Ethical Aspects and Regulatory Guidelines of Telemedicine: Medical Interns’ Perspectives on Social Media and Medical Applications Usage in Patient Care Open Access

Telemedicine is the provision of healthcare through advancing information and communications technology, aiming to overcome geographical barriers and improve health outcomes [1]. In this study, we define key terms for clarity and consistency. Telemedicine refers to the remote delivery of healthcare services via telecommunications, including video consultations and remote monitoring. Social media (SM) encompasses online platforms for social interaction and information sharing, such as Facebook and Twitter, particularly in health communication. Medical applications (apps) are applications designed to assist in health management, including patient education and appointment scheduling. These definitions provide a framework for understanding their roles in our research.

According to the Centers for Disease Control (CDC), the utilization of telemedicine includes engaging in case management for patients facing difficulties in accessing healthcare, following up after hospitalization, and providing education and training for healthcare professionals [2]. Recently, online health platforms, including SM and medical apps, have emerged as vital tools in the implementation of telemedicine. These platforms enhance health information dissemination, influence patient behavior, and facilitate improved physician behavior, ultimately leading to value creation in healthcare delivery. Recently, online health platforms have grown to become vital tools of telemedicine implementation due to their affordability, ease of use, and scalability. To illustrate, SM has been used to improve communication between patients, physicians, and stakeholders, promote healthcare, distribute knowledge, and educate patients [3].

Moreover, a marked integration of telemedicine in healthcare provision has been witnessed, due to the universal aim to mitigate the current coronavirus disease 2019 (COVID-19) to advocate and increase social distancing; in illustration, physicians now provide 50-175 times the number of telemedicine visits as compared to afore the pandemic [2, 4]. Accordingly, with the major role of information technology in healthcare, the guidelines and ethical deliberations pertaining to the use of telemedicine should be taken into consideration by its users. Nevertheless, low levels of awareness of related guidelines among users are still reported as a major barrier of adequate telemedicine utilization. Ideally, compliance with the appropriate guidelines, such as those provided by the Health Insurance Portability and Accountability Act (HIPAA) would be expected of healthcare providers and users of telemedicine [5, 6]. Additionally, with the rapid utilization of telemedicine, novel ethical circumstances have arisen and require critical handling to ensure the safety and confidentiality of patients and their personal information [7].

Though telemedicine is available in the Kingdom of Saudi Arabia (KSA) since 1993, the Kingdom has recently accelerated its implementation of modern telecommunication technology in healthcare services. The restrictions accompanying COVID-19 pandemic have also contributed to the rapid expansion of telemedicine utilization for healthcare provision in KSA [8, 9]. Some studies have been published regarding telemedicine utilization in KSA; however, very few explored healthcare workers’ views of the ethical and legal considerations of telemedicine [5, 10‒13]. Understanding medical interns’ perspectives is critical, as they represent the future of the healthcare workforce and are often at the forefront of adopting new technologies. Their insights can inform the development of targeted training and guidelines tailored to the unique cultural, regulatory, and technological landscape of KSA. Thus, in the current study, we aimed to assess medical interns’ awareness and behavior of ethical and legal aspects related to the use of SM and medical apps for healthcare provision.

This was a cross-sectional study and targeted medical interns from the 5 main KSA regions, namely: Eastern, Western, Central, Northern, and Southern regions. Data were collected between June and September 2020, utilizing a structured, pretested, self-administered online questionnaire distributed to medical interns via key SM groups for interns in KSA. The inclusion criteria were as follows: medical interns of both genders who were working or undergoing training in any of the 5 main regions. Additionally, the interns were required to have completed their entire internship training year between 2019 and 2021, with the deadline set at July 2020. Conversely, our exclusion criteria were: medical interns working outside KSA and interns who have not completed at least one full internship training period.

To ensure a sufficient number of medical interns from the 5 main regions of KSA, the study initially determined that a minimum sample size of 384 interns was needed. This calculation was performed using the EpiInfoTM Software, with a confidence interval of 95%, a p value of 0.05, and a margin of error of 5%. However, in order to further enhance the representation of interns in the study, the final sample size was increased to 800 medical interns.

