Perception and Knowledge of Telemedicine Technology in Hispanic Practicing Physicians: Instrument Validation


 Background During the COVID-19 pandemic, multiple countries has taken measures, such as isolation and quarantine to prevent person-to-person spread of disease. This forced many physicians to adopt new techniques to continue patient care, such as telemedicine, that has proven to be useful in continued care of non-COVID 19 pathologies. Different factors influence the perception of telemedicine in medical practitioners such as security, confidentiality, cost-effectiveness issues, comfort, and the risk of malpractice. Methods The original questionnaire included 6 domains with 40 questions, each question was measured with a five-point likert-scale ranging from very high [5] to very low [1]. Consequently, the survey was translated to spanish using machine translation (MT). The translation was reviewed independently and then a consensus was made regarding minor changes in the syntax of the survey to facilitate understanding. After the expert feedback and questionnaire indicators, the research team members proposed to reduce the instrument to 13-items in 4 domains, due similarity of questions. The sample was divided into 2 groups, randomly selected. Results The 382 surveys were collected and separated in two random samples, S1 and S2, (198 and 184 respectively). In exploratory factor analysis (EFA) the 13-items are grouped into the four theoretical domains, item 7 presented cross loading between factors and was removed. Confirmatory factor analysis (CFA) was performed to assess scale reliability and inter scale associations; three models were tested. Conclusions The translated instrument was clear, with adequate internal consistency, readability, and appropriate to be applied in the physician setting. This validated questionnaire made it possible to evaluate the real knowledge of telemedicine in order to increase its use, especially in the COVID-19 pandemic.

in the physician setting. This validated questionnaire made it possible to evaluate the real knowledge of telemedicine in order to increase its use, especially in the COVID-19 pandemic.

Background
The use of information and communication technologies (ICTs) in healthcare has signi cantly changed the physician-patient relationship (1). Telemedicine is the implementation of ICTs to deliver a distance medical care (2). During the COVID-19 pandemic, multiple countries had taken public health measures. Isolation and quarantine were the community containment plan to prevent person-to-person spread of disease (3). This unique situation forced many physicians to adopt new techniques to continue patient care (4). Telemedicine has proven to be a useful tool during the pandemic. As a result, it has been used in the assessment and triage of patients with COVID-19 reducing healthcare load. Nevertheless, it has proven to be useful in continued care of non-COVID-19 pathologies (5)(6)(7).
The adaption to new technologies is generally a process of constant evaluation of costs and bene ts (8). For instance, different factors in uence the perception of medical practitioners such as security, con dentiality, cost-effectiveness issues, comfort, and the risk of malpractice (9). Kuo et al. (2015) described several factors that could induce the intention to adopt use in physicians such as attitude, subjective norm, and perceived behavioral control (10). In addition, telemedicine may reduce costs due to decreased prolonged hospital stays (11).
The appropriate assessment of knowledge and perception of clinicians about telemedicine is essential. Thereby, create a reliable tool that can detect changes in physicians' perceptions about the use of telemedicine in the future (12)(13). The aim of this study was to adapt a validated Spanish version questionnaire of the perception and knowledge of telemedicine in healthcare professionals (9).

Study Design
We followed the STROBE guidelines for observational studies.
The original questionnaire included 6 domains with 40 questions, each question was measured with a ve-point Likert-scale ranging from very high [5] to very low [1] (9). Yang et al. (2018) proposed a model for the adoption of machine translations (MT) (14). Consequently, the survey was translated to spanish using MT. The translation was reviewed independently by every research team member, then a consensus was made regarding minor changes in the syntax of the survey to facilitate understanding.
The translated instrument was converted into a google form survey and was implemented as pilot test among 65 physicians.
The survey objective was to ensure that the redaction, vocabulary, design, and time needed to complete the survey was appropriate enough to prove its stability and comprehension (15).
After the expert feedback and questionnaire indicators, the research team members proposed to reduce the instrument to 13items in 4 domains, due similarity of questions. In the same way were excluded questions that could not be used due to differences in administrative characteristics (budget management, conferences, trainings or guidelines).
Sample size was determined by multiplying the number of questions (13 items) by 5 (lower limit) and 20 (upper limit), as proposed by Suhr (2005) and other studies of validation in Ecuadorian population (16)(17)(18). The total sample was 65 to 250 doctors.
Eligibility criteria included physicians from private and public services with an active medical/clinical practice. The questionnaire was answered by 404 participants and 22 of them were excluded because they did not belong to the Ecuadorian population. The sample was divided into 2 groups, randomly selected. The rst group consisted of 198 doctors for sample 1 (S1) to perform exploratory factor analysis (EFA). The second group included 184 doctors for sample 2 (S2) for con rmatory factor analysis (CFA).

Statistical Analysis
Descriptive Analyze A descriptive statistical analysis was implemented for sociodemographic data. Descriptive variables were presented as frequencies and percentages, and quantitative variables as means and standard deviations. The perception of each aspect of telemedicine was represented by mean response value in the corresponding group of questions. Age, gender, educational level, and area information were used as independent variables on each analysis.

