Introduction

Emergency departments (EDs) represent critical access points within healthcare systems, providing immediate care for acute illnesses and injuries. In Saudi Arabia, EDs face significant challenges, including increasing patient volumes, geographic disparities in specialist availability, and variable resource distribution across different regions and facility types [2]. These challenges can impact timely access to appropriate emergency care, particularly for patients in rural and underserved areas or those requiring specialized expertise not immediately available at the presenting facility.

Telemedicine, defined as the use of telecommunications technology to provide clinical services when participants are at different locations, offers potential solutions to these emergency care challenges [3]. Telemedicine applications in emergency medicine include teleconsultation with specialists, remote triage and assessment, virtual supervision of procedures, remote interpretation of diagnostic studies, and virtual follow-up care. These applications have demonstrated benefits in various healthcare systems globally, including improved access to specialist expertise, reduced time to treatment for time-sensitive conditions, decreased unnecessary transfers, enhanced resource utilization, and improved clinical outcomes for selected conditions.

The Saudi healthcare system is undergoing significant transformation under Vision 2030, with emphasis on digital health solutions to improve access, quality, and efficiency [4]. The National Digital Health Strategy explicitly identifies telemedicine as a priority area for development and implementation. This strategic emphasis aligns with the broader national focus on digital transformation as a key driver of healthcare improvement and economic diversification.

Despite this strategic emphasis, the actual implementation of telemedicine in Saudi emergency departments remains variable and poorly documented. Previous research on telemedicine in Saudi Arabia has primarily focused on general applications, technical aspects, or theoretical frameworks, with limited attention to emergency department-specific implementation, barriers, and facilitators [1]. This knowledge gap hinders evidence-based planning and policy development to optimize telemedicine integration into emergency care delivery.

The implementation of telemedicine in emergency settings involves complex interactions between technology, clinical workflows, organizational structures, and human factors. International experience suggests that successful implementation requires attention to technical infrastructure, staff engagement and training, workflow integration, regulatory frameworks, and sustainability planning [5]. These factors likely operate in the Saudi context as well, but potentially with unique manifestations reflecting the specific characteristics of the Saudi healthcare system, workforce composition, and cultural environment.

This study aims to address the knowledge gap by providing a comprehensive assessment of telemedicine implementation in Saudi emergency departments. Specifically, we seek to: 1. Document the current status of telemedicine implementation across Saudi EDs 2. Identify technical, organizational, and cultural barriers to implementation 3. Determine factors associated with successful implementation 4. Develop a framework for effective telemedicine integration in Saudi emergency care

The findings will inform healthcare administrators, policymakers, and clinicians seeking to implement or optimize telemedicine applications in emergency settings within Saudi Arabia and similar healthcare contexts.

Figure 1: Application of Telemedicine in Emergency Care Challenges1

Methodology

Study Design and Setting

This study employed a sequential explanatory mixed-methods design, combining quantitative and qualitative approaches to provide a comprehensive assessment of telemedicine implementation in Saudi emergency departments. The study was conducted between October 2024 and February 2025, following approval from the Institutional Review Board of King Faisal University (approval number: KFU-IRB-2024-10-05).

The quantitative phase consisted of a cross-sectional survey of emergency department directors across Saudi Arabia. The qualitative phase involved detailed case studies of four emergency departments with established telemedicine programs. This mixed-methods approach allowed for triangulation of findings and provided complementary insights into the complex phenomenon of telemedicine implementation in emergency care.

Survey Development and Distribution

The survey instrument was developed based on a comprehensive literature review and consultation with experts in emergency medicine, telemedicine, and implementation science. The initial questionnaire was reviewed by a panel of seven experts, and content validity was assessed using the Content Validity Index (CVI). Items with CVI scores below 0.78 were revised or eliminated. The final questionnaire was pilot-tested in five EDs not included in the main study to assess clarity, comprehensibility, and time required for completion.

The final survey consisted of five sections: 1. Hospital and ED characteristics (10 items) 2. Current status of telemedicine implementation (15 items) 3. Applications and utilization patterns (12 items) 4. Barriers to implementation (15 items on a 5-point Likert scale) 5. Facilitators and success factors (15 items on a 5-point Likert scale).

