Centurion University Of Technology

And Management
Jatani, Bhubaneswar

Subject: Marketing Research

Subject Code: CUTM1203
Topic: Online doctor consultation behavior

Guided By :
Dr. Ansuman Jena(PhD)
Associate Professor, School of Management
Centurion University of Technology and Management
Jatni, Khordha, Odisha, India, PIN-752050

Submitted by:
Gyanendra Pradhan
210402100027

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 Contents
Sl.no. Content Page Number
1 Abstract 03
2 Research objective 03
3 Introduction 03-05
4 Literature Review 05-09
5 Research Methodology 09-11
6 Data Analysis 12-21
7 Conclusion 21-23
8 Supplementary Materials 23
9 References 23-26

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 Abstract
This study develops 3 main things which would be highlighted;
Develops a theoretical framework that highlights facets of perceived risk and their relationship with
behavioral intention. Previous literature highlights that the higher the risk perceived by doctors, the more
prospects that they will not adopt telemedicine. Therefore, addressing these risks will help doctors to
overcome their apprehensions about telemedicine. The data were collected through the field as well as an
online survey. An online survey link was shared with doctors of various hospitals in north India. The final
sample consisted of 215 observations. Structural equation modeling (SEM) was applied to validate the
hypothesized relationships among constructs. The results confirmed that social risk, time risk, technology
risk, and security risk had a negative impact on behavioral intention. Surprisingly, financial risk emerged
as an insignificant construct. This study contributes to the literature by presenting and validating a theory-
driven framework that unveils the facets of perceived risk as barriers to telemedicine adoption
A multi-dimensional telemedicine patient satisfaction measure is utilized to provide managerial insights
into where service improvements are needed and factors that impact patient service perceptions. This
research explores the influence of patient demographics on telemedicine satisfaction. Four
dimensions of telemedicine patient satisfaction (health benefits, patient-centered care, monetary costs,
and non-monetary costs) were compared across patient gender, income, and education levels. Methods: A
survey of 440 US telemedicine patients on patient satisfaction was measured with Likert scale items to
create a multi-dimensional construct using the SERVQUAL model. MANOVA, ANOVA, and linear
contrasts were used to examine the impact of patient demographics on telemedicine satisfaction
dimensions. Results: The findings revealed that patient demographic characteristics moderated various
dimensions of their telemedicine experience satisfaction. Satisfaction with telemedicine health benefits
was moderated by patient gender and income levels. Patient-centered care was moderated by patient
gender, income, and education levels. Satisfaction with the monetary cost of telemedicine was associated
with patient gender and education level. Patient education level influenced their satisfaction
with telemedicine non-monetary costs. 
A study to find out the category of people who are interested in telemedicine and whether this is a
permanent change in behavior or a temporary change according to the situation and certain circumstances.
A random survey of 57 students of Centurion University of Technology and Management, Jatani has been
taken to conclude the final results. For this, I have prepared a Questionnaire method to collect data from
different students. Result: Most of the students who are interested in online doctor consultation usually
belong to a society where they have someone of their own working in the healthcare background. The
change is temporary and is based on certain circumstances.

Research Objective:
 To find the demographic behavior of people towards online doctor consultation
 To find the problems caused to health center for online doctor consultation
 To find my area behavior towards online doctor consultation