The survey inquired of medical interns about their perspectives regarding the utilization of telemedicine, including SM and medical apps. Also, their awareness of telemedicine guidelines, and their knowledge, attitude and practice related to the ethical and legal regulations that oversee the utilization of SM and medical apps in healthcare.

The research team developed the questionnaire by reviewing the existing literature on ethical and legal guidelines related to telemedicine [14‒19]. To ensure its quality, independent physicians who were knowledgeable about the topics evaluated the questionnaire for its content validity and comprehensiveness. Subsequently, the survey was tested on a separate group of 5 medical interns to assess the feasibility of the study. These 5 interns were selected from the intern-colleague-circle of the authors and were later excluded from participation in the actual survey. Feedback from these pilot participants was received either in written format or verbally. From this pilot feedback, we ensured several aspects were adequate, such as survey items’ understandability, acceptability, and length. Additionally, Cronbach’s Alpha estimate is 0.71, indicating good internal consistency for the 11 main items tested in our survey (excluding demographic variables).

To prevent common method bias and variance, at the design and implementation stages of our survey, we included the following:

• 1.

  We ensured that the structured questionnaire was clear, concise, and accurate. To refine the phrasing of each item, we conducted a pre-testing phase.

• 2.

  To minimizes biases stemming from extreme responses and non-conformity, we employed different formats and interchanged the wording of the items. These formats included positive statements, action-oriented statements, neutral statements, and questioning statements.

• 3.

  To prevent participants from perceiving the measurement of the multi-item scale to be repetitive, we presented the scale items in diverse formats. Also, we utilized various response options such as a yes/no questions and others as Likert scale. These measures are intended to discourage participants to use one item as a guide for answering related questions.

• 4.

  Prior to data collection, we assured each participant that their responses would remain anonymous, accessible only to the research investigators, and only for research purposes. This is meant to reassure participants and to create an honest answer when responding to the questionnaire items.

In addition, we conducted an assessment specifically designed to test for common method bias. For this purpose, we employed Harman’s single factor test, utilizing exploratory factor analysis in SPSS (IBM SPSS Statistics for Windows, version 28; IBM Corp., Armonk, NY, USA). The results of the test showed that the total variance explained by a single factor was 27.503%. Since this value is below the 50% threshold, it suggests that CBD does not significantly impact our data. Therefore, our results can reflect to be reliable and valid.

Data were coded and analyzed using SPSS v.28, and the results were presented in tables and figures as frequencies, percentages, and summary statistics. Pilot study data were excluded from the final analyses presented in this article. The association of region of residence in KSA with the medical interns’ awareness of guidelines for health-related use of telemedicine was tested using Chi-square test of significance and a cut-off value for significance of p ≤ 0.05.

Ethical approval for this study was obtained from the Institutional Review Board. Prior to collecting any data, informed consent was obtained, electronically, from all participants involved in the study. Participants were also provided with the assurance that their research data would be treated as confidential, handled solely by the research team, analyzed without personal identifiers. Participants were reassured that they had the right to withdraw their participation at any point if they chose to do so.

A national sample size of 889 medical interns completed the online, self-administered questionnaire. The mean age of the participants was 25 years, with a range between 23 and 28 years old. Additional participants’ demographics are presented in Table 1.

Disease explanation and clinical investigations topped as healthcare services for which medical interns perceive the use of telemedicine would be appropriate, accounting for 471 (53.0%) and 463 (52.1%), respectively. Other healthcare services cited as amenable to telemedicine use are shown in Figure 1.

Two-thirds of the surveyed interns (n = 542, 61%) are not aware of any guidelines for health-related use of telemedicine. There is variation in guidelines’ awareness among the interns sampled from the 5 main regions in KSA, ranging from 91 (55.8%) among participants from the Southern province to 48 (20%) among interns in the Western province (p = 0.000; Table 2).