Table 1: Structure of the Final Survey

The survey was distributed electronically to the medical directors of 65 emergency departments across Saudi Arabia, representing different geographic regions, hospital types (government, private, academic), and levels of care (secondary, tertiary). Three reminder emails were sent at two-week intervals to maximize response rate.

Case Study Selection and Data Collection

For the qualitative phase, we conducted detailed case studies of four emergency departments that had successfully implemented telemedicine programs. These sites were selected using purposive sampling to ensure diversity in terms of: - Geographic location (different regions of Saudi Arabia) - Hospital type (academic, government, private) - Telemedicine application type (specialist consultation, triage, follow-up) - Implementation maturity (recently implemented vs. established programs)

Data collection for each case study included: 1. Semi-structured interviews with key stakeholders (ED director, telemedicine coordinator, physicians, nurses, IT staff, administrators) 2. Document review (implementation plans, protocols, evaluation reports, usage statistics) 3. Direct observation of telemedicine applications in clinical use.

Table 2: Data Collection Methods for Case Studies

The interview guide was developed based on preliminary survey findings and included open-ended questions exploring implementation processes, barriers, facilitators, success factors, and lessons learned. Interviews were conducted in person or via videoconference, lasted 45-60 minutes, and were audio-recorded with participant consent. All interviews were conducted in English or Arabic based on participant preference.

Data Analysis Methods

Quantitative Analysis

Survey data were analyzed using SPSS version 28.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize hospital characteristics, implementation status, and application patterns. Continuous variables were presented as means and standard deviations, while categorical variables were presented as frequencies and percentages.

Barriers and facilitators were ranked based on mean scores, and factor analysis was conducted to identify underlying dimensions. Principal component analysis with varimax rotation was used, and factors with eigenvalues greater than 1 were retained.

Bivariate analyses including chi-square tests, t-tests, and one-way ANOVA were conducted to examine associations between hospital characteristics and implementation status, barriers, and facilitators. Multivariate logistic regression was performed to identify independent predictors of active telemedicine implementation, controlling for potential confounders. Statistical significance was set at p<0.05 for all analyses.

Qualitative Analysis

Interview recordings were transcribed verbatim, and Arabic interviews were translated into English by bilingual researchers. Transcripts were analyzed using thematic analysis following Braun and Clarke’s six-step approach: familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

Two researchers independently coded the transcripts using NVivo 14 (QSR International, Melbourne, Australia). Initial codes were compared and discussed to develop a coding framework, which was then applied to all transcripts. Emerging themes were reviewed and refined through iterative discussion among the research team until consensus was reached.

Case study data were analyzed using both within-case and cross-case approaches. Within-case analysis focused on understanding the unique implementation journey of each site, while cross-case analysis identified common patterns, success factors, and challenges across sites.

Integration of Findings

Quantitative and qualitative findings were integrated using a weaving approach, where results from both methods were presented together by theme rather than by method. This integration allowed for a comprehensive understanding of telemedicine implementation in Saudi EDs, with qualitative findings providing context and depth to quantitative results.

Results

Current Implementation Status Across Saudi Emergency Departments

Of the 65 ED directors invited to participate, 45 completed the survey (response rate: 69.2%). Participating EDs represented diverse settings, with 26.7% from academic medical centers, 53.3% from government hospitals, and 20.0% from private facilities. The majority (73.3%) were in urban areas, while 26.7% were in rural or semi-urban settings. Regarding level of care, 60.0% were tertiary and 40.0% were secondary care facilities.

The current status of telemedicine implementation varied significantly across the surveyed EDs (Figure 1). Among the 45 EDs, 10 (22.2%) reported active implementation of at least one telemedicine application, 15 (33.3%) were in planning or early implementation stages, and 20 (44.4%) had no immediate plans for telemedicine implementation. Among EDs with active implementation, the median duration of implementation was 1.5 years (range: 0.5-3.5 years).

Implementation status was significantly associated with hospital type (p=0.012) and level of care (p=0.008). Academic medical centers had the highest rate of active implementation (41.7%), followed by government hospitals (16.7%) and private hospitals (11.1%). Similarly, tertiary care facilities had higher rates of active implementation (33.3%) compared to secondary care facilities (5.6%).