1. Introduction

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The potential of telemedicine in patient care is still to be matched with its rate of adoption. The
effectiveness of this coupled with the convenience should provide us with a good reason to implement it.
However, there are numerous hurdles ranging from financial constraints to patient safety and privacy
issues that act as impediments in widespread implementation of this technological innovation. The
COVID-19 crisis has brought the potential of telemedicine to the forefront. Despite a lot of empirical
support for the impact and advantages of telemedicine in developing nations, its utilization is still
disappointingly low. In addition to providing the health-related services, doctors are the primary users of
telemedicine. There the success of systems related to telemedicine relies heavily on their perception and
acceptance of the technology. It is imperative to understand the barriers in order to offer solutions which
can enhance the ease and rate of adoption of telemedicine in India. Health care consists of complex social
systems. There are multiple stakeholders with diverse backgrounds, expectations, values and experiences.
The study by Khan, Hossain, Hasan, and Clement (2012) comprehended that the majority of the users
were hesitant to utilize the technology in hand due to their prevailing doubts on the efficacy and
effectiveness of the Information and Communication Technology (ICT). Telemedicine has immense
potential as a health care delivery system and has the ability to address systemic issues confronted by the
traditional health care delivery system. To achieve the structural changes that are believed attainable by
the proponents of telemedicine, an important parameter is the willingness of the physicians Received: 28
July 2020 Revised: 16 December 2020 Accepted: 20 December 2020 DOI: 10.1002/sres.2774 128 ©
2021 John Wiley & Sons, Ltd. wileyonlinelibrary.com/journal/sres Syst Res Behav Sci. 2022;39:128–
142. to use it. Additionally, comprehensive technical training and constant support towards the optimal
use of the technology also influence technology adoption. Telemedicine also needs an intrinsic shift from
traditional, wellaccepted methods of patient care and medical practice to new, unfamiliar ways of
practising which lacks the physical proximity and contact previously available. These non-technological
issues may also have a deep influence on physician approach towards the adoption and the use of
telemedicine for patient care (Bakshi, Tandon, & Mittal, 2019). At present, there exist a number of health
care encounters in India. World Health Organization (WHO) estimates envisage that by 2035, there will
be a deficit of 12.9 million health care workers (HW); the figure stands at 7.2 million at present. In India
as well, as per National Health Profile (2018), there is just one allopathic government doctor for around
11,082 people across the country, as against the recommended ratio of 1:1000 as per WHO norms
(Bakshi et al., 2019, p. 4368). Along with the scarcity of the compulsory manpower, medical resources
are available in urban areas which further augments the problem. About 75% of health care facilities
(infrastructure as well as manpower) are present in cities, which caters to only around 27% of the national
population (Balarajan et al., 2011). According to Gudwani et al. (2012), by 2022 the beds per 1000
population figure is projected to be 1 to 1.2 in rural areas as compared to 3.8 to 4.2 in urban areas. This
deficiency of qualified manpower is more prominently exhibited at the level of specialists. Around half of
the posts for doctors are found vacant in rural areas (Bhandari & Dutta, 2007). The 2020 COVID-19 crisis
has not only highlighted these already existing lacunae and disparities but also changed the entire
landscape of health care delivery systems. It presents a myriad of challenges for not only the government
and the service providers but also the patients who require these services. It has brought new challenges
such as the potential risk of exposure to the health care providers, patients and attendants. Telemedicine
can provide effective resolution to these issues by providing timely access to the physician, reducing the
time, cost and risk of infection associated with travel, reducing waiting time for the consultation and
supporting home health care. It allows doctors to collaborate in providing quality health care across
settings and locations, thereby not only improving access and convenience, and engagement for patients
but also several clinical benefits such as improved utilization of resources and decreased readmissions
which are preventable through remote monitoring. Regardless of the efforts by the government of India to
promote telemedicine, its implementation in India had not been able to make much headway primarily

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due to lack of regulatory framework. However, on 25 March 2020, in a significant move, the Ministry of
Health and Family Welfare issued the Telemedicine Practice Guidelines for enabling registered medical
practitioners to provide health care using telemedicine. This has paved the way for successful
implementation of telemedicine solutions in the current Indian scenario. However, it is imperative at this
moment to understand the barriers in the implementation process so as to ensure the readiness of our
health care delivery system to the changing health care ecosystem. The ubiquitous accessibility of high-
speed internet and computers and mobile devices equipped with highdefinition cameras are some of the
important factors that have made telemedicine and teleconsultation possible in remote areas. But several
other trends are encouraging the rapid adoption of tele-health technologies as a means to enhance the
capabilities of the existing health systems. These include

 The increased longevity and consequently large ageing population

 Enormous health care provider shortage
 Increase in lifestyle diseases and chronic ailments
 Increasing awareness and demand by the patients
A difficulty facing telemedicine administrators is that measurement of telemedicine patient satisfaction
has typically not considered the multiple dimensions that determine overall satisfaction simultaneously.
Studies are needed to develop a method to measure telemedicine satisfaction as a multi-dimensional
construct. The usefulness of a multi-dimensional measure is that it can provide managerial insights into
where service improvements are most needed.
Significant growth in the telemedicine (telehealth) industry continues in the United States (US) and is
estimated to exceed a market size of 550 billion dollars by 2027. Telemedicine services benefit patients
and medical providers by minimizing disease exposure to participants, increasing healthcare accessibility,
and allowing for more efficient utilization of hospital resources In addition, increased reimbursement
for telemedicine services and changes in privacy laws are contributing to increased service
offerings. Telemedicine services have expanded even more rapidly in recent years because of the
COVID-19 pandemic.
Patient health is often moderated by patient demographics. For example, coronary heart disease and
differential drug metabolism are known to vary based on a patient’s gender. In addition, patient health can
be impacted by the patient’s financial affluence and education levels. Financially affluent and higher
educated patients tend to exhibit healthier lifestyle habits such as eating better diets and receiving regular
medical screenings.
In addition, better patient treatment outcomes can be achieved with higher patient satisfaction because
satisfied patients are more motivated to adhere to medical advice and regimens. Higher patient
satisfaction with a medical service is beneficial to the provider as well through higher insurance
reimbursements and greater patient loyalty behaviors—both of which lead to increased revenues for the
provider. Personal demographics have been shown to impact service expectations and perceptions,
which, in turn, drive satisfaction levels. Thus, patient satisfaction can be moderated by their demographic
profile.
As discussed above, a greater understanding of the patient satisfaction construct can lead to improved
patient health and advanced medical services. To understand telemedicine patient satisfaction more fully,
factors that moderate this multi-dimensional construct must be examined. The purpose of this study is to
examine how various dimensions of telemedicine satisfaction are moderated by patients’ gender, income
levels, and education levels.

