The promise of telemedicine in Pakistan: A systematic review

Abstract Background Telemedicine offers the possibility of provision of medical assistance to remote patients, and it has great potential in developing countries like Pakistan. Telemedicine solves logistical barriers, gives support to weak health systems, and helps to establish worldwide networks of healthcare professionals. Because of the high implementation costs, it is not possible yet to adopt telehealth systems for low‐ and middle‐income nations. Objective To present a revision of region‐based telemedical services in Pakistan. Methods Libraries such as PubMed (Medline), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus (EMBASE), and Google Scholar were used for document search. Newcastle‐Ottawa Scale (NOS) was adopted to conduct study quality. Many of the studies (n−8) included in the review were of high quality as assessed through the Newcastle‐Ottawa scale. Selected study characteristics were further analyzed based on different parameters such as publication year, sample size, study design, methods, motivation, and outcomes. Results Search produced 955 articles and 11 items were ultimately selected to conduct the review. These studies were further characterized as region‐based telemedicine implementation. Out of 11, eight studies were conducted in the urban region and three studies were conducted in the rural areas of Pakistan. Many studies produced evidence on telehealth interventions by smartphone services such as SMS, apps, and web‐based telemedicine. Conclusions Telehealth interventions such as mHealth, eHealth, telemedicine, and telepharmacy in Pakistan were introduced starting from the last two decades. For obtaining the full benefits of these technologies, it is necessary that they but certainly need to become an integral part of Pakistan's current health infrastructure.


| INTRODUCTION
Telemedicine is an integration of technology and medicine. 1 Telemedicine is the way to provide better health care to people in isolated, difficult access areas or zones suffering from a shortage of health services. 2 One of the objectives of telemedicine is to provide equal access to medical expertise irrespective of the geographical location of the person in need. It is more efficacious and extremely useful especially where experts are rare, distances are large, and/or infrastructure is limited. 3 The first experiences of telemedicine date at the beginning of the previous century, when in 1903, Einthoven transmitted the first electrocardiogram. Radiotelegraphy was also used from 1920 for assisting patients onboard ships, which represent the prototype of remote and isolated places. 4 Modern telemedicine techniques have been underdevelopment for nearly 50 years by Wittson and colleagues, which were the first to employ IATV for medical purposes. 5 In 1959, they used a microwave link for telepsychiatry consultations between the Nebraska Psychiatric Institute in Omaha and the state mental hospital 112 miles away. In the 1970 and 1980s, limited telemedicine projects were instituted at several sites in North America and Australia, including the Space Technology Applied to Rural Papa go Advanced Health Care (STARPAHC) project of the National Aeronautics and Space Administration (NASA) in southern Arizona, a project at Logan Airport in Boston, Mass, and programs in northern Canada. 6 Except for the assistance to ships with no medical facilities onboard, which are now assisted by specialized institutions called Telemedical Maritime Assistance Services (TMAS), a 20-year-old telemedicine program at the Memorial University of Newfoundland, St-John's, none of the programs born before 1986 has survived. Although data are limited, the early reviews and evaluations of those programs suggest that the equipment was reasonably effective at transmitting the information needed for most clinical uses and that users were, for the most part, satisfied. 7 Telemedicine has a strong impingement in developing countries since it allows remote areas of a country to get access to medical care and to create local knowledge. 8 It is a flourishing industry, valued at billions of dollars globally. 9 It has been of particular interest for the past few years due to its ability to transcend the common barriers, which prevent people from accessing health care. 10 These include long distances to a functional health facility, lack of doctors in rural areas, and the high cumulative costs associated with a doctor's visit (cost of transportation, income lost due to time off work, and the doctor's fee).
Telemedicine holds the promise of being able to connect patients in the remotest of regions to qualified doctors in urban areas.
Pakistan, like most emerging markets, has a healthcare problem. The rapid increase in population combined with an unstructured system of health care has led to an uneven distribution of doctors, which results in the chronic shortage of doctors in peri-urban and rural areas. In Telemedicine has obvious advantages in the case of emergencies in remote environments such as on ships, in planes, and possibly on the battlefield. 10 In all these situations, it is very difficult that patients can be referred to the doctor in time. Telemedicine has and continues to benefit the Pakistani people healthcare system in terms of preventive care and disease treatment. Several companies are in the process of providing the telecommunication support needed for telemedicine, but much remains to be accomplished before telemedicine can glean its bragged benefits for Pakistan's exponentially growing population.
Pakistan is in a unique position for building its telemedicine infrastructure. With its highly qualified medical practitioners and an emerging technological industry, the country can create products and services to cater to this evolving area. Given proper access and awareness, Pakistan seems Equanimeous to incorporate telemedicine beyond its current rudimentary projects to large-scale programs that can serve as a model for itself and the developing world. 2 By considering these facts, we have reviewed the current situa-  The key search terms included ("Telemedicine" OR "Telecare" OR "Mobile health" OR "eHealth" OR "mHealth" OR "e-health" OR "telehealth") and ("Pakistan").
The sources of each qualifying paper were also scanned for related papers that may not have appeared in the search term results.
The search and selection of studies followed the SPIDER question format and the PICO tool ( Figure 1). Experts were also contacted to find any studies that were missing. Two reviewers among coauthors independently checked the title/abstracts of all the studies listed for inclusion. The full text of the papers was retrieved for further assessment of potentially qualifying research and two review authors separately tested their eligibility. Possible differences were settled through negotiation with a third review author. References to full-text publications meeting the inclusion criteria were reviewed to identify other related records. No grey literature has been searched or included in the study, as well as no dissertations or unpublished studies.

