Proposal:

Implementing a Telemedicine Program for Rural

Areas in Saudi Arabia

Prepared by Mohamed Alkherb

For any questions, please email: arealeader@gmail.com

Outlines
I. Background
II. Benefits of Telemedicine
III. Barriers to Health Care Access:
A. Transportation
B. Distance
C. Regional variations & Rural and urban areas inequalities
D. Other barriers in rural areas
IV. The Proposed Program:
A. Step 1: Defining the proposal
B. Step 2: Identifying the causes
C. Step 3: Prioritizing the causes
D. Step 4: Deciding the program services
E. Step 5: Designing the program
F. Step 6: Implementing Security and Privacy measurements
G. Step 7: Program Maintenance
V. Challenges and Solutions of the Program
VI. Recommendation
VII.
Conclusion

Background:
The use of telemedicine was facilitated when the telephone was
invented in the nineteenth century. In 1906, Einthoven transmitted
electrocardiogram (ECG) tracing via telephone lines, which is one of
the earliest recorded utilization of information communication
technology in telemedicine (Hjelm & Julius, 2005). By the 1930s,
specialist medical centers received medical information that were
transmitted from remote regions of Australia and Alaska. Advances in
television and video conferencing resulted in the adoption of

telemedicine in consultations and patient monitoring with the invention

of the television in the 1950s (Murphy & Bird, 1974).
In 1960s, National Aeronautics and Space Administration (NASA)
implemented and used modern telemedicine during manned space
flights for remote physiological monitoring of astronauts, which is
perhaps the earliest utilization of modern telemedicine (Zundel, 1996).
NASA continued to develop telemedicine solutions with the
development of the Space Technology Applied to Rural Papago
Advanced Health Care (SARPAHC) project conducted in Arizona, USA, in
1972. This STARPAHC project used a van that is equipped with an X-ray
machine and other medical devices as well as two employed
paramedics. This van was connected by two-way microwave
transmission to the Public Health Service Hospital that is linked by a
clinic in a different area, which has a physician assistant linked to the
control center in the hospital (Freiburger, Holcomb, & Piper, 2007).
NASA also established the first international program to use
telemedicine after the 1988 earthquake disaster in Armenia, which is
known as the Spacebridge to Armenia that enabled interactive
telemedicine consultation between healthcare centers in the United
States and Armenia (Doarn & Merrell, 2011). By the 1970s, a research
studying the reliability of telemedicine via satellite communication to
26 sites in Alaska, USA was funded by the National library of Medicine.
With the continuous improvements in telecommunications technology,
3

there were advances in network infrastructure that contributed to

enable the development of high-definition real-time interactive videoconferencing networks such as LiveCity project. These resulted to
increased research since the 1990s and increased use in telemedicine
during the past 40 to 50 years (Mencl et al., 2013).
It is not surprising that interest in the utilization of telemedicine
is growing with increasing access to high-speed technology and a vast
number of reports of success with different models ("Canadian
Telehealth Report," 2013; Rada, 2015). However, for over 40 years
being around, the making use of telemedicine has been slow. The
major barriers to its implementation have included issues regarding
privacy, logistics, cost, reimbursement, and insufficient evidence
supporting its use (Rada, 2015; Sikka N, 2014).
Benefits of Telemedicine:
Telemedicine can be divided into three main categories for
application. The first category concerns patient monitoring or home
care that allows healthcare providers to remotely monitor patients by
utilizing several technological devices, such as heart rate monitors. It is
mainly used to manage chronic diseases such as diabetes and heart
diseases. The second one consists of applications that allow interactive
or real-time communication technologies delivered using internet
between users. This includes teleconsultation, video-conferencing,

telerehabilitation, and similar applications. The third category consists

of store-and-forward applications that may not include real-time
interaction. This allows health care providers use technologies such as
teleradiology or telepathology to remotely receive medical data such
as medical images and lab results for assessment ("American
Telemedicine Association. Telemedicine/Telehealth Terminology.," ;
Sachpazidis, 2008).
The importance of telemedicine is increasing, whether for
distance diagnosis or intervention. There are many advantages in the
diagnostic use of telemedicine. It offers the expertise and specialized
care to remote population, it reduces overcall costs and waiting times
of preclinical and clinical examination, and it enables the performance
of accurate screening. Diagnostic telemedicine is heavily relied on in
some clinical specialties such as cardiology (Postuma & Loewen, 2005).
In addition, other applications are used. For example, telemedicine can
be used to accurately diagnose and treat skin diseases occurring at
sea and needs immediate care (Lucas, Boniface, & Hite, 2010).
In rural areas, telemedicine has many potential applications. One
way is that it provides the ability to access a healthcare provider
remotely, and this improves access to health care for patients who
have difficulties to travel long distances to receive the same care. In
addition, it delivers care to patients who would forego care because of
some reasons such as lack of transportation resources. Furthermore,
5

