International Symposium on Research in Innovation and Sustainability 2014 (ISoRIS ’14) 15-16 October 2014, Malacca, Malaysia

Specia issue
Sci.Int.(Lahore),26(5),1795-1800,2014 ISSN 1013-5316; CODEN: SINTE 8 1795
A REVIEW OF ADOPTION OF TELEMEDICINE IN MIDDLE EAST
COUNTRIES: TOWARD BUILDING IRAQI TELEMEDICINE FRAMEWORK
Mustafa Musa Jaber1*, Mohd Khanapi Abd Ghani1, Nanna Suryana Herman1,
Biomedical Computing and Engineering Technologies (BIOCORE) Applied Research Group, Universiti Teknikal Malaysia Melaka,
Melaka, Malaysia
Email: {mustafa*, khanapi, nsuryana}@utem.edu.my
ABSTRACT – The purpose of this paper is to develop a framework which can sustain local conditions of developing
countries. Design and implementation of sustainable telemedicine information systems is still a big challenge for most
developing countries, despite of its wide usage in the developed countries. While various frameworks exist, not much of
them have adequately addressed the issue of design for sustainability. This paper proposes an appropriate framework,
which will guide telemedicine information systems designers on designing telemedicine systems that are sustainable in
local conditions of developing countries. The proposed paper mainly works in the area of information systems design for
sustainability, from a developing country perspective. The main factor for designing sustainable telemedicine information
systems in developing countries were identified as the speed, ease to use and affordable.

Keywords: Telemedicine, Adoption technologies, Middle East telemedicine frameworks

1.1 OVERVIEW
In this study, development of framework for telemedicine
and the use of advanced telemedicine technologies are
explained. Telemedicine is the use of modern
telecommunications and information technologies for the
provision of clinical care to individuals at a distance, and
transmission of information to provide that care.
Telemedicine can be used for decision making, remote
sensing, and collaborative arrangements for the real-time
management of patients at a distance. The use of
telecommunications and information technologies in
providing health services is determined. Telemedicine is
described as combination of topics from the fields of
telecommunication, medicine, and informatics. The medical
systems infrastructure consisting of the equipment and
processes used to acquire and present clinical information
and to store and retrieve data are explained in details. The
challenges existing in telemedicine development in different
countries are given. Technological, political, and
professional barriers in applications of telemedicine are
defined. An investigation of telemedicine applications in
various fields is presented, and enormous impact of
telemedicine systems on the future of medicine is
determined.
In traditional information sharing, data is exchanged
between a sender and a receiver. After the September 11
attack in New York, information technology grew popular as
global information sharing among terrorists began.Electronic
information sharing refers to electronic data exchanges
achieved by using Information and Communications
Technology (ICT) tools, such as the Internet, email, phone,
and websites. With the increased amount of data transferred
through information sharing, the decision-making process
among policy makers are made more easy [1]. Moreover,
ICT is advantageous in that it significantly reduces the time,
energy consumption, and cost for obtaining information [2].
The clinical data warehouse is a place where healthcare
providers can access the clinical data collected throughout
the patient care process for research or management
purposes [3]. The organisation design of the captured data,
which includes data modelling, and normalization, facilitates
the measurement of the effectiveness of the treatment
protocols for systemic diseases and conditions [4]. Several
sectors of the Iraqi government, namely, the Ministry of
Health, Ministry of Municipal, Ministry of Interior, and the
Ministry of Higher Education and Scientific Research
launched a program that utilizes ICT to improve services in
Iraq.
To improve the e-services, the Iraqi government must
promote electronic information sharing among its various
sectors. Hospitals and clinics should share information to
make information available to the different medical
organisations in Iraq [5; 6; 7].The inadequate databases for
electronic information sharing paved the way for the
establishment of data warehouses [8]. Building a data
warehouse will enhance the efficiency of government
organisations as it will reduce the cost and improve the
quality of service. The flow of information across Iraqi
facilities, which largely uses paper forms, starts with the
District Health Office to the Governorate Directorate of
Health, and then to the central Ministry of Health. Despite
the computerization of the Central Health and Vital Statistics
Department, such development has yet to spread in the areas
of information analysis, dissemination, and usage. To
efficiently respond to disease outbreaks, governorates and
health districts require the capacity and authority to enforce
operational service changes based on the collected data.
However, the centralized structure of the existing health
system limits this approach. Thus, the government should
aim to develop the analytical capacity to address
epidemiological and demographic questions related to
healthcare and the adequacy of services in Iraq. To achieve
such a goal, the issues involved in the application of wireless
technology in tele-surgery applications must be examined.