Among EDs with active implementation (n=10), the most common telemedicine applications included teleconsultation with specialists (90.0%), remote triage and assessment (70.0%), virtual follow-up care (60.0%), remote interpretation of diagnostic studies (50.0%), and virtual supervision of procedures (30.0%). The specific specialties most frequently involved in teleconsultations were neurology (88.9%), cardiology (77.8%), pediatrics (66.7%), and toxicology (55.6%).

Regarding integration with existing systems, 70.0% of telemedicine implementations were integrated with electronic health records, 60.0% with picture archiving and communication systems (PACS), and 40.0% with clinical decision support systems. The majority (60.0%) were commercial solutions from established vendors, while 30.0% were developed through academic-industry partnerships and 10.0% were developed in-house.

Table 3: Current Implementation Status of Telemedicine in Saudi EDs

Application Types and Their Clinical Impact

The survey assessed perceived clinical impact of telemedicine applications on a 5-point Likert scale (1=no impact, 5=significant impact). Among EDs with active implementation, the highest-rated applications in terms of perceived impact were teleconsultation for stroke (mean score: 4.5±0.7), teleconsultation for pediatric emergencies (4.2±0.8), and remote triage for mass casualty incidents (4.0±0.9).

Case studies provided deeper insights into specific applications and their clinical impact. At Site A, an academic medical center in the Central region, a telestroke program had been implemented for 3.5 years. The program connected the ED with neurologists for rapid assessment of potential stroke patients, facilitating timely thrombolysis decisions. Implementation was associated with a 35% reduction in door-to-needle time and a 20% increase in thrombolysis rates:

“The telestroke program has transformed our ability to deliver timely care for stroke patients. Before, we often had to transfer patients without treatment or make thrombolysis decisions without specialist input. Now, neurologists can assess patients remotely within minutes, guiding our treatment decisions and improving outcomes.” (ED Director, Site A)

At Site B, a government hospital in the Western region, a pediatric teleconsultation program had been implemented for 2 years. The program connected the ED with pediatric specialists at a tertiary children’s hospital, providing real-time consultation for complex pediatric cases. Implementation was associated with a 40% reduction in unnecessary transfers and improved management of pediatric emergencies:

“Having immediate access to pediatric specialists has significantly enhanced our confidence and capability in managing critically ill children. We can now provide more definitive care locally for many conditions that previously would have required transfer, reducing stress for families and preserving tertiary center capacity for the most complex cases.” (ED Physician, Site B)

At Site C, a private hospital in the Eastern region, a virtual follow-up program had been implemented for 1.5 years. The program provided virtual follow-up appointments for selected ED patients, reducing the need for in-person returns. Implementation was associated with improved patient satisfaction and reduced ED revisits:

“The virtual follow-up program has been particularly valuable for patients with limited mobility or those living far from the hospital. We can assess wound healing, medication response, and symptom resolution without requiring patients to physically return to the ED, which has been very well received by patients and providers alike.” (Telemedicine Coordinator, Site C).

Table 4: Telemedicine Applications and Their Clinical Impact in Saudi EDs

Technical, Organizational, and Cultural Barriers

Respondents rated various barriers to telemedicine implementation on a 5-point Likert scale (1=not a barrier, 5=major barrier). The highest-rated barriers are presented in Table 1. Technical infrastructure limitations received the highest mean score (4.2±0.9), with 77.8% of respondents rating it as a significant or major barrier. Other prominent barriers included staff resistance to change (4.0±1.0, 71.1%), workflow integration challenges (3.9±1.1, 66.7%), inadequate training (3.8±1.0, 64.4%), and concerns about legal liability (3.7±1.1, 62.2%).

Factor analysis of barrier items identified four underlying dimensions: technical barriers (explaining 27.5% of variance), organizational barriers (explaining 24.3% of variance), human factors barriers (explaining 20.8% of variance), and regulatory/legal barriers (explaining 15.4% of variance).