The professional and ethical use of telemedicine were tackled from different aspects: medical interns' views regarding the reliability of information showed that 406 (45.7%) of interns were aware of the reporting system if there were any accounts found sharing unreliable information, 554 (62.3%) think it is important for healthcare professionals to provide the source of information they post online, 554 (62.3%) think it is essential to report any account that shares unreliable health-related information, 530 (59.6%) agreed that if they found one of their colleagues sharing incorrect information about a certain medical condition in their personal SM accounts, they would feel responsible to tell them the true information and ask them to delete/correct the post, and 515 (57.9%) agreed that they would make sure to provide adequate and reliable information for their patients if they ask about their illness via SM (Fig. 2).

The medical interns were also asked about their awareness of any guidelines governing physicians’ online self-promotion activities: 316 (35.5%) reported that they are aware of the rules and regulations about online self-promotion (Fig. 3). Concerning patient privacy and confidentiality, 526 (59.2%) of medical interns would report accounts violating patient privacy and 548 (61.7%) would obtain a patient’s informed consent before sharing their information for healthcare purposes on SM (Fig. 4).

This study sample covers medical interns who had completed their internship, representing future physician behavior of online health platform use. Our data reveal that only about a third of participating interns were aware of telemedicine guidelines or regulations governing physicians’ online self-promotion activities; 39% and 35.5%, respectively. The low levels of awareness can be attributed to several factors, including gaps in medical education, insufficient emphasis on telemedicine in training programs, and possible regional disparities in access to resources and information. Many medical curricula may lack comprehensive training on digital health technologies, leading to a disconnect between theoretical knowledge and practical application. Furthermore, institutional support varies significantly, with some medical schools prioritizing telemedicine training more than others. To address these gaps, it is imperative for medical institutions to integrate telemedicine education into their curricula comprehensively. Specific strategies could include developing standardized training modules, fostering partnerships with telemedicine platforms for hands-on experience, and ensuring ongoing professional development for interns and practicing physicians alike. These measures will better prepare future physicians to navigate the evolving digital landscape in healthcare.

Recent studies highlight the growing importance of telemedicine in Saudi Arabia, especially during the COVID-19 pandemic. Telemedicine has been utilized for triage, direct care, follow-up, and consultation [20]. However, disparities in access exist, with older, less educated, and rural populations having lower usage rates [21]. The Saudi Vision 2030 supports digital healthcare investment, but barriers such as cultural issues and technical difficulties need addressing [20]. Telerehabilitation guidelines have been established to standardize practice across the country [22]. During the pandemic, Saudi Arabia developed numerous apps and platforms for public health and healthcare services [23]. While physicians reported overall satisfaction with telemedicine (64.3%), only one-third preferred it over office visits [10]. Patient satisfaction with telemedicine services was high (88.82%), suggesting its potential as a permanent healthcare solution [24].

Disease explanation and health promotion were cited, as suited for delivery via telemedicine modalities, by 53.0% and 43.6% interns, respectively. This aligns with recent studies during the COVID-19 pandemic, which reported that 85.3% and 90.94% of physicians agreed that health promotion could be effectively delivered through audio and video consultations [25, 26]. The consensus among our participants, with 52.1% agreeing that telemedicine could facilitate communication of patients’ laboratory and radiological investigation results, echoes findings from a Bangladeshi study where 49% of physicians confirmed that investigation results could be communicated online [27].

Regarding history taking and physical examination, approximately one-third (41.7% and 34.9%, respectively) of our participants agreed these can be carried out through telemedicine modalities. While telemedicine can provide valuable diagnostic clues [28], concerns about misdiagnosis persist, with 62.2% of physicians in the UAE expressing similar apprehensions [25]. A significant number of Saudi physicians (54%) believed that initial patient visits should not occur via telemedicine, favoring in-person consultations for comprehensive assessment [10]. Likewise, international literature revealed that 87% of physicians do not agree that patients’ physical examination can be conducted remotely through telemedicine [29] with only 32% stating they could perform a complete examination via telemedicine [30]. However, it is worth noting that the role of telemedicine in physical examination is expected to expand, particularly during public health crises like the COVID-19 pandemic. Various disciplines have demonstrated suitability for patient remote engagement, including tele-psychiatric evaluations [30‒32]. Additionally, it has been shown to be effective in managing various diseases, and specific studies have explored its effectiveness in managing conditions such as rheumatoid arthritis, heart failure, and cancer pain [33‒35].

