Virtual hospitals in the Kingdom of Saudi Arabia: A scoping review

Abstract

Virtual health hospitals have been on the rise significantly since COVID-19 globally. The Kingdom of Saudi Arabia has established several initiatives as part of Vision 2030, where Tele/Virtual Health is key part of this vision. The purpose of this review is to evaluate and establish the expected challenges and the potential value in virtual hospitals in Saudi Arabia. It also aims to identify and analyze gaps in existing knowledge to ideally aid the planning and commissioning of future research on this subject. Results of this review highlight several themes from the literature evolved as follow: 1) need for improvement in Saudi healthcare, 2) emergence of virtual healthcare due to COVID-19, 3) Virtual healthcare has many pros and cons to consider, and, 4) Virtual healthcare has many challenges.

Introduction

Saudi Arabia is going through significant transformation. It is constantly evolving and positioning itself to become a region defined by its exemplary innovation and growth by 2030, as highlighted in the KSA Vision 2030. The Healthcare Sector Transformation Program as part of this vision has placed an enhanced focus on the keenly improving access to healthcare, modernizing facilities and equipment, while engaging with key stakeholders to ensure that this transformation meets the needs of every member of our society.

Virtual healthcare is a promising development in the Saudi Arabian Healthcare space which has had increased focus due to Vision 2030’s commitment towards ensuring healthcare is more accessible and prevention focused.[1,2,3,4] As the Ministry of Health builds on the momentum it garnered through the swift and effective management of the COVID-19 pandemic, the enhanced focus on tele-medicine consultations and data-driven treatment plans shows the commitment towards innovating in the healthcare space. Furthermore, all this consolidates into the titular innovation of virtual hospitals, an innovation that Saudi Arabia has just begun to reap the rewards of as it launched the world’s largest virtual hospital, and the first of its kind in the Middle East called SEHA virtual hospital (SVH).[5] SVH covers 12 main specialties and more than 35 sub-specialties, including hospital at home follow-ups where chronically ill patients can stay connected with their doctors from the comfort of their home.[6,7,8,9] While there may be preconceptions that such implementations tend to overlook their clinical value proposition which get overshadowed by technological ones, it can be argued that virtual hospitals are a unique example that provide an ideal balance of the two. Saudi Arabia’s healthcare has mainly suffered because of the disparity of the accessibility within its urban and rural regions, while also having to navigate how to best utilize and build on strained healthcare resources and services to overcome the challenges.[10,11] However, the country has seen changes in disease patterns, with chronic diseases becoming more prevalent than communicable ones, placing added strain on existing healthcare services.[12,13,14,15] This transition in disease pattern suggests that primary health care services, including patient follow-up strategies and preventative health educator activities are ineffective and insufficient thus far.[16]

While it is evident virtual hospitals have the potential to eradicate these issues, the purpose of this review is to ascertain the expected challenges and the potential value in overcoming them. It will also focus on how its success in this context can be accomplished via an approach that not only enhances the accessibility of high-quality healthcare to every member of the society, but also works to raise awareness of health issues and educating the population on how to mitigate and manage them. Finally, it will also ideally identify and analyze gaps in existing knowledge to ideally aid the planning and commissioning of future research on this subject.

Methodology

In this paper, we used the JBI Scoping Review Methodology in conjunction with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) Checklist. A scoping review was conducted of the literature of four databases: MEDLINE, CENTRAL, Saudi Medical Journal and IEEE Explore to retrieve eligible publications. The search was conducted on the title, abstract and keywords for the terms: (“virtual health*” OR “virtual clinic” OR “virtual hospital” OR “tele-health” OR “telehealth” OR “tele-medicine” OR “telemedicine” OR “e-health”) AND (“Saudi Arabia” OR “Middle East” OR “MENA” OR “Middle-East”) Additionally, Google Scholar was used to identify gray literature containing research from a global standpoint. This supplemented the scoping review by providing a holistic outlook on virtual hospitals and the related research questions from a Western and far Eastern perspective, and the following search was conducted on the title in order to get the appropriate results from the global perspective: (“virtual health*” OR “virtual clinic” OR “virtual hospital” OR “tele-health” OR “telehealth” OR “tele-medicine” OR “telemedicine” OR “e-health”). The results were organized and collated using a data charting template designed for scoping reviews to better highlight and map the relevance, gaps in research and themes in the findings.