Table 5: Key Barriers to Telemedicine Implementation in Saudi EDs

Case studies provided deeper insights into these barriers. Regarding technical infrastructure, participants highlighted challenges with internet connectivity and bandwidth:

“Reliable high-speed internet is essential for real-time telemedicine applications, but connectivity remains inconsistent in some areas of our facility, particularly during peak usage times. This has occasionally disrupted teleconsultations at critical moments.” (IT Director, Site D)

Staff resistance emerged as a significant challenge, often rooted in concerns about workflow disruption and technology reliability:

“Initially, many physicians and nurses viewed telemedicine as an additional burden that would slow them down during already busy shifts. There was skepticism about the reliability of the technology and concern that it would complicate rather than streamline care processes.” (ED Director, Site B)

Workflow integration challenges were frequently mentioned:

“The biggest implementation challenge was integrating telemedicine into existing workflows without disrupting efficiency. Early attempts created parallel processes that added steps rather than replacing them, leading to resistance and workarounds.” (Telemedicine Coordinator, Site A)

Cultural factors also influenced implementation:

“There were concerns about how patients would perceive telemedicine, particularly older patients or those from traditional backgrounds. Some staff worried that patients would feel they were receiving lower quality care if seen virtually rather than in person.” (ED Physician, Site C)

Table 6: Summary to the key insights from the case studies on telemedicine barriers

Success Factors and Implementation Strategies

Respondents rated various facilitators of successful telemedicine implementation on a 5-point Likert scale (1=not important, 5=very important). The highest-rated facilitators are presented in Table 2. Leadership commitment received the highest mean score (4.6±0.6), with 84.4% rating it as important or very important. Other key facilitators included dedicated telemedicine champions (4.4±0.7, 80.0%), adequate training programs (4.3±0.8, 77.8%), phased implementation approach (4.2±0.8, 75.6%), and clear clinical protocols (4.1±0.9, 73.3%).

Multivariate logistic regression analysis identified several factors independently associated with active telemedicine implementation. These included leadership commitment (OR=3.8, 95% CI: 1.9-7.6, p<0.001), dedicated telemedicine champions (OR=3.2, 95% CI: 1.6-6.4, p=0.001), phased implementation approaches (OR=2.7, 95% CI: 1.4-5.3, p=0.003), and academic affiliation (OR=2.4, 95% CI: 1.2-4.8, p=0.012).

Table 7: Summary to the key success factors and implementation strategies for telemedicine

Table 8: Factors Associated with Active Implementation (Multivariate Analysis)

Case studies revealed several successful implementation strategies. A problem-first rather than technology-first approach was emphasized:

“Our successful implementations started with a clearly defined clinical problem that telemedicine could potentially address, not with a technology looking for an application. This ensured relevance and facilitated clinician buy-in.” (ED Director, Site A)

Engaging frontline clinicians throughout the development and implementation process was consistently highlighted:

“We established a clinical advisory group that participated in every phase from initial needs assessment through post-implementation evaluation. Their input shaped the user interface, clinical protocols, and workflow integration, which was crucial for adoption.” (Implementation Lead, Site B)

A phased implementation approach was universally employed:

“We started with a limited pilot in one area of the ED, refined based on feedback, then gradually expanded. This allowed us to identify and address issues at a manageable scale before wider deployment.” (Telemedicine Coordinator, Site C)

Robust evaluation frameworks were established from the outset:

“We defined clear metrics for technical performance, clinical outcomes, workflow impact, and user satisfaction before implementation. This provided objective data to demonstrate value and guide refinements.” (Quality Improvement Director, Site D)

Continuous education and support were emphasized:

“We developed a multi-modal education program including workshops, simulation sessions, at-elbow support, and just-in-time resources. This ongoing support was critical for maintaining engagement and addressing evolving needs.” (Clinical Educator, Site A).

Table 9: Summary to the successful implementation strategies for telemedicine

Discussion

This study provides the first comprehensive assessment of telemedicine implementation in Saudi emergency departments, revealing both the current landscape and a path forward for effective integration [6]. The findings highlight significant variability in implementation status, with academic and tertiary care centers leading adoption. This pattern reflects a common trajectory for healthcare innovations, where academic centers often serve as early adopters due to their research orientation, educational mission, and typically greater resources for innovation.

