Telemedicine adoption in Ecuador: an assessment of physician perceptions and knowledge towards its benefits and limitations

Introduction

Telemedicine (TM) is defined as the remote clinical care of patients utilizing telecommunication technology as a substitute for face-to-face contact (1). Its implementation can be seen across the medical field for the management of respiratory, endocrinological, cardiovascular, neurological, dermatological, oncological, and mental health disorders over time (2-5). Healthcare providers (HCPs) can also benefit from TM models by strengthening connections between healthcare professionals to improve ongoing medical education and reducing professional isolation (2).

TM is expected to bring various benefits, especially to those countries where the majority of the population lives in rural or remote areas without access to basic healthcare (6,7). It is a growing field that has the potential to improve patient care, but also has many challenges associated with its adoption and usage. For instance, some studies have found that the implementation of technology may be negatively impacted by user-perceived barriers (8,9). Furthermore, a previous systematic review identified the expenses of technology and lack of literacy as major obstacles interrupting the successful implementation of TM (8). Therefore, identifying the main barriers among patients and HCPs is a key step for successful implementation of technology that needs to be addressed with additional studies.

Notably, the perceptions and knowledge concerning TM vary among HCPs, with beliefs differing between users and non-users (10). Factors including lack of technical expertise, and insufficient integration of data for continuity of care are notable barriers between clinicians and TM (8,10). As previously described, it can lead to a situation in which despite widespread use of availability of TM, the limited knowledge of clinicians regarding these technologies could potentially lead to underutilization of the resources (11).

Although TM utilization reached its pinnacle during the coronavirus disease 2019 (COVID-19) epidemic, recent data reveal a general decrease in its application. Nonetheless, 32.5% of physicians in the USA persist in offering TM consultations. Significantly, physician preferences, visit time, and visit nature—rather than solely patient necessity—were recognized as primary determinants affecting TM utilization (12). A study in Israel revealed that TM access was more prevalent in primary care visits, resulting in fewer prescriptions and higher follow-up visits, with no evidence of missed diagnoses, worse outcomes, or heightened expenditures (13).

In contrast, TM adoption in Latin American countries predates the pandemic, with several nations having well-established programs. In Mexico, the National Center for Technological Excellence in Health (CENETEC-Salud) has provided TM programs since 2004 to ensure continuity of care for patients requiring specialist follow-up (14). Similarly, Brazil has operated two TM programs since 2006, offering tools such as second opinions, conferences, and continuing medical education (15). Argentina, even earlier, introduced TM programs in 1997, incorporating teleconsultation, telerehabilitation, and teleradiology (15).

Colombia has also demonstrated significant progress in TM. A TM program for patients with solid tumors in breast and prostate cancer revealed no significant differences in emergency room referrals, hospitalizations, or mortality between rural and urban patients (16). Another study in Colombia focused on an endocrinology TM program for patients with type 1 and type 2 diabetes, showing that teleconsultations enabled effective patient follow-up and metabolic control, independent of follow-up duration. Additionally, it allowed early identification of disease exacerbations, reducing the need for secondary management (17).

Ecuador established its inaugural TM program in 2009, outlining preliminary strategies to incorporate broadband technologies to improve diagnostic and treatment capabilities for patients in remote areas (18). In 2018, a proven TM platform proved effective in rural healthcare environments, functioning as a significant resource for documenting clinical situations and enhancing medical education (19). In 2020, Cherrez-Ojeda et al. (20) indicated that more than 90% of physicians in Ecuador utilized information and communication technologies (ICTs) to communicate with colleagues and patients (P<0.01). Although 89.5% of physicians interacted with peers on social media, hardly 58.1% utilized these sites for patient engagement (P≤0.01). Younger physicians with less postgraduate experience and non-specialists demonstrated a more positive attitude towards ICTs. Privacy issues, patient confidentiality, and time management were the predominant obstacles to TM implementation.

Given these trends, Ecuador’s TM landscape offers an opportunity to assess HCPs’ perceptions and knowledge of TM, providing insights into the factors shaping TM adoption and potential strategies for improving its implementation. We present this article in accordance with the STROBE reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-92/rc).

Methods

Study design and participants

We conducted a cross-sectional online survey-based study from June to December 2022 and included HCPs actively practicing in Ecuador. The sample size was determined following the recommendations of Dhillon et al. (21) and other studies in Ecuadorian populations (22,23), applying a ratio of 5–20 participants per questionnaire item (12 items), resulting in a required sample size of 65–250 physicians. Due to social distancing measures during the COVID-19 pandemic, we employed a non-discriminative selective snowball sampling approach where recruited participants provided referrals to recruit other HCPs, ultimately leading to the recruitment of 382 physicians, who anonymously responded to the 12-item Likert-scale survey.