telemedicine can provide an effective alternative for appointments that

do not require physical presence. If the quality of provided care is the
same as the quality of services provided in cities, cost and burden are
saved for patients (HRSA, 2015).
Barriers to Health Care Access:
Even though access to healthcare is known internationally as a
major human right (Grad, 2003), many areas still experience
inadequate population access to health care services (Armstrong,
Gillespie, Leeder, Rubin, & Russell, 2007; Joyce, McNeil, & Stoelwinder,
2006). Globally, rural areas and remote communities are usually known
to be the most highlighted groups who need health care because of
their usual poor health status (Saihw, 2015), face many access
obstacles to health care services. For many rural and remote
populations around the world, the most critical issue is access to health
care due to several barriers (Strasser, 2003).
In Saudi Arabia, geographical barriers to access health care
services may include three identified aspects: transportation, regional
variations, and inequalities between rural and urban areas. Several
actions should be made to mitigate the costs, reduce/eliminate travel
burden, or ensure the availability of healthcare facilities (Kronfol,
2015).
Transportation:
6

Transportation can be an important issue for people who rely on

public transportation, such as the Saudi bus network, to access
healthcare. In particular, this is a major issue in rural areas.
Furthermore, people with disabilities need more assistance to arrive at
health care centers (Manfred Huber & Elisabeth Jelfs, 2008). Costs of
transportations, availability of buses, and the ease of boarding in some
areas can be a concern for some people. This is an issue especially for
the older population (Foster, Dale, & Jessopp, 2001; Stark, Reay, &
Shiroyama, 2002).
Distance:
Another barrier to access health care is distance (Smith & Peter,
1998). This is an issue including transportation arrangement, and if the
health care clinic have early closing hours, which may be a barrier for
people (Dixon-Woods et al., 2006; Smith & Peter, 1998). Distance have
an impact on preventive services such as screening, which appears to
greater issue than curative treatments, particularly where follow-up
treatments are needed (Haynes, 2003; Smith & Peter, 1998). In the
more disadvantaged groups, it should be noted that car ownership is
limited.
People with disability have very specific needs to access health
care facilities and access to information (Dixon-Woods et al., 2006). For
example, in some scenarios it is important to guarantee that health

care facilities are easily accessible for patients on wheelchairs, or that

leaflets or other sources of information are available in convenient
formats for people with visual impairments (Kronfol, 2015).
Regional variations & Rural and urban areas inequalities:
Rural and urban areas inequalities in access to health care
facilities are an imperative issue. This is especially because rural areas
often have a more fragile economic and demographic situation
compared to urban areas, with more poverty and social isolation risks
for people living in rural areas (Boutayeb & Helmert, 2011).
Furthermore, it has been shown that some people who live in rural
areas may have health beliefs that may result in late appearance and
delay early treatments with health care facilities (Boutayeb & Serghini,
2006).
Other barriers in rural areas:
Other small research have studied patient satisfaction with
health care facilities and services in Saudi Arabia. These studies were
mainly focused on the primary healthcare centers of the Saudi Ministry
of Health. Among those studies, most of them concluded a high
percent of patient dissatisfaction. The main negative factors that
mostly impacting patients satisfaction were regarding facility
characteristics, including distance travelled, lack of specialty clinics,
confidentiality measures, facility working hours, waiting time, and
8

waiting area structure. As for staff characteristics, most issues include

surgeons services, language barriers and communication about health
status with physicians. As of patients characteristics, females and the
educated patients appear to be more satisfied than males and more
educated users, respectively (Al-Doghaither, 2005; Ali & Mahmoud,
1993; Haran, 1999).

