An Assessment of the Knowledge and Practice of Telemedicine Among Medical Doctors in University of Nigeria Teaching Hospital (UNTH), Ituku-ozalla, Enugu State, Nigeria


 Background: The outbreak of the novel SARS-COV-2 virus, created a paradigm shift in the practice of medicine, a speciality well known for its integration of clinical expertise and manual dexterity in the management of its patients. Telemedicine, a previously less conventional approach in developing countries, has now come to the forefront of patient care. This study assessed the knowledge and practice of telemedicine among doctors in the University of Nigeria Teaching Hospital, Ituku-Ozalla in Enugu state.Methodology: A questionnaire-based survey was used to obtain relevant information among 149 doctors in the University of Nigeria Teaching Hospital (UNTH), including their knowledge and awareness of telemedicine, its relevance and impact on the clinical outcomes of patients as well as factors limiting its use. Data was analyzed and presented in tables, graphs and pie charts.Results: There were 149 doctors, who were mostly aged 15 – 30 years (63%). Most 146 (98%) have heard about telemedicine but only 100 (67.3%) have consulted using telemedicine. Doctors were more likely to employ telemedical consultation for follow-up and emergency scenarios but least likely to use telemedicine for first-time visits and the management of chronic diseases.Conclusion: There is a good knowledge of telemedicine among medical doctors in UNTH but ICT illiteracy, inadequate patient-doctor interaction, patients’ preference, lack of internet access, high cost of set-up and maintenance and ethical issues were some of the factors limiting its practice.


Background
Accessing health care services in Nigeria is embattled by a myriad of problems like dilapidated and poorly equipped health care centres, insu cient medical personnel who are poorly remunerated, unviable road networks and poor funding. Therefore, any innovative solution that connects health care professionals to patients in the shortest period, reduces costs and improves clinical outcomes will markedly improve the quality of life of Nigerians. Telemedicine has been shown to close the gap of barriers that limits access to health care services in both developed and developing countries. As the rst electrical telecommunication tool in the history of humanity, the telegraph was rst used for medical purposes (teleconsultation) in Australia in 1874. [1] Thomas Bird was the rst to formally de ne telemedicine as "the practice of medicine without the usual physician-patient confrontation. … (via an interactive audio-video communications system." [2] The World Health Organization de nes telemedicine as the delivery of health care services, where distance is a critical factor, by all health care professionals using Information and Communication Technologies for the exchange of valid information for the diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care provider, all in the interests of advancing the health of individuals and their communities. [3] The essence of telemedicine is to cut down promptly deaths, morbidity or unproductivity resulting from inaccessibility to specialist care, inaccurate or slow patient information transmission and the use of alternative but harmful healthcare which sometimes involve self-medication, quackery and herbal concoctions. In 2015, the Federal Ministry of Health and Federal Ministry of Communications Technology jointly developed the National Health Information and Communications Technology (Health ICT) Strategic Framework which articulates the collective vision and necessary actions of stakeholders involved in the health system in Nigeria. It encompasses three phases: phase one (set-up), phase two (deploy, maintain and support) and phase three (consolidate and continuous review) to leverage current and future ICT investments to build an integrated national health information infrastructure and enable universal health coverage by 2020. [4] Its implementation was projected to achieve this through: improved access to health services through the effective use of telemedicine and other information and communication technologies for health worker training and support; improved coverage of health services as well as tracking demand and supply of health services and commodities; increased uptake of health services through the effective use of mobile messaging and cash transfer incentives for demand creation; improved quality of care through the effective use of information and communication technologies for decision support within the continuum of care; increased nancial coverage for health care services through the effective use of Information and communication technology for the National Health Insurance Scheme and other healthrelated nancial transactions and increased equity in access to and quality of health services, information and nancing through the effective use of information and communication technologies for delivering appropriate health services for those who need them. Currently, there are no updates as to the successful outcome or otherwise of these resolutions.
The emergence of the deadly COVID-19 has further reduced the need for physical contact between health caregivers and patients who encountered di culties in communicating due to the physical distance, mask, personal protective equipment and often did not understand the instructions given by the doctors. [5] Therefore, maintaining an optimal telemedical service delivery requires a fast, and uninterrupted internet service since most telemedicine services involve medical data processing, retrieval of up-to-date information and real-time communication between patients and experts. In 2020, UNTH entered a partnership with the Federal Ministry of Health to introduce telemedicine hospital response services which will enable regular patients dial-in to access critical health information and consultations with medical practitioners. [6] Physician's knowledge, attitude and acceptance are considered some of the main challenges for telemedicine [7] while poor internet connection, lack of education about telemedicine, instability of basic infrastructure with special emphasis on the electric supply in Africa top the ladder of challenges faced by African countries in the establishment of a good telemedical network. [8] A study revealed that about 75% of telemedicine projects in developed countries and 90% in developing countries are abandoned or fail outrightly. [9] In Nigeria, this hesitancy in the full implementation of telemedicine has been linked to the lack of a national telemedicine policy and regulatory bodies as well as low internet connectivity, the initial huge start-up cost of information and communication technology infrastructure and malpractice-related issues.
Objectives Of The Study 1. General Objective: To assess the knowledge and practice of telemedicine by medical doctors in the University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu.
2. Speci c Objectives: a. To determine the level of telemedicine services/systems available at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu.
b. To ascertain the quality of care delivered using telemedicine in this hospital.
c. To evaluate the clinical outcomes associated with the practice of telemedicine in this hospital.
d. To identify the factors that limit the complete adoption of telemedicine in this hospital.