The predominance of specialist teleconsultation applications, particularly for time-sensitive conditions like stroke and complex presentations like pediatric emergencies, aligns with international trends in emergency telemedicine [7]. These applications address high-priority clinical challenges where specialist expertise can significantly impact outcomes, and where traditional approaches to specialty consultation may be suboptimal due to geographic or temporal constraints [8].

The barriers identified in this study—technical infrastructure limitations, staff resistance, workflow integration challenges, inadequate training, and legal concerns—echo findings from telemedicine implementation studies in other healthcare systems [9]. However, the specific manifestations of these barriers reflect the unique Saudi healthcare context. For example, technical infrastructure challenges may be more pronounced in certain regions or facility types, while cultural considerations regarding virtual care may have distinctive characteristics in the Saudi population [10].

The success factors identified—leadership commitment, dedicated champions, adequate training, phased implementation, and clear protocols—provide valuable guidance for implementation efforts. The critical importance of leadership commitment aligns with broader literature on healthcare innovation, which consistently identifies leadership as a key determinant of successful change 11]. The significance of dedicated champions highlights the value of individuals who can bridge clinical and technical domains, advocate for the innovation, and support colleagues through the adoption process.

The implementation strategies revealed through our case studies offer practical insights for emergency departments considering telemedicine adoption. The problem-first approach ensures that telemedicine applications address genuine clinical needs rather than representing technology in search of an application [13]. This approach aligns with user-centered design principles and increases the likelihood of meaningful impact and sustained adoption. Similarly, the phased implementation approach allows for iterative refinement and manageable change, reducing the risks associated with large-scale technology deployment.

Based on our findings, we propose a framework for effective telemedicine integration in Saudi emergency departments [12]. This framework emphasizes five interconnected domains: needs assessment, infrastructure development, workforce preparation, implementation approach, and evaluation. Within each domain, specific strategies are recommended based on the identified barriers and facilitators [14].

For needs assessment, we recommend a systematic approach to identifying high-priority clinical challenges amenable to telemedicine solutions, considering both local needs and organizational readiness. For infrastructure development, we advocate for investment in reliable connectivity, user-friendly interfaces, and seamless integration with existing systems as foundational elements for successful telemedicine implementation.

Regarding workforce preparation, our findings support a comprehensive approach including education about telemedicine benefits and limitations, training in virtual care competencies, and attention to cultural considerations [15,16]. For implementation approach, we recommend a phased strategy with pilot testing, iterative refinement, and gradual expansion, coupled with clear protocols and workflow integration.

For evaluation, we emphasize the importance of comprehensive assessment across multiple dimensions, including technical performance, clinical outcomes, workflow impact, and user experience [17]. This multifaceted evaluation provides a more complete understanding of value and guides ongoing refinement.

This framework aligns with the objectives of Saudi Vision 2030 and the National Digital Health Strategy, suggesting potential synergies between telemedicine implementation in emergency care and broader healthcare transformation efforts [18]. The emphasis on infrastructure development, workforce capacity building, and evidence-based implementation particularly resonates with national strategic priorities.

This study has several strengths, including its mixed-methods design, diverse sample of emergency departments, and detailed case studies of successful implementations. However, certain limitations should be acknowledged [19]. First, despite efforts to ensure representativeness, the sample may not fully reflect all Saudi emergency departments, particularly those in very remote areas. Second, the cross-sectional design provides a snapshot of implementation status but cannot capture the dynamic nature of implementation over time. Third, self-reported data may be subject to social desirability bias, although anonymity was maintained to minimize this effect [20].

Conclusion

This cross-sectional survey reports variation in telemedicine use among responding emergency departments; it cannot establish a national growth trend or causal patient benefit.

The stated barriers and facilitators are respondents’ reports and require verification; the small-sample associations do not establish effective interventions.

The framework is exploratory and requires independent validation and appropriate clinical and operational oversight.

Future research should explore the long-term impacts of telemedicine implementation on clinical outcomes, cost-effectiveness, and staff experience in Saudi emergency departments. Additionally, comparative studies examining different implementation approaches would provide valuable insights into optimal strategies for the Saudi healthcare context. As telemedicine technologies continue to evolve, ongoing assessment of implementation status, barriers, and facilitators will be essential to guide evidence-based integration into emergency care practice.

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