Step 1: Define stage:

Domain:
The total population of Saudi Arabia is over 30 million, with around 5
million of them living in rural areas (Geohive, 2015). There are 270
hospitals; most of them resides in the large cities such as Riyadh
(MOH, 2014).
Problem statement:
In the past years, many patients in rural areas in Saudi Arabia are
facing increasing need for quality healthcare at a time when access is
difficult. In addition, physicians and other healthcare providers who
work in rural areas are not qualified enough to properly diagnose some
9

advance illnesses. As a result, the patients satisfaction rate has been

significantly declined (Al-Doghaither, 2005; Ali & Mahmoud, 1993;
Haran, 1999).
Goal statement:
Provides a solution to enable patients who live in rural areas in Saudi
Arabia to easily access healthcare services, receive accurate diagnosis,
and high-quality health care services. The objective is to increase
patients satisfaction rate by eliminating or mitigating the problem.
Step 2: Identifying the causes:
Figure 1 is a visualization tool was used to identify the root causes
that led to high patients dissatisfaction rate. This tool is typically used
in Six Sigma methodology to summarize the potential causes for a
problem and make it easy to brainstorm or organize the reasons that
led to an effect. Although this project is not directly related to Six
Sigma, it is utilized here to analyze and find out the possible root
causes of the patients dissatisfaction and put them into categories.
Figure 1 shows the brainstormed factors and barriers that led to
patients dissatisfaction rate in rural areas in Saudi Arabia. The main
skeleton consists of four major categories 1) human (such as service
provider and patients), 2) organization (such as clinic or hospital), 3)
material (such as cars, equipment and supplies), and environment

10

(such as nature and weather). Each one of these categories has the
causes that is can be listed under this category.
Figure 1: Developed Fishbone diagram:

Category: Human

Lack

of

specialty:

some

physicians

and

other

healthcare

providers are not specialized in in an area of care or are not

board certificated.

11

Limited experience: some physicians may lack the necessary

work experience.
Limited education:

some

physicians

and

other

healthcare

providers may not be qualified enough to treat advanced

illnesses.
Language barriers: patients may be unable to express their
health status clearly or do not understand physicians due to
accents or languages.

Category: Organization

Lack of clinics: some rural areas do not have healthcare centers

or very limited clinics.

Limited working hours: healthcare providers may not be available

in both shifts.
Workforce shortages: most healthcare facilities are understaffed.
Long schedule time: patients wait for unreasonable time to see
their physicians.

Category: Material:

Limited medical equipment: physicians need advanced

equipment to analyze data.

Limited IT equipment: there may be a lack of computers.
Absence of EHR: patients may find difficulties to share their
health records due to missing papers or not implementation of

electronic health records system.

Lack of transportations: patients may be unable to transport to
clinic.

12

Category: Environment

Distance: clinics may not be available to travel within a

reasonable distance.
Rough roads: the roads in rural areas may not be suitable for

patients to travel.
Extreme weather: summer can be a barrier due to extreme hot
weather in Saudi Arabia

Step 3: Prioritizing the causes:

After identifying the potential causes of the high patients
dissatisfaction rate, the next step is to prioritize the causes of the
problem. Because each cause may not be as important as others, it is
important to conduct an assessment for the causes to know the
importance of each one. This will allow us to focus the majority of time
and effort on the most important issues.
A methodology that is typically used to conduct Risk Assessment in
organizations is utilized here to prioritize the causes. This methodology
considers two factors to determine the priority rating: impact level and
probability (or likelihood). In this assessment, numbers are used to
express the level of each factor. Figure 2 shows the meaning of each
number that will be used in the assessment:
Figure 2: Impact level and probability rates explanation:
Impact level (Consequences)
3. Highly prevents access to

Probability (Likelihood)
3. Very Likely
13

healthcare
2. Somehow prevents access
healthcare
1. Do not prevent access
healthcare

2. Likely
1. Unlikely

To determine the priority rate, a formula will be used:

Impact level x Probability = Priority rate
Figure 3 shows the priority rate descriptions after applying the formula:
Figure 3: Priority rate explanation:
Priority rate
6 to 9 (High)
3 to 5
(Medium)
1 to 2 (Low)

Description
Solving the cause is very important.
Solving the cause is important.
Solving the cause is preferred.

In figure 4, the identified causes will be filled in a table and

analyze each cause individually to rate the priority. In addition, it will
be organized based on the calculated priority rate. This table is based
on research and literature. The impact of each issue has been analyzed
individually with two questions. What is the impact this issue has done
to the patients based on the research and literature? Is it possible that
it could prevent them from accessing health care? If yes, to what
extent? These questions led to the impact score. To analyze the
probability, a question has been asked. What is the likelihood of this
impact to occur? Does it happen frequently, occasionally, or rarely?
Answering this question led to the probability scores. Both impact level
14

scores and probability scores have been distributed in Figure 4 based

on research and literature.
Figure 4: Developed Impact level, probability, and
calculated priority rates based on research and literature:
Issue