Likewise, the issues in the quality of service in current and
future wireless technologies must be analyzed, as these are
necessary for successful tele-surgery data transfer.
Moreover, the difficulty in sending and receiving medical
information from one site to another should be resolved
through the implementation of an internet data network that
transfers the tele-medical and tele-surgical applications in
Iraq. Finally, a wireless technology to support tele-medical
applications across healthcare organisations should be
developed as well.
1796 ISSN 1013-5316; CODEN: SINTE 8
1.2 TELEMEDICINE ISSUES
At present, the healthcare system in Iraq is characterized by
an increased burden on resources that impede patients’
access to healthcare since 2003 [9]. Other significant
measures include aggressive retention policies, including
enhancing the remuneration and working conditions of
physicians, as well as the protection, safety, and use of
telemedicine [9]. In Iraq, maternal death is considered by the
local community as an avoidable disaster resulting from
negligence. By contrast, deaths caused by medical or
surgical illnesses are regarded as a decree of fate. As such,
obstetricians aim to provide the best possible care to patient
to avoid catastrophes. The availability, accuracy, and
completeness of patients’ health records will be of
considerable help to clinicians [10]. The completeness of
patients’ lifetime health records (LHRs) must be presented
chronologically in a single application system or health
institution, as well as in different applications and
institutions [11]. Health records must be integrated along a
timeline (and independently of sources), such that relevant
and necessary patient information can be easily accessed and
serve as the basis for formulating proper and accurate
medical advice, diagnosis, and treatment for patient
wherever they are. This longitudinal and seamless view of a
patient’s health record will improve the clinicians’ plans for
providing continuous care throughout a patient’s lifetime
[12]. Such objectives will not be attained if the ICT
applications (e.g., telehealth, telemedicine, and hospital
information systems) developed in support of the clinical
processes are rigid. These scenarios are exacerbated by
inadequate Telecommunication infrastructures and limited
system interoperability (e.g., different set-ups of hospital
information systems).
Good care is dependent on the flexible access to previous
LHRs; which must be a feature of future health systems.
Rather than being episodic or fragmented, healthcare must
take the patient’s entire health history into consideration in
order to provide a long-term outlook [13].
Nevertheless, electronic information sharing among
hospitals remains limited, as reported by [5] the Director of
National Centre for Management Development and
Information Technology of the Ministry of Planning in Iraq.
He conducted an extensive survey in various locations in
Iraq, including Baghdad, Salah Al-Deen, Basra, and Al-
Anbar, with a sample of 35 hospital staff members. His
findings showed that information sharing between medical
organisations is 54%, and the authorization among medical
organisations is 34%. Many doctors either left or were killed
in Iraq at the height of the conflict. Although this outflow
has recently diminished, about a quarter of 1500 to 1800
new medical graduates leave for the UK, the USA, and
Australia every year [14].
1.4 CONTRIBUTIONS AND SIGNIFICANCE OF
THE PAPER
The present study will produce a validated flexible
framework for a comprehensive Iraqi telemedicine system.
The framework will be presented to the Ministry of Health
of Iraq for the deployment or the further development of the
telemedicine system in Iraq. The data and results can assist
Sci.Int.(Lahore),26(5),17951800,2014
in benchmarking current telemedicine concepts in Iraq, as
well as in measuring the practicality of the existing
approach.
This study shows important tools to improve healthcare
services for patients by co-locating LHRs with the patient.
Moreover, the patient’s LHR can be accessed and seamlessly
during a doctor–patient encounter regardless of the patient's
location. Such feature of health system/records reduces
medical mistakes and avoids errors in the delivery of
healthcare services.
1.5 TELEMEDICINE IN DEVELOPING
COUNTRIES
Developed countries who have implemented telemedicine
have benefited from its application. Despite the problems in
these systems, they have functioned effectively. By contrast,
developing countries have poor infrastructures, limited
healthcare services, and a significant shortage of doctors and
medical staff. Developing countries should learn from the
experience of developed countries to promote technological
development in the field of healthcare.
The lack of knowledge about the use of technology and the
Internet among doctors and patients are among the
impediments to the spread of telemedicine among
developing countries. In spite of the rising number of
internet users in developing countries, industrial countries
still have more users in comparison [15].Furthermore,
developing countries are faced with economic deficits and
limited resources, which prevent them from developing a
telemedicine project [16]. The limited technology and
internet use in developing countries make people
apprehensive of adopting new technology [17]. As a result,
decision makers and possible sponsors fail to fully
understand the potential benefits from the system, leading to
a shortage in funding [17]. Given the importance of decision
makers in the development of telemedicine, information
dissemination targeted to such players is essential. Thus,
healthcare providers and decision makers can offer seminars
and conferences on the advantages of telemedicine and its
applications to drum up government support.