In the sensitive context of breaking bad news, less than a quarter (22.2%) of our respondents approved conducting it during a telemedicine patient encounter. Traditionally, bad (medical) news would be delivered by a physician, in-person and in a specific environment such as choosing a quiet private place to deliver the bad news [36]. Nevertheless, attitudes are changing regarding this issue and delivery of bad news via telemedicine modalities is currently growing in practice, as reported in some oncology clinics [37]. This shift reflects a broader trend where healthcare providers recognize the potential of telemedicine to facilitate difficult conversations, especially when in-person meetings are not feasible. Such changes underscore the need for training and guidelines to help healthcare professionals navigate these challenging interactions effectively.

Awareness of regulating guidelines for health-related use of telemedicine is essential for safe clinical practice nevertheless, only 39% of our interns were aware of any such guidelines. This finding parallels similar results among Saudi physicians [6, 12] and highlights a significant gap in knowledge that could impact the quality of telemedicine services. Of note, telemedicine regulations in KSA were recently published by the Saudi National Health Information Centre [15]. Previous regulations published by the Saudi National Health Information Centre [38] emphasize the necessity of establishing a clear telemedicine legal framework. Such frameworks should address the complexities arising from the interplay of various guidelines and ethical considerations [11]. Moreover, targeted training for healthcare professionals is essential to enhance their understanding and compliance with these regulations, ensuring that they are well-equipped to provide safe and effective care.

Moreover, our data reveal variation of interns’ awareness of telemedicine guidelines ranging from 20.0% to 55.8% among different KSA regions. This inconsistency suggests that access to training and resources may differ across regions, impacting healthcare professionals’ overall knowledge of telemedicine [12]. Such disparities highlight the need for a standardized approach to telemedicine education and training that can ensure all healthcare workers, regardless of their location, are equipped with the necessary knowledge and skills. Establishing a unified framework could facilitate better implementation of telemedicine practices and improve patient care across diverse settings [11‒13].

Previous reports assessing the quality and reliability of health information found on SM showed it could be unreferenced, incomplete or informal thus, of low quality [18, 19]. In our study, less than half (45.7%) of interns were aware of reporting systems for unreliable health-related information, though two-thirds (62.3%) agreed on the necessity of such reporting. This is consistent with literature highlighting the ethical duty of physicians to combat misinformation and misconceptions [14], since reporting helps combat spread of misinformation and misconceptions. Two-thirds of our respondents agreed they would feel responsible to correct colleagues found posting incorrect information about a certain medical condition in their SM accounts, and request deletion/correction of such a post; this is also supported by the American Medical Association (AMA) recommendations [39]. Moreover, with regards to sharing health-related information on the internet, 62.3% of the participants in our study expressed the importance of including the source of such information. Additionally, 57.9% of the participants agreed that if their patients were to inquire about their medical condition through SM, they would take necessary measures to provide accurate and trustworthy information.

Regarding physicians’ online self-promotion, only a third (35%) of our interns were aware of its governing rules and regulations, while 44.4% found that it helps in spreading awareness about the medical field. Earlier reports revealed that SM use can significantly boost the image of a medical center or hospital; for instance, 57% of consumers stated that a hospital’s SM presence would greatly influence their choice of healthcare provider, and 12.5% of surveyed healthcare organizations successfully attracted new patients through SM [40, 41]. This aligns with our findings, emphasizing the importance of establishing a strong online presence for healthcare professionals. Consequently, it is crucial to raise awareness among both physicians and patients regarding the rules and regulations related to online media, as its use by both parties is becoming increasingly unavoidable. Furthermore, 21.9% of our respondents indicated they would pay SM influencers to advertise for them, echoing another study that reports 11% of physicians use their blogs to advertise and endorse products. This highlights a growing trend in the medical field where online marketing strategies are becoming commonplace. In this regard, the Federal Trade Commission regulations require the disclosure of material connections between advertisers and endorsers [14], underscoring the necessity for transparency in physician marketing practices.