Human:
Lack of specialty
Limited experience
Limited education
Language barriers
Organization:
Lack of clinics
Limited working hours
Long schedule time
Workforce shortages
Material:
Lack of transportation
Absence of EHR
Limited medical
equipment
Limited IT equipment
Environment:
Long distance
Rough roads
Extreme weather

Impact level
(1-3)

Probability
(1-3)

Priority Rating
(Impact x
Probability)

3
2
2
1

3
3
3
2

9 (High)
6 (High)
6 (High)
2 (Low)

3
2
1
1

3
2
2
2

9 (High)
4 (Medium)
2 (Low)
2 (Low)

3
3
2

3
3
2

9 (High)
9 (High)
4 (Medium)

4 (Medium)

3
1
1

3
2
2

9 (High)
2 (Low)
2 (Low)

Step 4: Deciding the program services:

Based on the found priority rates in Figure 4, a telemedicine
program will be developed to be used in rural areas in Saudi Arabia
and to addresses the identified causes accordingly in order to provide
better healthcare and receive improved patient satisfactions in these
areas.

15

The proposed telemedicine program will deliver health care service

at home. An ambulatory car will be equipped with IT and network
equipment. This car will use a Satellite connection because even if the
area does not have broadband internet, the healthcare provider will
still be able to connect via satellite, regardless if there are
implemented cables or not. This car will reach patients in need to these
services at home and deliver them. A trained healthcare provider will
assist the patient, gather the data, and connect the patient to the
proper physician. The physician will remotely provide treatment and/or
consultations to the patient and document the visit. The benefits of the
proposed program include:
Offered services:

Provides healthcare in rural areas even if clinics may not be

available.
Access to specialized healthcare services and consultations to

patients.
Patients will not travel, and will receive healthcare services at

home.
If needed, translator will be available for communication with

physician.
Data will be analyzed with advanced medical equipment in a

timely manner.
Access to national Electronic Health Record system will be
available.

16

The program will use interactive video-conferencing technology

to deliver healthcare services.

The program will provide training skills for maintenance.
The program is reliable, secure and deliver a user-friendly
experience.

Impact:

Improved access to healthcare & specialists.

Increased patient satisfaction with care
Improved health status of the population in rural areas.
Improved health related quality of life.
Reduction in emergency room utilization.
Improved clinical outcomes
Reduction in workload for healthcare centers in the surrounding

areas.
Cost savings.

Step 5: Designing the program:

After deciding the services the program will offer and providing
the impact of these services, the next step is to identify the project
cycle, including requirements, activities, and the outcomes. Again, a
tool called SIPOC is adopted from Six Sigma methodology and
adjusted for this program and used here to design the process map.
A SIPOC diagram is a tool used to identify all relevant elements
of a process development project before work begins. Figure 5
shows the developed SIPOC diagram for this proposed telemedicine
program. The input represents the requirements that is used before
the process starts. The activities briefly show the process of this
17

project. The output shows what are the products of this process
Finally, the outcome shows what are effects of these products.
Figure 5: Developed SIPOC Tool:

After identifying all the relevant elements for this telemedicine

program and developing the SIPOC diagram (Figure 5), a detailed
technical workflow diagram is needed. This detailed workflow diagram
is needed to show the internal process of the proposed telemedicine
program. Therefore, Figure 6 has been developed to provide this
technical map.

18

Figure 6 shows the developed internal workflow of this proposed

telemedicine program. The following steps are shown:

Level 1 care: The ambulatory car uses satellite network to

connect. It is equipped with IT infrastructure & network,
medical equipment, a healthcare provider and patient. This
ambulatory car is linked to the closest primary care facility,
which includes a physician and equipped with IT infrastructure
& network. Both of the car and primary care facility are
connected to the same network and Electronic Health Records

system.
Level 2 care: If the physician was unable to diagnose the
patient due to limited qualifications, the primary care facility
will proceed to level 2 care, which transfers the connection to
a regional hospital, which has several physicians and

healthcare providers.
Level 3 care: If the regional hospital was unable to diagnose
the patient and required specialized care, then the hospital
will proceed to level 3 care, which transfers the patient to a
specialty hospital. This specialty hospital is also connected to
several other specialty hospitals in order to continue the cycle
until a qualified physician virtually meets the patient. All the
linked hospitals in this program are connected to the same
satellite network and Electronic Health Records system.