Developing countries must promote telemedicine through
campaigns and conferences for people to appreciate the
services that telemedicine can offer. In addition, relevant
courses can be offered to educate people and the youth may
be introduced early to computers and technology in order to
develop proficiency. In this manner, students become more
familiar with this technology and open-minded to any
technology-related innovations in the future. Overall,
developing countries have many problems that prevent them
from deploying telemedicine and its applications, whereas
developed countries have overcome most of these problems,
allowing them to utilize telemedicine effectively.
1.6 TELEMEDICINE IN MIDDLE EASTERN
COUNTRIES
The selection and development of suitable instruments for
data collection and analysis are crucial to build a framework.
Likewise, examining an organisation’s readiness for the
adoption of a telemedicine framework is necessary.
Attaining a comprehensive understanding of the
 International Symposium on Research in Innovation and Sustainability 2014 (ISoRIS ’14) 15-16 October 2014, Malacca, Malaysia
Specia issue
Sci.Int.(Lahore),26(5),1795-1800,2014 ISSN 1013-5316; CODEN: SINTE 8
environment and exploring the factors believed to be the
most influential for telemedicine system adoption are
essential. The introduction of telemedicine to the Middle
East is complicated, considering the diverse cultural and
social features of the region. The theories and models
included in the ICT adoption discussed in the previous
chapter are used to develop a framework that encompasses
essential determinants and factors that need to be addressed
and assessed prior to the adoption of telemedicine.
In this regard, three main aspects of readiness are
considered. Firstly, telemedicine readiness is assessed based
on the readiness of technology, as well as the organisation
and the individual. Secondly, evaluating readiness for
telemedicine adoption confers two advantages: first, the
factors determined as positive can be enhanced, and negative
factors that can delay or obstruct the introduction of
telemedicine can be reduced. Thirdly, the degree of
technical, practical, and administrative changes needed to
adopt a telemedicine system can be assessed. The
determinants of the conceptual framework developed for this
study focused on the Kuwaiti healthcare system and on
patients referred overseas for treatment.
Hence, the study will include individual, organisational, and
technical (i.e., the infrastructure for ICT) evaluations. The
diffusion of innovation indicates that the adoption process
must pass through several stages to achieve the intended
decision, from awareness and knowledge to adoption and
implementation [16]. Therefore, the framework identifies the
three factors that are crucial for stakeholders, namely,
individual, organisation, and the ICT infrastructure. The
assessment of the readiness of individuals and their
acceptance of telemedicine are performed based on their
perceptions and concerns. An organization's readiness is
evaluated by exploring future plans for ICT usage,
approaches implemented to reduce the cost of sending
patients abroad for education and training programs, and the
"fertility of the ground" (i.e., encouraging and inhibiting
factors). Technological readiness with regard to the ICT
structure is determined by the availability and capability of
ICT use and the ability of the department to receive the ICT
structure (i.e., telemedicine). These determinants are
collectively influenced by external factors such as culture,
social norms, and beliefs [17]. These factors can be
influential in Arabic societies, and thus, their investigation is
critical for this study. The role of the organisations’ policy
makers in the readiness and usage of ICT at the Kuwait
Ministry of Health is explored by considering its existing
polices. More importantly, appropriate policies for the
telemedicine practice for overseas referral patients in the
Kuwaiti healthcare system must be established, and an ICT-
based strategy must be developed to deliver healthcare
services. Finally, the users will decide to either accept or
reject the new system.
1.7.1 Telemedicine in Saudi Arabia
The Kingdom of Saudi Arabia has recognized the vital
importance of ICT. Thus, the country has made remarkable
progress in different ICT fields including connectivity and
1797
access, sector reforms, national IT initiatives, and e-services
over the years.
1.7.1.1 Saudi Arabian readiness for telemedicine
Prior to telemedicine implementation, readiness must be
determined to ensure the success of the implementation of
telemedicine services in the existing health systems.
Evaluating the readiness for healthcare innovation can
reduce the risk of failure after its introduction [18].