Eligibility criteria

To better understand the eligibility criteria, it is important to highlight the relevance of the PCC Framework. The PCC Framework, covering the population, concept, and context, is recommended as a guide to construct clear meaningful objectives and eligibility criteria for a scoping review (Pollock et al., 2022).[17] As the population would largely be any patients and practitioners, who could benefit from the increased adoption of virtual healthcare, the eligibility criteria from this standpoint were kept broad open. However, the concept element consisted of interventions and phenomena of interest from a virtual healthcare standpoint. This meant taking into consideration studies of the awareness and the effectiveness of virtual healthcare, as well as considering outcomes of interest from studies pertaining to the strain on primary healthcare within the region, since this forms a strong rationale in favor of the innovation. Lastly, the context would aim to place a higher emphasis on research and studies of and from the Middle East and Saudi Arabia using global research supplementarily to inform how the research questions can be answered.

Furthermore, an enhanced emphasis would be placed on sources of data created from 2016 onwards, as this was the year that the Vision 2030 was introduced, and the country shifted its strategic outlook significantly to adopt an innovation-centric approach. Finally, sources of data in the recent years (since 2020) would be given a higher level of relevance as the COVID-19 pandemic accelerated the need for virtual healthcare interventions. All these design decisions would, therefore, ideally enable better contextualization of the scope and challenges of establishing and operating virtual hospitals in the region. In addition, the quality and capacity of primary healthcare will be covered, especially in rural regions as the disparity between urban and rural healthcare continues to be a key proponent of the increased adoption of virtual healthcare.

Data charting

These results were then charted onto an Excel Data Charting template highlighting important details such as the key words, themes, gaps in research as well as the relevance to the scoping review itself. It is vital to highlight what would constitute a high level of relevance prior to reviewing the themes. The data charting aims to give a higher level of relevance on research in primarily a Middle Eastern context, ideally a Saudi Arabian one, given the need for the themes and discussions to be relevant to the local healthcare landscape. It also factors towards giving higher priority towards systematic reviews on the subject matter given the depth of analysis these provide. The search strategy did not include limitations on the region and language however, as any research on virtual healthcare from a global standpoint would still contain elements of medium relevance towards the thematic analysis and add credence to the result synthesis. As mentioned previously, a higher level of relevance for research carried out after the introduction of the KSA Vision 2030 and post the Covid-19 pandemic as both these events shifted the healthcare industry towards innovating and growing rapidly towards virtual care. Low relevance has been given to evidence which, for instance, discusses virtual healthcare, its prominence in global regions that do not transpose into the Saudi healthcare, or the technology involved but does not explicitly go into much detail regarding the pros, cons, or operational challenges of establishing virtual hospitals.

Synthesis of results

Finally, the identified sources and evidence have been analyzed to determine if they contain any relevant key words or further sources of evidence that can be searched and charted. As an example, the MEDLINE database tends to include a “Similar Articles” and “Cited By” section to allow further insights to similar evidence of research that cover materials of relevance. Consequently, this search has then informed if the sources could provide further valuable insight in the review of themes, the implementation and evaluation plan or the discussion. These results are then synthesized and summarized to provide insights for how they can supplement the implementation and evaluation plan, as well as the discussion towards enabling successful healthcare leadership from a virtual healthcare standpoint.

Results

A total of 1243 articles were identified. Of those, n = 87 was removed due to being classified as duplicates. Of the remaining n = 1156, n = 793 were assessed for eligibility and n = 363 were excluded to missing full text. A total of n = 30 articles were included after meeting all eligibility requirements. Figure 1 shows the PRISMA flowchart. Of those 30 studies, n = 10 was labeled as low relevance, n = 9 were labeled as medium relevance, and n = 11 as high relevance. The next section lists the themes that were found in these studies.

Figure 1.