Methodology
Study area: This study was carried out at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State. A major referral centre for hospitals within South-East Nigeria. It provides in-patient and out-patient services to its clients and offers both emergency and long-term health care to residents of Enugu and its environs. It is located along Enugu-Port Harcourt expressway, 21 kilometres from Enugu capital city and occupies an area of about 747 acres. [10] It has been in existence for over 50 years.
Enugu is the largest state by landmass in the South-East geopolitical zone. [11] It lies between 6°27′10″N 7°30′40″E / 6.45278°N 7.51111°E / 6.45278; 7.51111 and has an estimated population of 4,411,119 in 2016 [12] with an annual growth rate of 2.8% and a density of 1,300 per km 2 .
The study duration was between July and August 2021. Using N ( nal) = n/ (1 + n/N) for a study with a sample population < 10,000 Where, N = estimated total of the population N = 556 (Number of doctors working in UNTH) [14] N ( nal) = 239/ 1 + (239/556) Minimum sample size will be 167.
A 10% allowance for non-responders = 17 The Sample size for the study will be 184.
Due to scarcity of resources, a convenience sampling was done to include 150 doctors. One doctor declined consent hence, data from 149 doctors was analyzed.
Data collection methods: Data was collected using a self-administered questionnaire. It was adapted using a Likert-type scale with items answered on a ve-point scale and telemedicine assessment tools such as Technology Acceptance Model and Telehealth Usability Questionnaire. Brief questionnaires are preferable to improve response rates as studies using long questionnaires based on Technology Acceptance Model have reported low response rates. [15] The questionnaire had ve sections comprising of socio-demographic and socio-economic characteristics of participants, awareness of telemedicine and source of information, perception and practice of telemedicine, factors limiting telemedical practice and recommendations for rectifying identi ed factors.

Results
After collection, the data was analyzed and presented in tables, graphs and pie charts. Then, conclusions were drawn from it.
Age: Most of the respondents were between the ages of 15 and 30 (63%). Channels of telemedicine delivery: Most respondents (68%) deliver telemedical services using phone consultations.
Most participants volunteered that telemedicine services available at the hospital were essentially more of interactive sessions (65.1%) than of remote monitoring (25.6%) and storing-and-forwarding (9.3%).

Conclusion
There is a good knowledge of telemedicine (98%) among doctors practising at the University of Nigeria Teaching Hospital (UNTH), although only about 67.3% have consulted using telemedicine. In keeping with the objectives of this study, the quality of care delivered using telemedicine received a good rating and remarkably improved the clinical outcome of their patients by ensuring that patients are included in decision making, exposure to infectious diseases are minimized, cost of accessing medical care is reduced and continuity of care is promoted. Our results correspond with another study [16] that telemedicine cannot replace personal medical care in all cases, especially in severe or unstable conditions or whenever the physician's examination is needed. Most of the doctors admitted that they understood the advantages and disadvantages of telemedicine but a profound demerit of telemedicine from our study is that it does not allow the healthcare provider to see more patients. This could be attributed to technicalities from the machinery, the longer time required to effectively communicate by both parties and the unstable and often, chaotic internet connectivity.
Therefore, to achieve a telemedicine system in Nigeria that meets the high standards of conventional medicine, telecommunication bodies, public and private organizations must collaborate to ensure a seamless telemedicine service. Also, proper legal framework and guidelines must be laid down by appropriate bodies and government agencies because telemedicine encompasses general legal matters like data protection, consent, informed consent, privacy, medical negligence, contracts, medical ethics and more speci c medico-legal concerns like e-advising, e-consultation, e-prescribing, e-dispensing and econsent [17] because transmitting patient les via the internet threatens patient privacy. [18] These should be addressed by formulating a national telemedicine policy or at least, revisiting and updating previous policies, incorporating telemedicine services in the National Health Insurance Scheme and addressing the ethical concerns of healthcare professionals and patients through a vetting process that checks and eliminates substandard health practices.

Declarations
Ethics approval and consent to participate: Ethical clearance was not obtained from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital before the research was conducted because the researcher felt it was a simple questionnaire survey.
Consent for publication: Participation was voluntary, and the purpose of the research was explained to each respondent. Informed consent was obtained before inclusion into the study. However, anonymity of participants was ensured, and no personal information was collected during the survey.
Availability of data and material: Additional data from the research project could be made available by the author on request.