Overall, our sampled interns displayed good knowledge of the ethical codes, as designated by the AMA [19, 39], regarding the use of SM in healthcare. Notably, 59.2% recognized the need to report any account that violates patient privacy, and 61.7% understood the importance of obtaining informed consent before sharing a patient’s personal data on SM for healthcare purposes. This knowledge is crucial, as online patient privacy breaches can cause severe and lasting harm, given the wide reach of SM and the longevity of digital information. Of note, the American HIPAA Privacy Rule, levies heavy charges on unauthorized disclosure of individually identifiable health information, whether intentional or inadvertent [5, 14, 42]. Physicians should be cognizant of standards of patient privacy and confidentiality and assure maintenance of their protection online as in all environments [39]. Even when physicians post the information anonymously, some investigative methods can directly link legal information to a specific person [43, 44]. Research has shown that healthcare providers do not encourage sharing of safety incidents that occur in hospitals through SM as this may affect everyone’s privacy including patients, hospital personnel and the hospitals themselves and their policies [45]. Furthermore, while sharing personal health information online may be highly rewarding, such as when transmitting patients’ data in those cases when a second opinion is solicited, [45, 46], it should be balanced against the potential risk to patients’ confidentiality and privacy it carries [47]. This underscores the necessity for healthcare professionals to navigate the complexities of online sharing with a strong ethical compass.

As evidenced by many articles and studies, patient privacy is a delicate matter and may be threatened by telemedicine and SM’s vulnerability to violation, posing as a major barrier to the wide adoption of telemedicine [11, 14, 18, 43, 48]. In line with this, only a third of our participants agreed that it is legal to give consultation through personal accounts. According to the AMA, under the circumstance that a patient-physician relationship already exists, informed consent with careful discussion of potential risks and limitations, before-hand, is necessary for any clinical interaction by physicians with their patients online [14, 39]. Healthcare providers can find themselves facing legal consequences if any violation, intentional or otherwise, is to occur in connection to patients’ requests for medical advice online [18]. Recent reports found that 42.9% of physicians believed telemedicine disrupts the doctor-patient relationship [49], and establishing a patient-physician relationship on SM may be medically and ethically objectionable [11, 50]. Nonetheless, patient interaction through SM is reported as popular, favored by 60% of sampled physicians interacting with patients through SM [1], and that “supplemental electronic communication emphasizes physicians’ advice and improves adherence for patients with chronic diseases” [51]. These findings highlight the need for a balanced approach in leveraging SM for patient interaction, weighing the benefits of increased communication against the potential risks to privacy and ethical standards.

Globally, telemedicine presents numerous ethical and legal challenges, including patient privacy, confidentiality, informed consent, data security, and autonomy [46, 52]. Key concerns involve the doctor-patient relationship, malpractice, cross-border licensure, and reimbursement [53]. Ethical dimensions encompass equitable access, quality of care, and maintaining professional standards in virtual settings [54]. Legal issues arise from cross-border consultations, jurisdictional problems, and the need for updated legislation and infrastructure [30, 55]. The rise of “selfie telemedicine” introduces additional complexities regarding record-keeping, image quality, and unsolicited medical advice request [56]. Despite these challenges, telemedicine offers significant benefits in improving healthcare access and continuity of care [57]. Addressing these issues requires collaborative efforts to establish clear guidelines, secure patient data, ensure informed consent, and create adaptable regulations [52].

The COVID-19 pandemic catalyzed a rapid expansion of telemedicine, transforming it from an underutilized service to a primary mode of healthcare delivery [58, 59]. This shift was facilitated by relaxed regulations, increased insurance coverage, and technological advancements [60, 61]. Studies indicate that telemedicine offers benefits such as improved access to care, convenience, and cost-effectiveness [62, 63]. However, challenges persist, including technological barriers, regulatory issues, and concerns about equitable access [58, 64]. To ensure the sustainable adoption of telemedicine post-pandemic, recommendations include developing comprehensive policies, investing in infrastructure, and addressing licensure and privacy concerns [60, 63].