PRISMA chart showing the list of studies that were included. Source: Page MJ, et al. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/

A total of 4 themes evolved from the selected articles. First and foremost, a key theme highlighted was the need for improvements in Saudi Healthcare. In a system that prides itself on the high quality of service, this theme highlighted the strains within the system and the variety of reasons influencing it, further making the case for the value that virtual hospitals bring and compare how this has been successfully done globally to implement virtual healthcare more effectively.

Regarding virtual healthcare, the overarching theme in most sources was the significance of Covid-19 acting as a catalyst to the adoption and uptake of virtual healthcare in Saudi Arabia, again alluding to the value of virtual healthcare in the region. Research focused on how the public embraced virtual healthcare, despite it being a novel form of healthcare up until that point. Even though Vision 2030 had laid the groundwork of creating a vision where virtual healthcare revolutionized the Saudi healthcare and its accessibility, it was not until the pandemic hit that the research began to cover the breadth of its impact and possibilities going forward. This is evident as the current research, for at least the past 3 years, has covered a plethora of factors ranging from its adoption, advantages, and disadvantages, to the various perceptions of the practitioners and public towards it.

The subsequent theme revolves around research detailing the pros and cons of virtual healthcare. The theme covers these from the perspectives of patients, practitioners and institutes while focusing on which pros we need to highlight more going forward, as well as which cons we need to stay wary of and aim to mitigate in the future. This, in turn, briefly introduces the final theme, which covers the enablers and inhibitors of virtual healthcare. This theme addresses the challenges of establishing and operating virtual hospitals, as well as the value in mitigating these. The synthesis of the literature enabled the understanding of the various sources discussing at length the key factors which enabled and inhibited virtual healthcare delivery. Being a reasonably innovation in the region, this theme also leveraged research from a global perspective to understand what has been done right so far, where we can improve for the future and what needed to be given special consideration for ensuring future success as well.

Discussion

In this section a discussion and interpretation of each the four themes will be discussed below in depth.

Theme 1: Need for improvement in Saudi healthcare

While contextualizing the other themes, it can be argued that the theme for the need for improvement in Saudi Arabian healthcare is what underpins the need for better virtual interventions altogether. It lends credence towards the need to better understand the value, pros, cons, and challenges in establishing and operating virtual healthcare altogether.

Saudi Arabia finds itself in a unique conundrum where the disease patterns have shifted away from communicable diseases to a higher prevalence of chronic diseases; the primary healthcare workforce is strained due to increased demand and shortage of physicians; the Ministry of Health’s Vision 2030 has matured into a strategy which aims to mitigate the low levels of acceptability and accessibility of primary healthcare to all.[16] Using data collected from all healthcare sectors in Saudi Arabia’s thirteen administrative regions, it was evident that there was a high dependence on Primary Health Care Centers (PHCs) in rural areas, which further strained the workforce and led to conclusions that the capacity of those PHCs did not seem to meet the demands of the population.[18]

Normally, a coherent, structured approach would aim to build from the bottom up, equipping institutes such as Academic Medical Centers (AMCs) and the practitioners with the right digital technology and respective training. As evidenced by hospitals in the US, AMCs are digital health catalysts to effectively improve the quality of patient care, reduce costs, and increase patient-centeredness in healthcare.[19] Saudi Arabia, too, has begun transitioning towards a higher emphasis on AMCs as well where it would enable them to standardize and enable electronic health records, video-imaging technologies, and innovations such as smart beds to serve patients more effectively, while also allowing rural people to be connected to consultants at AMCs as well, thus enhancing accessibility.[20] However, as we know, be it globally or in the Middle East, the pandemic played a significant role in defining how vital virtual healthcare has become now.[21]

Theme 2: Emergence of virtual health clinics due to COVID-19

From a global standpoint, the use of virtual healthcare was not unfamiliar to the US healthcare providers as nearly 76% of hospitals in the USA were utilizing telemedicine prior to the pandemic; however, most patients still received their care through in-person encounters. This indicated they had the infrastructure and interventions in place to utilize it effectively in a situation like the pandemic.[22] Australia, on the other hand, launched their first virtual hospital in February 2020 and has since delivered safe and effective virtual care to over 37,000 patients with nil adverse events. With 2,260 patient surveys showing very high levels (>80%) of satisfaction, their model of care evolved during the pandemic and is now able to be redirected towards hospital avoidance programs and the ongoing delivery of hospital level care in the community.[23] From a survey of 819 therapists from across the world, 70% reported they currently use virtual visits in their practice, whereas this figure was less than 5% prior to COVID-19, indicating a 15-fold increase in virtual visits since the beginning of the pandemic.[24]