| Inclusion/exclusion criteria
The eligibility criteria for the analysis were that the research should be in the English language. No criteria were set up for the range of the studies and the explanation for this is that only a few studies were identified for mHealth or telehealth in an LMIC setup like Pakistan.
The demographic limitation was set up as we included only those studies that have been conducted in Pakistan. There were no limitations on the study design except for reviews, short communications, or editorials. No limitations on the area of research were applied, although due to the scope of the analysis, most could be categorized as mHealth, eHealth, or telehealth.
Exclusion criteria included narrative reviews, short communications, editorials, and letters to the editors. Telehealth or mHealth studies that were conducted in other low-and middle-income countries (LMICs) setup outside Pakistan were excluded. Studies published in non-indexed or non-peer-reviewed journals were also excluded.
factor was decided considering different parameters such as study selection, preliminary outcomes, and comparability. Based on study quality resulting from the results of the NOS scoring, papers were divided into three categories, namely poor (0-4), moderate (5)(6), and good (7-9) quality. The authors collectively decided these scores by recording each quality parameter score on independent excel sheets. The majority of the studies included in the final review achieved a good (NOS ≥ 7) rating as detailed in Table 1. Selected publications were further characterized based on publication year, sample size, study design, methods, motivation, and outcomes that were further explained in the next section.
3 | RESULTS   Two cross-sectional studies assessed telemedicine knowledge and attitude among doctors 21 and university students. 23 Evaluation of telemedicine use/applications among physicians was found to be in the average but doctors welcomed the integration of new technologies in Pakistan health care. 21 University students in disciplines not related to health expressed a high confidence rate of e-health literacy scale (eHEALS) in searching for health information on the web. 23

| Telemedicine interventions in rural areas of Pakistan
Telehealth services are essential in rural areas to provide reasonable quality health care at low costs. This will result in benefits to rural communities of LMICs by reducing travel costs and time in accessing special care. It is reported that telemedicine has a large potential in improving chronic disease outcomes in LMICs and it can diminish the socioeconomic barriers by cost reduction, also by enabling long-term management and early intervention. 17 Given this, the use of mHealth interventions should be encouraged in remote areas. A study highlighted the efficiency of mHealth on young children (≤24 months). An easy-to-use, smartphone android-based audiovisual application was developed for lady health workers who were then qualified and monitored to use it in the frame of the Infant and Young Child Feeding (IYCF) program. 19 The use of these approaches enables us to understand the use of mHealth in enhancing the knowledge, practices, and attitudes of IYCF mothers in rural areas of Islamabad. Another work on childhood immunization in rural districts of Pakistan provided a qualitative experience on the utilization of digital health technologies among medical staff. 22 The authors developed an android-based app.

| Highlights
Increasing evidence considers telemedicine and mHealth as feasible and alternative forms of health service delivery, particularly for people living in remote areas to access health care in their local communities. Unfortunately, only a few studies have analyzed the satisfaction of patients and caregivers with telehealth. We have identified only three studies conducted in the rural region of Pakistan, suggesting that both patients and caregivers were satisfied with telehealth due to a variety of reasons. 17,19,25 Specifically, attending an appointment in one's local community via telehealth compensated for the hassle of commuting long distances to an urban center for the same appointment. 17 A few studies have used geospatial monitoring along with mHealth for the need for immunization and the significance of completing a sequence of vaccines. 15,16 One study has utilized qualitative interviews to evaluate the experience of district officials during their use of the software to track their daily immunization experience. 25 This work has also tested the acceptability and operability of the program as a tool for tracking vaccine experience. 25 Some studies have also considered the application of telehealth technologies in chronic conditions such as diabetes and hypertension.

CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest during the publication of this work.

AUTHOR CONTRIBUTIONS
Design

TRANSPARENCY STATEMENT
Dr Gopi Battineni affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.