, 2020 ).