Questionnaire

For this cross-sectional study, the questionnaire by Ayatollahi et al. was previously adapted and validated for its use in the Ecuadorian HCP population (11,24). The survey consisted of two parts. The first part included the demographic information of participants (age, gender, higher education degree, medical specialty, and work experience). The second part of the survey included 4 domains where participants described their knowledge and perceptions about TM as follows:

• Knowledge about TM (KAT): Q₁–Q₃;
• Perception of utility of TM (PUT): Q₄–Q₆;
• Perception of the disadvantages of TM (PDT): Q₇–Q₉;
• Knowledge of the security of TM (KST): Q₁₀–Q₁₂.

Each domain had 3 questions, for a total of 12 questions. Each question was answered based on a five-point Likert scale that ranged from very low [1] to very high [5]. Each of the questions in the survey, according to their domains, can be visualized in Table S1.

Statistical analysis

The present study reports demographic characteristics using descriptive statistics. Nominal variables are presented as frequencies and percentages, while normally distributed continuous data is summarized through means and standard deviations. For the purposes of analysis, the 5-point Likert scale was used as a categorical variable, as a chi-square goodness of fit test was used to assess if the observed frequencies of each of the survey’s query responses were as expected by chance or not. In case of assumption violation, Fisher’s exact test was applied. All statistical analyses were performed using SPSS for Windows (version 25.0; SPSS Inc., Chicago, Illinois). Statistical significance was considered as P<0.05.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Additionally, this study was approved by “Comité de ética e Investigación en Seres Humanos” (CEISH), ethical review board, Kennedy Hospital, Guayaquil-Ecuador (#HCK-CEISH-18-0060). Informed consent was obtained from all participants.

Results

Descriptive statistics of demographics

A total of 382 participants completed the survey, with a response rate of 95%. The average age was 51.3 years [standard deviation (SD) 11.4], and 58.6% were male. Most respondents reported having a medical specialty (66.8%), while only 10.2% had a Master’s or Doctorate degree. The most frequent specialties were pediatrics (28.0%) and traumatology (13.1%), and 53.4% had more than 20 years of work experience (Table 1).

KAT

When assessing familiarity with TM (KAT), approximately half of respondents reported low or very low familiarity [χ² (4) =88.497, P<0.001]. Roughly 3 out of 10 patients had an average familiarity with such topics, while only around 20% were highly to very highly familiarized.

Perception of the utility of TM

Regarding perceptions of utility (PUT), 32.5% believed that TM is highly effective in reducing hospital costs [χ² (4) =78.812, P<0.001], though fewer respondents perceived that it is significantly less time-consuming or improves healthcare speed.

PDT

In terms of disadvantages (PDT), 27.0% believed that TM highly increases malpractice risk [χ² (4) =31.534, P<0.001].

KST

Concerning security (KST), over 80% strongly agreed on the need for legal and privacy frameworks for TM [χ² (4) =250.749, P<0.001].

About 8 out of 10 participants expressed that, from a high to a very high extent, a framework should be created to prevent breaches of data confidentiality when using TM [χ² (4) =250.749, P<0.001], that TM requires legal clarification for patients [χ² (4) =263.628, P<0.001] and that this technology requires a formulated and clear framework for access to medical information [χ² (4) =240.670, P<0.001].

Regression and predictors of TM attitude

To assess predictors of overall attitude toward TM, a multiple linear regression was performed with the total score as the dependent variable. In the first model, age was a significant predictor [β =−0.153; 95% confidence interval (CI): −0.16 to −0.03; P<0.003], indicating that older physicians tend to show less favorable attitudes. In the second model, medical specialty was also included and found significant (β =0.104; 95% CI: 0.01–0.54; P=0.04), suggesting that specialty type influences openness to TM.

Figure 1 illustrates the partial regression plot for age, confirming that younger physicians tend to report higher attitude scores toward TM, differing from older physicians’ stance. Figure 2 presents a boxplot of attitude scores across medical specialties, revealing that physicians in dermatology and allergology showed more favorable attitudes, while those in general medicine and intensive care reported lower scores. These visual findings support the results of the regression analysis. Variance inflation factors (VIF) (<1.02) and condition indexes (<12) indicated no concerns regarding multicollinearity.

Figure 1 Partial regression plot for age. The negative linear trend indicates that as age increases, the total attitude score toward telemedicine tends to decrease. This association is adjusted for other variables in the model.