Organisational readiness is vital for ensuring the long-term
success of telemedicine program and services. The readiness
for telemedicine is a flexible concept that has been related to
the planning and the workplace [19]. This concept is
reflected in the beliefs, attitudes, and intentions of an
individual with regard to the extent by which changes are
necessary, as well as the capacity to successfully introduce
changes within the organisation [20]. Findings indicate that
e-health acceptance among stakeholders in military hospitals
is superficial because they lack awareness on the nature of e-
government and e-health programs. The apparent and
persistent digital divide contributes to this perception. Thus,
information literacy activities such as information
dissemination, awareness campaigns, and training initiatives
should be implemented to supplement the limited knowledge
of e-health and other e-government issues of the public, as
well as reduce the rate of digital divide among Saudi
nationals [22].
1.7.1.2 Telemedicine initiatives in Saudi Arabia
In 1993, a royal decree established the e-Health Centre
project titled “KFSH&RC.” The centre utilizes fibre optics
and international video-conferencing through the Saudi
Telecom Company to access medical consultations and to
disseminate healthcare educational materials [18]. The use
of health telematics in the King Faisal Specialized Hospital,
as well as in a cluster of military and private hospitals, has
been met with remarkable success. "One of the most active
parties in telemedicine in Saudi Arabia is the Sultan Bin
Abdulaziz Al-Saud Foundation, which has established the
Sultan Bin Abdulaziz Medical and Educational
Telecommunications Program and the MeduNet Program to
promote and support telemedicine in the Kingdom and
telemedicine cooperation with top medical centres around
the world" [21]. Recently, the Ministry of Health launched a
project that aims to build a centralized national electronic
health record database that connects hospital information
systems in the Kingdom for electronic data and creates a
national electronic healthcare system. The project is
implemented in one of the major hospitals of the five main
regions, with a regional server connected to the Ministry’s
server and a smart ID card for access, which is currently
being designed [22]. The Ministry of Health have likewise
directed its efforts on a program that links 25 more hospitals
from major cities and vital rural areas to advance
telemedicine services and infrastructure, as well as facilitate
international connectivity [21]. Furthermore, the Ministry
started to connect its constituent hospitals through a WAN
and utilize health information systems in these hospitals
[22]. The connected sites of the National Telemedicine
Network increased from 5 to 20 for remote diagnostics and
1798 ISSN 1013-5316; CODEN: SINTE 8
actual operations, as well as voice and video-conferencing
services. Government healthcare providers in Saudi Arabia
intensified their efforts in adopting advanced ICT systems.
Nevertheless, the lack of effective coordination affected the
establishment of a single national network and repository of
health records. Twenty different health information systems
are deployed separately, particularly in large regional
hospitals in Saudi Arabia [22].
1.7.2 Telemedicine in Jordan
A few telemedicine projects have been implemented in
Jordan. In 1998, Madaba was implemented, which was a
joint venture between the King Hussein Medical Centre and
Mayo Clinic in 1990. These efforts, which ran for three
months, ceased because of the lack of funding. The project
was conducted in Jordan in 2008. The sample included key
stakeholders such as doctors, technicians, engineers,
decision makers, and patients. Questionnaires and interviews
were completed by the respondents and other stakeholders.
The results indicated the following major common themes
[23].
1.7.2.1 Funding
Was identified as a major problem in the healthcare system
by several people in Jordan. Most of the private clinics and
hospitals are successfully funded as owners regard these
hospitals as investments and business projects; that is,
improved services increase the benefits received. However,
problems persist in public hospitals in remote areas, such as
in Amman. These public healthcare services require funding
and support to introduce systematic improvements. The
government allocated a budget to each ministry; however,
with the limited budget for healthcare, most of the funding is
channelled to the country budget.
1.7.2.2 Training in IT
Training is no less important than funding or infrastructure,
particularly to understand the essential telemedicine
equipment and its management. Trained nurses and
physicians who are cognizant of the functions and processes
of telemedicine applications are necessary for conducting
such training sessions. These sessions are accomplished with
a remote doctor, who explains relevant information to a
patient who provides the doctor with accurate information,
with the goal of arriving at a correct diagnosis.
1.7.2.3 Doctors and Patients Resistance
A significant issue that prevents telemedicine from being
accepted in Jordan was raised by several doctors: the patient
should be physically present in the same session for the
doctor to provide proper diagnosis in order to reduce errors
in diagnosis. The study found that a number of patients
prefer face to face contact with a doctor and reject
telemedicine. Most patients expressed their concerns on the
backgrounds of the doctor they will consult (e.g., online
consultation); that is, telemedicine might connect them with
a doctor from a different background, resulting in
misunderstandings due to different cultural or religious
backgrounds, as is the case with female patients.