19

Figure 6: Developed internal workflow for the proposed

telemedicine program for rural areas in Saudi Arabia:

Step 6: Implementing Security and Privacy measurements:

The proposed telemedicine program is HIPAA compliance:
Although Saudi Arabia does not have security and privacy law for
health information (at least for now), the proposed program is in
compliance with HIPAA law in order to demonstrate a high privacy and
security level for this program. Patients privacy is in top priorities and
20

all the conversations are fully secured and confidential. The highlighted
areas in the Privacy Policy of the proposed program could be
summarized as following:

A detailed consent will be provided prior conversations.

No other entity will be able to access the conversation between

patient and therapist.

The conversation will not be recorded or retained.

The conversation will not be shared with non-covered entities.

Stored ePHI will not be shared with non-covered entities.

The conversation and ePHI are fully encrypted at-rest and intransit with strong encryption algorithm.

More detailed policies are included as well to protect patients

security and privacy.

Step 7: Program Maintenance:

In order to ensure program usability, a training program will be
developed for the health care professional. This training program will
provide healthcare providers who work in the ambulatory cars with the
necessary skills to operate, maintain, and troubleshoot the system. If
the interactive video-conferencing between the patient and physician
interrupted for some reason, the healthcare provider will be able to fix

21

the issue. In addition, the program will include basic troubleshooting

help, answers to frequently asked questions, and a phone number for
technical support department in case if any additional help is needed.
To evaluate usability, a basic survey will completed by both the
patients and the discharging healthcare providers. This survey will
evaluate patients satisfaction rate and evaluate whether it meets the
causes assessment and goal statement provided in the previous steps
of this project.
If the survey result did not meet the desired objectives, the
product will be sent to the quality management department where
they can start the refinement process. They will identify, measure,
analyze, improve, and control the products process and generate a
report to apply their work. This report will be passed to several
departments for approval and make sure that it addressed the issues
facing the patients.
Challenges and Solutions of the Program:
Despite the advantages of the proposed telemedicine program, it
does have some limitations. The healthcare provider will not be able to
conduct a physical exam on the patient. Therefore, it limits the ability
to assess the patients health status. In addition, the satellite internet
may not be perfect for use all the time. Some areas may experience
interruptions due some factors such as conflicted signals with other
22

devices or inappropriate weather. Finally, the patient may not be used

to this technology and may not accept a treatment from distance.
As stated in the previous steps, the program will provide
solutions to mitigate these issues. The proposed telemedicine system
is extensible. The ambulatory car has medical equipment connected in
it. Some medical equipment will be connected to the computer via USB
or Bluetooth, others will be used by the healthcare provider in car to
assist the patient. In addition, the gathered data will be shared with the
physician for assessment.
Furthermore, if the internet connection is interrupted, the
healthcare provider in the car is trained to provide troubleshooting and
fix the problems. If this issue was not fixed, then the healthcare
provider can contact the technical support department for further
assistance. This will provide the best possible solutions to maintain a
stable connection between the physician and the patient.
Finally, if the patient is not used to telemedicine systems, the
healthcare provider will be there to guide him/her. From the time the
provider arrives at patients home to discharge, the patient will be with
the healthcare provider and be carefully guided. This will enable the
patient to accept this system and improve overall patients satisfaction
rate.
Recommendation:
23

In my view, I find telemedicine is a necessary method of care

that the Ministry of Health in Saudi Arabia should consider. This is
because the access of health care in some rural areas in Saudi Arabia
is not sufficient. This is because, in my opinion, most physicians and
healthcare providers do not want to live in rural areas. Perhaps this
may not only apply to Saudi Arabia, but many other countries too. This
led to the discussed issues such as lack of clinics and specialties.
In order to solve this issue, I recommend that the ministry of
health to implement my proposed program to expand the healthcare
access in these areas. This program will utilize the current technologies
and use effective alternatives for healthcare and ensures that
everyone will have access to healthcare. All the requirements and
resources of this project are available, so at least they should consider
trying it for few rural areas at first, for a short period of time to
evaluate its effectiveness. If it met the desired results, which I am sure
it will, then they should officially implement it in the other areas. In
short, this program will take the access of healthcare to a greater level.
Conclusion:
Telemedicine is useful to deliver healthcare to rural areas. It uses
technology to provide virtual visits between two different areas. It can
be utilized in a wide variety of settings and can treat several illnesses
from distance. If this technology is used for rural populations in Saudi

24

Arabia, more people will have access to health care. It is recommended

to implement it in Saudi Arabia as it will lead to several benefits such
improved patients satisfaction and better health status for the
population.
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