Psychometric Analysis
The Kaiser-Meyer-Olkin (KMO) measure was calculated to evaluate the sampling adequacy of each item on the anti-image of the correlation matrix (19). All sampling measure cutoff points were set at 0.5 to be considered acceptable (19). Bartlett's test of sphericity indicated suitability for analysis being relevant to the scale (20). Commonality analysis was performed and after this procedure the questionnaire was reduced to ensure construct parsimony and usability.
The scale structure was determined by several indicators. Initially, eigenvalues were extracted. A factor structure with eigenvalues above 1 were selected as candidate for EFA. Maximum likelihood estimation (MLE) was performed. Therefore, MLE supported the reduction of the instrument in 4 domains, according to the model t test. The chi square showed a nonsigni cant result, supporting the MLE.
The internal consistency was calculated by Cronbach's alpha for both, the full scale and for each of the subscales found in EFA. Cronbach's alpha measures the interrelation of the items, with values ranging between 0 and 1 (21). The results were considered acceptable above the threshold of > 0.7.

Readability
Fernandez-Huerta index and Crawford were used to assess readability and estimate grade level, respectively. Scores were reported (range 0-100), higher results indicated greater readability, and a result of 60-70 represented an easy understanding for the population of ~ 15 years old (24).

Results
The 382 surveys were collected and separated in two random samples, S1 and S2, (198 and 184 respectively). EFA was performed in S1. Sociodemographic characteristics of the sample were presented in table 1 and showed that 110 (55.6%) of doctors had 20 years of experience. Additionally, 60 (30.5%) of all doctors worked in hospitals, 174 (87.9%) of them had permanent employment, and 41 (20.7%) worked in primary care (see Table 1) Exploratory factor analysis In EFA the 13-items are grouped into the four theoretical domains, item 7 presented cross loading between factors and was removed. However, item removal at this stage did not improve reliability statistics (see Table 2). From the original instrument, the domains that remained were "Knowledge about telemedicine", "Perception of the utility of telemedicine", "Perception of the disadvantages of telemedicine", and "Knowledge of the security of telemedicine".
Global Cronbach's alpha for internal consistency was 0.76. Con rmatory factor analysis.
CFA was performed to assess scale reliability and inter scale associations. Three models (M1, M2, M3) were tested, establishing that the questionnaire had greater reliability (see Table 3). The removal of item 7 at this stage provided the best goodness of t measures as a result from the nal model. Goodness of t measures were recorded in table 4 (see Table 4). Figure 1 shows the results for model 3 with RMSEA (0.009) and CFI (0.999) (see Figure 1).   (25). These results indicated that these items were likely to be understandable by a typical 14-15-year-old individual and required a minimum of six years of schooling, respectively.

Discussion
The result of this validation study achieved a slim, and reliable instrument. The present results can be used to rapidly assess the perception towards a new technology backed up by data derived from a large cohort of medical practitioners. Several studies concluded that the length of the questionnaires had an inverse relation with their response rate (26)(27). Although, due to the short amount of time available for physicians, the survey offered a shorter and feasible model.
The digital transformation of medicine had enabled new ways to improve communication between patients and physicians.
However, they had negative perceptions about their use. Misleading a diagnosis or how their patient's information security can be compromised were some of them (28)(29). The knowledge about new technologies is an important key to identify negative.
In consequence, healthcare professionals will have to learn and adapt their tool communication and technology for better results.
Evidence reported that MT can be very useful to the scienti c literature for reliability measures of an instrument (30). The question syntax was simple enough to be rapidly translated to a different language with acceptable results. In addition, participant characteristics and sample size ensure that this instrument was appropriate for validation. Another strength of the validation was the heterogeneity of the sample, with different medical specialties responding to the questionnaire. There were some limitations of our study that need to be discussed. First, our population covered only Ecuadorian physicians, and the sample may not be representative in other Hispanic countries. Second, we used only 4 of the 6 domains of the original version. Nevertheless, we had a robust methodology to con rm validation of our survey.
The original survey compiled 6 characteristics domains towards the population and was validated using face and content validity methods. The reliability of the original questionnaire reported a Cronbach's alpha coe cient of 0.73 (9). Additionally, our instrument exhibited an acceptable KMO test, a signi cant Bartlett, and explained the variance of the 4 dimensions with a strong signi cant association. Furthermore, our questionnaire in comparison with the original one had some other statistical tests such as chi square, RMSEA, TLI, NFI, PNFI, CFI, and PCFI indicating goodness of t.

Conclusions
Our study provided a translated and validated questionnaire to evaluate physician knowledge and perception of telemedicine. The translated instrument was clear, with adequate internal consistency, readability, and appropriate to be applied in the physician setting.
After performing the CFA, it was possible to obtain the 12 items grouped into the four theoretical domains.
It was essential to identify the di culties medical doctors have to adapt themselves to new technologies. This validated questionnaire made it possible to evaluate the real knowledge of telemedicine in order to increase its use, especially in the COVID-19 pandemic.

Availability of data
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no con ict of interest.

Funding
The funds for the development of this research where given by Universidad de Especialidades Espíritu Santo.

Authors contributions
ICO and GA coordinated the study. The design, acquisition, analysis, and interpretation of data was performed with substantial contributions from all participating authors. CV, CKY and NSP drafted the manuscript. The statistical analysis was performed by GA and CV. All authors contributed to edited drafts of this manuscript. All authors read and approved the nal version of the manuscript. Proposedinstrument.docx