Furthermore, many patients lose confidence in public
doctors and paramedics that apparently lack training and
knowledge; however, these patients are left with no choice
but to visit public hospitals as they are unable to afford
Sci.Int.(Lahore),26(5),17951800,2014
treatment in private hospitals. Doctors are aware of these
concerns, particularly with patients from remote areas.
1.7.3 Telemedicine in Syria
The research was conducted in Syria in 2008. A
representative sample of key stakeholders including doctors,
technicians, engineers, decision makers, and patients were
interviewed, and questionnaires were completed by the key
stakeholders and patients. This study identified the following
major common themes.
1.7.3.1 Infrastructure
The interviewees emphasized poor technological
infrastructure as the major problem in the application of
telemedicine in Syria. In Syria, high technology remains at
its infancy, with mobile phones and internet only having
been present in the country for a few years. According to the
Global Information Technology Report (2008), Syria has the
poorest network infrastructure among the eastern
Mediterranean countries, with a low internet penetration (an
estimated 7.8% in 2007), high cost of internet access, and
lack of internet security. Large international companies with
newly opened branches in Syria reported that the poor
internet performance and security as one of the major threats
to their business. As such, these firms had to establish their
internet connection through an internet service provider
based in a neighbouring country.
Other issues identified in this study include the lack of
regulations protecting the privacy and security of e-
applications, such as e-transaction, e-documentation, and e-
commerce. Consequently, the patients’ data will not be
protected or secured if they are transmitted online between
doctors or hospitals.
1.7.3.2 Funding
Given the poor condition of infrastructure, the application of
telemedicine in Syria will incur a considerable cost. The
government must allot an adequate budget to develop and
maintain the infrastructure, as well as support the application
of telemedicine. Serious efforts should be made towards
collaborating with different ministries to accomplish this
mission. Nevertheless, the Ministry of Health and the
Ministry of Communication are unwilling to fund a project
that has uncertain benefits. Hence, the ministry is waiting for
the private sector to establish a telemedicine project before
making a decision related to a public telemedicine project.
However, the private sector is not willing to fund any
telemedicine project until the government provides the
proper infrastructure and relaxes the process of importing
computers and medical devices.
1.7.3.3 Training and Education
[24], Syrian companies encounter difficulties in training
employees and finding staff with technological experience.
Syria’s market is in need of competent labour force in IT,
and thus, training the staff involved in telemedicine
application is essential. Furthermore, providing training and
seminars for doctors and decision makers is highly
important, because if they value the benefits of technology
in the medical field, they will reap the benefits of the
adoption of telemedicine and facilitate its application.
1.7.3.4 Doctor and Patient Resistance
 International Symposium on Research in Innovation and Sustainability 2014 (ISoRIS ’14) 15-16 October 2014, Malacca, Malaysia
Specia issue
Sci.Int.(Lahore),26(5),1795-1800,2014 ISSN 1013-5316; CODEN: SINTE 8
Almost all interviewees in Syria indicated that social issues
including doctor and patient resistance are the main barriers
in the use and expansion of telemedicine. Most doctors
oppose telemedicine considering the worry on shifting to
this new technology and the lack of relevant experience.
Patients are used to consulting with a doctor who is
physically present in the same room. In particular, older
patients may be more set in their ways, with little or no
experience of modern technology such as computers. Most
patients interviewed in Syria are unfamiliar with
telemedicine. After hearing an explanation, however, a
number of them considered telemedicine as a promising tool
that could improve healthcare standards. Educating people
will help avert resistance and encourage them to accept and
promote the adoption of telemedicine and its applications.
CONCLUSION:
Telemedicine is use of telecommunication system and
information system to remote delivery of healthcare services
over the telecommunications infrastructure. It helps in
eliminating the distance barriers and will improve access to
medical services that wouldn’t be consistently available in
rural communities. In this paper we analyze the need of
telemedicine in developing countries. In Saudi
teleconsultation the author used the grounded theory to find
out the factors while in Syria and Jordan used the theory-
drive to create the conceptual framework, moreover Kuwait
used the technology acceptance model. It is clear that the
design of Telemedicine framework improves the medical
practice in developing countries. But the greatest barrier as
perceived by healthcare providers for not adopting
telemedicine system was lack of knowledge about the
telemedicine and its applications, benefits. For adopting of
telemedicine, the most common cited barriers were lack of
sufficient knowledge about the implementation and other
services of telemedicine, followed by difficulty in the
application and then lack of time to adopt telemedicine. The
Federal government of Iraq and Department of IT in Iraq has
to play a vital role in encouraging telemedicine facilities in
the country by initiating several pilot schemes, funding the
development of telemedicine software and sponsoring major
telemedicine projects.
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