As alluded to previously in this review, virtual healthcare was introduced in Saudi Arabia initially with the aim of improving the quality, accessibility and acceptability of the healthcare provided to everyone. The emergence of the COVID-19 pandemic catalyzed the need for, and subsequent adoption of virtual healthcare due to the highly transmissible nature of the virus. The review uncovered a variety of studies which corroborate and further build upon this theme showcasing the value virtual hospitals brought and continue to bring in the healthcare space.

Quarantines, social distancing, uncertainty regarding the virus and an already strained medical workforce all amalgamated to a complex situation for Saudi Arabian healthcare, requiring innovative interventions. Outpatient visits posed a high risk for the rapid spread of the disease and telemedicine provided the ideal platform to deliver medical care via virtual clinics.[2] Not only was it vital in ensuring the patient and physician safety, but it also managed to provide an efficient solution regarding the healthcare provider and patient’s time.[25]

To better facilitate the innovation and to comply with regulations from the Saudi government around social distancing, the telehealth program (consisting of a suite of applications) expanded rapidly to provide users with a suite of features whether it was providing virtual healthcare to patients, enabling COVID-19 passes to access communal areas or to track quarantines of COVID-19 patients.[26] The drive to improve the suite and requiring people to have the telehealth apps downloaded and signed onto the platforms helped elevate the level of awareness of virtual healthcare, with a study indicating that from a sample taken, 70.6% of the participants were aware of virtual clinics whereas 34.6% were post-pandemic users.[27] The study was the first to measure public awareness and use of virtual clinics following COVID-19 in Saudi Arabia and highlighted the importance of sociodemographic characteristics such as age, gender, marital status, income, and education level when it came to better understanding the use and awareness of virtual health among the population. With enhanced accessibility and better workforce management being key rationales for the implementation of this innovation on a broader scale, it can be argued that the pandemic provided virtual care with the appropriate platform and opportunity to mitigate the issues being faced in the region. Another study found that in addition to getting appointments without the need to travel and flexibility of appointment, more than half the respondents chose not having to worry about the anxiety of crowded waiting rooms as the most important advantage of telemedicine. This shows the significance of the role played by the pandemic in catalyzing the adoption of virtual healthcare, and how this is a global trend as evidenced by massive increases in use of telemedicine in USA as well.[2] Mann et al. (2020) reported an during the first quarter of 2020, specifically in one month from march to April, a significant increase of telemedicine up to 800 daily from around a 100 was seen.[28]

Theme 3: PROS and CONS of virtual healthcare

Another key theme that a variety of studies revolve around is using practitioner’s and patient’s perceptions and feedback to have a better understanding of the pros and cons of virtual healthcare from various perspectives. From a patient standpoint, the increased access to a variety of healthcare services, the ability to deliver care to rural areas, better flexibility in scheduling and crucially, saving them time and money in seeking care all are major pros of virtual care delivery.[29] As highlighted by a study from a Canadian hospital which implemented a virtual family visiting program during the pandemic, a key global advantage often overlooked is the ability to mitigate separation trauma and enable families to connect and stay aware of their admitted loved ones.[30] Furthermore, as alluded to earlier, a USA study highlighted one of the key pros of virtual healthcare being the opportunity it brings to enhance accessibility and facilitate healthcare with a focus on equity, especially to those of lower socioeconomic status.[31]

A cross-sectional study conducted at primary healthcare centers showed that a high majority of the participants (82.7%) were satisfied with telemedicine services.[32] A separate study conducted with Saudi adults with type 1 diabetes showed that due to the significant benefits of virtual healthcare, over 70% of the participants indicated their preference of continuing their routine diabetes appointments in virtual clinics as opposed to traditional in clinic visits.[33] However, it is important to highlight there are limitations as well which patients face, ranging from a dependence on e-health literacy, impacts on continuity of care to feeling as though the online interactions are not as helpful or thorough as in person experiences.[32] Another barrier people from rural regions may face is limited connectivity or lack of access to proper communication equipment. Such limitations can be eliminated by policies which have a focus of strengthening digital infrastructure and engaging all stakeholders at their core. From incentivizing patients with a lower fee-for-service, to consolidating and improving user interface design to enable enhanced access to the relevant technological platforms, there are a multitude of mitigations that can be considered and implemented to eliminate the limitations faced by patients.[27]