Figure 2 Boxplot of total attitude scores by medical specialty. Physicians in dermatology and allergology reported more favorable attitudes toward telemedicine, while those in general medicine and intensive care had lower scores. Median and variability are shown for each specialty group.

Differences by gender, workplace, education, and employment type

Boxplots were used to visually explore differences in domain scores (KAT, PUT, PDT, KST) by demographic and professional variables. Female participants tended to score slightly higher in PDT and KST. Physicians with permanent employment showed higher median scores across domains compared to those employed temporarily. Educational level showed clear effects: participants with graduate degrees scored higher in both knowledge and security-related domains (KAT, KST). Although variables such as gender, education level, and employment type were not retained in the regression model, exploratory boxplot analyses revealed meaningful patterns across these groups (Figures 3-6).

Figure 3 Boxplots of telemedicine domain scores by gender. Scores in the PDT and KST domains are slightly higher among female physicians, reflecting a gender-based variation in perceptions of disadvantages and security in telemedicine. KAT, knowledge about telemedicine; KST, knowledge of security; PDT, perception of disadvantages of telemedicine; PUT, perception of utility of telemedicine.

Figure 4 Boxplots of telemedicine domain scores by employment type. Physicians with permanent employment exhibited higher scores across all telemedicine domains—KAT, PUT, PDT, and KST—compared to those employed temporarily. The difference was especially notable in the KST domain, suggesting greater familiarity with legal and security issues among permanent staff. KAT, knowledge about telemedicine; KST, knowledge of security; PDT, perception of disadvantages of telemedicine; PUT, perception of utility of telemedicine.

Figure 5 Boxplots of telemedicine domain scores by education level. Physicians with Doctorate degrees showed the highest scores across most domains, particularly in KAT, PUT, and KST. In contrast, those with a Master’s degree reported the lowest scores in several domains. These findings suggest that doctoral-level training may be associated with greater understanding and acceptance of telemedicine. KAT, knowledge about telemedicine; KST, knowledge of security; PDT, perception of disadvantages of telemedicine; PUT, perception of utility of telemedicine.

Figure 6 Boxplots of telemedicine domain scores by workplace setting. The distribution of scores across workplace settings reveals that physicians in private practice and non-traditional settings (“Other”) tend to report higher KAT and PUT. KST remains consistently high across all groups. These findings suggest that the workplace environment may shape familiarity and perceived benefits of telemedicine. KAT, knowledge about telemedicine; KST, knowledge of security; PDT, perception of disadvantages of telemedicine; PUT, perception of utility of telemedicine.

Summary of inferential findings

Although these patterns were statistically significant in many cases, the overall effect sizes were modest (R² =0.034 in the full regression model). The use of multiple boxplots and regression analyses allows a nuanced understanding of the data beyond P values alone.

Discussion

TM is a growing field with the potential to improve healthcare delivery; however, it is important for proper implementation to understand how physicians and patients perceive the benefits and limitations related to their use. In our study, we found that roughly half of participants expressed a low familiarity with TM technologies and their application in medicine. This finding contrasts with a previous study among physicians in Saudi Arabia, in which around 46.1% reported average KAT (25), and has been confirmed by a recent study in low- and middle-income countries (26). It is possible that organizational structure and culture affect health care providers’ perceptions of TM based on the diffusion of innovation theory (27,28). According to this theory, the key to adoption is that individuals must perceive the idea as “innovative” to enable greater diffusion. This is one area where a change in healthcare organization’s culture and structure may be able to affect HCPs’ perceptions of TM (29).

Dahmardeh et al. found that health professionals under the age of 40 with more work experience possessed better knowledge and a more positive attitude towards TM (30). Similarly, our findings indicate that younger doctors are more eager to incorporate TM into their practices. Another key finding is that a physician’s specialty affects their attitude towards TM, with allergists and dermatologists showing the most favorable views. There has been a notable rise in TM use among dermatologists, and teledermatology offers potential benefits for underserved populations by helping them overcome obstacles to accessing healthcare (31,32). As expected, educational level had a significant impact on knowledge and security-related concerns (KAT, KST).

Our results suggest that age, specialty, and education influence physicians’ attitudes towards TM, though other unmeasured factors may also be involved.