Our study has several strengths to support its results, such as recruitment of medical interns from all 5 main regions of KSA, a reasonably large sample size of about 900 participants and a balanced male-to-female ratio. Additionally, the inclusion of medical interns who were at the end of their internship training ensured that their perspectives truly reflected those of typical interns. Furthermore, data collection was done a few months after the major shift to telemedicine in KSA, due to COVID-19 pandemic restrictions, ensuring our participants’ familiarity with the aspects reported here regarding telemedicine, SM and medical apps’ use in healthcare delivery. Nevertheless, our findings have several limitations. First, the relatively restricted online communication that our target study population, medical interns, has with patients may limit the generalizability of our results to more senior medical trainees and physicians, who may have different levels of online interaction. Additionally, reliance on self-reported data may introduce biases, as participants might overestimate their knowledge or experiences. Furthermore, biases arising from the online recruitment process may affect the representativeness of our sample. Since our study aimed to describe the current “status quo,” it thus does not lend itself to qualitative insights that could provide a deeper understanding of participants’ perceptions regarding online healthcare delivery. Future studies should consider employing mixed-method approaches and enhancing recruitment strategies to address these limitations.

Moreover, future research should focus on specific areas to enhance the effectiveness of telemedicine. First, exploring its use among various healthcare professional categories, such as pharmacists and allied health providers, can provide insights into broader applications. Investigating the impact of specific training programs on healthcare professionals’ telehealth competencies and patient outcomes is also essential. Researchers should evaluate the effectiveness of proposed telemedicine guidelines to assess their impact on service delivery and patient satisfaction. Finally, identifying medical conditions best suited for telemedicine will help refine its application and improve patient care.

Our medical interns exhibited a relatively low level of knowledge regarding the potential utilization and the legal and ethical aspects of healthcare delivery through online health platforms such as SM and medical apps. Knowledge of guidelines regulating health-related use of telemedicine and online self-promotion was also low among our participants. Conversely, the reliability of health information shared online was deemed vital by the majority of respondents. These findings, coupled with the rapidly developing technologies and the increasing role of SM and medical apps in healthcare, underscore the necessity for developing and implementing specific regulations and guidelines. We recommend creating targeted training modules for medical interns that focus on the ethical and legal dimensions of telemedicine, as well as effective communication strategies for utilizing online platforms. Furthermore, establishing regional and institutional policies to address disparities in telemedicine knowledge and practice is crucial. Such measures would enhance the quality of healthcare delivery while protecting the safety of healthcare professionals and patients alike. To facilitate the proper use of these technologies, targeted training focused on both patient and physician behavior is warranted.

We would like to extend our deepest gratitude to our colleague Dr. Dhuha N. Boumarah for her valuable time and contribution in structuring and distributing the study questionnaire. Also, we wish to express our special appreciation and thanks to all our study participants, the medical interns, for their participation in this research and sharing their perspective on the study topic.

The study was held in accordance with the World Medical Association Declaration of Helsinki 1975 (revised in 2000). Ethical approval for this study was obtained from the Institutional Review Board (IRB) of Imam Abdulrahman bin Faisal University, vide letter No. IRB-UGS-2019-01-205. Informed written consent was obtained from all subjects involved in the study.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Dr. Dalia Yahia M. El Kheira conceived the concept and design choice for the study and has a role in implementing the study, data collection, analysis, and interpretation of data, and contributed substantially to the writing of this article, read, edited, and approved its final version and is the corresponding author. Dr. Razan Z. Alshammari, Dr. Sara A. Alali, and Dr. Razan Abdulrahman Alshamsi have similar roles in data collection, analysis and interpretation of data, and contributed substantially to the writing of this article, read, edited, and approved its final version. Dr. Loay M. Bojbara and Dr. Mohammed A. Alyahya have similar roles in data analysis and interpretation, and contributed substantially to the writing of this article, read, edited, and approved its final version.

The data supporting the findings of this study are not publicly available, as they contain information that could compromise the privacy of research participants. However, they are available from the corresponding author, D.Y.E., upon reasonable request.