From a physician standpoint, a study conducted in China highlighted how there are clear opportunities to harness the digital environment and integrated virtual imaging tools to improve accuracy of certain diagnoses of conditions such as Diabetic Retinopathy.[34] Additionally, as mentioned earlier, when primary healthcare centers in rural underserved regions have strained workforces due to higher levels of dependence, physicians need a solution from those PHCs from being overwhelmed. A study found high levels of participants agreed that proactive in-home triaging of patients with COVID-19 through utilization of a virtual hospital model was beneficial to both patients and physicians as it minimized unnecessary presentations to ED.[35]

However, a study conducted to ascertain physician’s perceptions towards telemedicine in a primary healthcare setting showed that despite the ease of discussion and efficient use of time being the other clear pros, 71.7% of the participants preferred in office visits.[36] whereas Balesta suggested that technical issues, feasibility of telemedicine and having to deal with privacy and confidentiality issues to be key cons which physicians must face in this setting.[37]

Using the smaller city of Taif in Saudi Arabia, (<1 million population) and its surrounding rural regions as another example, 44% of the participants in a study conducted believed the quality of care was enhanced due to telehealth.[38] However, a key limitation experienced was difficulty in reaching the correct diagnosis due to the lack of physical examinations, with the study suggesting a hybrid approach to enable benefits of both approaches.[38] It is important to point out that another study highlighted that 88.8% of participating patients were of the view that physical examination is important during a consultation, but 51.5% believed that the doctor can perform their job even if they are not able to conduct a physical examination.[39]

It can be argued that with the right infrastructure, communication strategies and relevant training programs, these cons can be turned into pros. While certain Saudi studies worried about lack of continuity of care being a potential con, a study conducted in the Netherlands contrasts this by highlighting how an integrated virtual care center can use remote monitoring, remote therapy, and data automatization to effectively create a continuum of care for patients suffering from chronic diseases.[40]

However, such efforts would require a thorough implementation plan on a national scale. The rapid expansion and adoption of virtual healthcare since the pandemic necessitates the need for a better understanding of the satisfaction from a patient and physician standpoint, while also exploring how to mitigate the barriers and limitations in its successful operation and implementation.[32]

Theme 4: Challenges of virtual healthcare

Finally, this theme covers the challenges faced in virtual healthcare enablement and based on lessons learnt, what improvements and considerations would enable successfully overcoming these operational challenges to deliver value. From a global standpoint, a key challenge faced in establishing the virtual clinic could be the need to involve a variety of stakeholders in the decision-making process, with a US study highlighting the need to embed telemedicine technology and processes within health equity strategies to better tackle the health inequities which disproportionally affect marginalized communities and that can be commonly found when comparing rural and urban regions.[41]

In another review paper from a Neurology perspective, Alghatani and Shirah highlighted the urgent need for improvement in the perception and knowledge of both medical personnel and patients concerning telemedicine as well as the appropriate use of advanced information and communication technology was highlighted.[42] They also highlighted another observation from the literature review showing the lack of methodological studies. It is imperative to highlight this gap in the current literature as well as the significance that methodological studies play in ascertaining how virtual healthcare can continue to be successfully enabled and implemented in the future.