Despite the low familiarization with TM among physicians in our study, most of them considered to a high extent that it can be effective in reducing the costs related to patient care in hospitals, saving a considerable amount of clinicians’ time, and also providing faster and better medical care. Similarly, a previous study among physicians in Indonesia found that most respondents considered that TM is beneficial for patients (89%) and were interested in its continued use (88%) (30). In Switzerland, physicians perceived that TM produced lower levels of exhaustion and might have a positive impact on physicians’ work-life balance and burnout (31). Previous studies have shown that TM can be particularly useful for patients with chronic diseases (32). For instance, Nguyen and colleagues reported that after taking into consideration all costs and effects of a TM-based national diabetic screening program in Singapore, it would still have significantly lower costs while generating similar quality-adjusted life-years compared to a physician-based model (33,34). In a randomized control trial from Japan, authors found that the use of a mobile application was a cost-effective tool that might help to reduce the incidence of dysmenorrhea and depression among women, and interestingly enough, most participants were willing or relatively willing to use it (35,36). In heart failure, TM has demonstrated to facilitate patients’ proactive engagement in self-care activities, including monitoring fluid intake, adhering to drug regimens, and implementing lifestyle adjustments (36,37).

TM technology can be beneficial for all HCPs and its successful execution relies on increasing awareness among various medical professionals and their functionality (30).

Despite its benefits, there are several aspects of TM inherent to its nature such as security and privacy concerns, along with the danger of affecting patient privacy or incurring malpractice. In our study, 4 out of 10 respondents considered to a low extent that TM may endanger patient privacy; however, a similar proportion stated that it may increase malpractice cases. Additionally, 8 out of 10 participants in our survey expressed that a framework should be created to access medical information and prevent breaches of data confidentiality when using TM. These interesting findings may be related to the fact that, as of today, mobile technologies not only manage personal data but also highly personal information including social interactions and emotions, creating new issues such as the appropriateness of physicians to communicate with patients through platforms outside of the electronic medical record (38). This represents an obstacle that needs to be addressed by healthcare organizations and providers to ensure that sensitive information is only shared among authorized individuals (21,39).

Furthermore, impediments such as insurance coverage, reimbursement issues, early-stage infrastructure costs and a shortage of technical personnel are identified as the most fundamental infrastructure obstacles for the implementation of TM technology (30).

Prior studies have determined that there is a growing interest in the use and application of TM in clinical practice, but there are still barriers ranging from the availability of internet and mobile devices to limitations of physical assessments, and even resistance to change that can affect the experience and satisfaction of using technology on a case-by-case basis (26,40). As of today, TM represents a primary means of expanding care to those with limited access to physicians, but to be truly patient-centered it must also be affordable and accessible (40,41). Considering the perceptions and knowledge of physicians related to TM is also essential to design more efficient and easier-to-use tools that ultimately will increase the participation in these new technologies (8).

Limitations

In light of our findings, there are several limitations worth mentioning. Nearly one-third of our sample consisted of pediatricians, while a sixth of it was composed of traumatologists, which may limit the generalizability of our results to physicians with other specialties. Around half of the participants were unfamiliar with TM, which may lead to biased answers when asked questions about topics requiring more in-depth knowledge of these technologies. A key limitation of this study is the use of a non-probability, snowball-sampling method, which may introduce selection bias. This approach could lead to overrepresentation of HCPs with greater digital engagement while underrepresenting those less familiar with TM. Future research should consider probability sampling methods to enhance the representativeness of findings. However, to the best of our knowledge our study is among the first to assess the perceptions of TM among Ecuadorian physicians, providing valuable insights that might be useful to design future interventions.

Conclusions

Understanding physician’s perceptions of the use of technology is an important step for identifying unmet needs and areas of improvement. In this study we found a considerable proportion of physicians reporting low familiarity with TM despite being aware of the benefits it can bring to patient care. Breaches of data confidentiality and the potential for malpractice were cited as the main concerns in need of a framework to prevent them. Future studies are needed to address the perceived barriers of technology to ensure safe and efficient use of TM in the healthcare setting.

Acknowledgments

The authors acknowledge the guidance and knowledge imparted by the MECOR Program for this study. Special thanks to all members of Respiralab Research Group in particular Dr. Christian Kuon Yeng for their initial input regarding this project. We want to also express our gratitude to Dr. Krunal Pandav (Larkin Health System, South Miami, FL, USA) for his early contributions to manuscript preparation. Finally, we want to express our gratitude to Universidad Espiritu Santo for their continuous support in our research endeavors.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-92/rc

Data Sharing Statement: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-92/dss

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-92/prf

Funding: This study was funded and supported by Universidad Espiritu Santo, Ecuador. The sponsor had no role in the design of the study or in the collection, analysis, and interpretation of data.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-92/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by Comité de ética e Investigación en Seres Humanos (CEISH), ethical review board, Kennedy Hospital, Guayaquil-Ecuador (#HCK-CEISH-18-0060). Additionally, informed consent was obtained from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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