From a technical standpoint, a study conducted in South Africa determined the challenge rural and underserved areas experience regarding virtual clinics being vastly dependent on the availability of reliable communication networks, which poses a challenge not only in their establishment but operations as well.[43] This was further substantiated by a systematic review conducted in Portugal which found lack of access to internet services, lack of access to technological devices, low digital literacy, concerns around data confidentiality and health reimbursement models to be key challenges when it comes to establishing and operating virtual healthcare.[44]

This leads us to the question of how these challenges can be mitigated and overcome. From a global perspective, a study focused on the rapid implementation of a virtual hospital in the US exemplifies the three steps integral to enabling success: Firstly, building a scalable, EHR-centered platform that mandated a data-informed patient eligibility assessment. Secondly, using a virtual telemedicine platform to maximize provider scalability. Lastly, operationalizing a patient- and resource-centric communication strategy with a keen focus on proactive monitoring and communication.[45]

Taking the example of the Specialized Diabetes Clinic at King Saud University Medical City, a Diabetes Telemedicine Clinic protocol was developed to highlight patient journeys through a flowchart all up to their satisfaction surveys at the end. This protocol clearly defined the technical requirements and logistics of each step of the process, while ensuring that the protocol harnessed the strength of virtual healthcare and its interconnected nature. For patients using continuous glucose monitoring (CGM) systems or insulin pumps, they linked their devices and data to our clinic cloud-based accounts as part of the routine clinic practice prior to the pandemic, tackling the key challenge. On the other hand, for those who needed to manually upload the data, an educational video on how to upload data from home was developed and shared.[46] Backed by a high majority of patients feeling valued and empowered through the experience, this example highlights the significance leveraging the strength of virtual healthcare from a practical and educational standpoint to build a robust implementation protocol.

Two key studies discovered in the literature review uses the Technology Acceptance Model (TAM) to link perceived usefulness, perceived ease of use and social influence factors to map them to the likelihood of using the virtual healthcare services.[27] A Pakistani study focused on the applicability of using the TAM with the inclusion of additional variables to model the adoption of telemedicine services in developing countries.[47] Such methodological studies are key in shedding light on how the momentum virtual healthcare built from the pandemic can be sustained and built upon.

Recommendations and suggestions

Policymakers and regulators should consider making the telehealth flexibilities that was used for the COVID-19 public health emergency permanent, including coverage for home-based care and a wider range of providers and conditions. Invest in public infrastructure to achieve universal broadband access and address technology affordability to prevent digital disparities.

Healthcare providers and organizations

Healthcare providers and healthcare organizations should consider Integrating virtual tools into value-based and chronic care management models, using remote patient monitoring (RPM) to follow patients more closely at home and reduce avoidable admissions.[48,49] Invest in interoperable technology systems and Electronic Health Records (EHR) integration to enable seamless data sharing and coordination within virtual hospital models.[49] Finally, provide digital literacy training and technical support for both clinicians and patients to foster successful adoption.

Patients and families: Advocate for policies that ensure equitable access to technology and telehealth services, addressing needs of diverse communities, those individuals with disabilities. Push for the inclusion of audio-only telehealth options to ensure access for those without video technology or broadband. Lastly, promote the role of care partners through policies that facilitate their virtual engagement in inpatient, outpatient, and long-term care settings.

Summary and Conclusion

The results show the key themes on the need for improvement in Saudi Healthcare to mitigate the risks posed by inequitable access and a strained workforce. With virtual health being an effective solution to both those risks, the subsequent theme focused on how the pandemic accelerated the need for and adoption of virtual healthcare on a global scale. As is the case with any innovation, it has its pros and cons. In addition, elaborating on the extent of these pros and cons to better understand the perception towards the innovation from both a patient and physician perspective. While most patients enjoyed the increased accessibility and cost-effectiveness of virtual healthcare, some struggled with infrastructure and a lack of training. While most physicians agreed on the value the innovation brought, they also argued that the lack of physical examinations made it harder for them to ensure a thorough diagnosis.

All these factors built into the final theme of challenges of successful virtual healthcare implementation, and how research suggested these could be mitigated to ensure successful establishment and operation of virtual healthcare. Therefore, the results show the need to play to virtual healthcare’s strengths, focusing on its interconnected nature for continuous monitoring, and ensuring user interfaces and training were user-friendly and focused on ease of access to combat the challenges. Finally, there is a clear gap in literature regarding methodological studies conducted in Saudi Arabia surrounding the use of virtual clinics to elevate the data elicited and analyzed through cross-sectional studies and build upon it extensively to ensure such literature informs and enables successful establishment and operations of virtual hospitals in the future.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.