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A brief study to show the locative study of different students of Centurion University and their perception
of online doctor consultation. As there are factors that influence each student differently and their
thoughts and beliefs towards a certain thing. So it is required to analyze the behavior of different people
who are interested in the online mode of doctor consultation and also to perform strategy to bring interest
into other students who are not interested or unaware of the facts and figures.

1. Literature Review
Understanding the multi-dimensional nature of telemedicine patient satisfaction is essential for improving
patient satisfaction. Since patients’ service expectations lead to perceptions of service
outcomes, telemedicine patient satisfaction studies often used survey tools where satisfaction was
measured with a singular question of whether the patient perceived that the services received met their
expectations. A search of articles indexed with PubMed from 2000 to the present was conducted using the
following keywords: “telemedicine patient satisfaction” and “measurement of telemedicine patient
satisfaction.” The results revealed that some studies have identified dimensions of the service that impact
overall patient satisfaction. For example, telemedicine patient satisfaction has been found to be based
upon the effectiveness of service provider communications and/or interactions with the patient. In other
studies, patient satisfaction has been linked to such factors as the healthcare benefits achieved, the
financial costs, or the time-saving convenience (i.e., non-monetary costs) of the service. These previous
studies highlight that satisfaction is a multi-dimensional construct.
SERVQUAL is a methodology commonly used in service-marketing consumer satisfaction research to
compute a multi-dimensional satisfaction index by using multiple items to measure various
dimensions of a given service. Recently, Mason presented an adaptation of the SERVQUAL model to
examine dimensional aspects of telemedicine patient satisfaction. Mason found that the SERVQUAL
model provided reliable and valid patient satisfaction measures and identified four latent
dimensions of patient satisfaction. The identified dimensions of patient satisfaction included patient
perceptions of the health benefits, patient-centered care, monetary costs, and non-monetary costs
associated with services received. More specifically, Mason found that patient satisfaction
with telemedicine health benefits was a function of their perceptions of the treatment outcomes. Patient-
centered satisfaction was found to be driven by patient perceptions of the provider’s display of empathy
and effective interpersonal interactions. Monetary cost satisfaction was found to be based upon patient
perceptions of the financial cost savings of telemedicine, and non-monetary cost satisfaction based on a
perceived reduction in non-financial costs associated with the telemedicine service such as inconvenience
and technology complexities.

 Perceived risk
To understand the barriers, perceived risk (PR) factors validated by Featherman and Pavlou (2003) have
been considered in this study. PR has been formally defined as ‘the expectation of losses associated with
purchase and acts as an inhibitor to purchase behavior’ (Peter & Ryan, 1976). Featherman and Pavlou
(2003) defined PR as ‘the potential for loss in the pursuit of the desired outcome of using an e-service’.
Despite PR being mostly measured as a unidimensional variable in the literature (e.g., Herzenstein,
Posavac, & Brakus, 2007; Meuter, Bitner, Ostrom, & Brown, 2005; Walker & Johnson, 2006), there is
ample evidence that it has various dimensions such as performance risk, financial risk, physical risk,
social risk and psychological risk (Tandon et al., 2017). There is a limited research that has examined the
impact of each dimension of PR on the adoption of telemedicine in India. The selection of the facets risk
type was based on previous studies of Featherman and Pavlou (2003) as well as interviews with the

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doctors practising telemedicine. Further, different types of risks (social, technology, time, security and
privacy risks) have been identified and validated as barriers in any technology adoption thereby
influencing the behaviour of individuals (Bakshi et al., 2019). Addressing facets of different types of risks
will help doctors to adopt telemedicine. Isabalija et al. (2011) studied the major hindrances or
impediments to telemedicine acceptance, adoption, implementation and sustainability in Uganda.
According to them, the prominent factors influencing telemedicine in Uganda were lack of a policy for
telemedicine, requisite knowledge and effective skills along with strong opposition to change by the staff
of the hospitals. Bickmore et al. (2013) studied the clinical staff perception about the adoption of
technology for health care services and established that health care professionals seem to be scared of
technology due to an assumption that technology will replace them, which resulted in resistance to
technology. Ayatollahi et al. (2015) propounded that it was the lack of the required knowledge about
telemedicine which restricted its usage. Another study by Gaggioli et al. (2005) emphasized that the
seniority and confidence about the role of telemedicine in making therapeutic intervention more effective
are crucial determining factors. Krog et al. (2018) emphasized that along with capability and opportunity,
motivation is the third key behaviour component that acts as barrier or facilitator. Bokolo (2020)
suggested that due to spread of novel coronavirus disease 2019 (COVID-19), telemedicine and use of
virtual software in health care delivery are capable of diminishing emergency room visits, protecting
health care resources and reducing the spread of COVID-19 by remotely treating patients during and after
the COVID-19 pandemic. However, according to Helou et al. (2020), a significant amount of scepticism
and uncertainty regarding telemedicine remains, especially concerning its efficiency, safety and the
adequacy of existing regulations. A recent study has highlighted the importance of trust, subjective norm,
perceived benefit and persisting habits in promoting the adoption of online health consultation services in
China (Gong, Han, Li, Yu, & Reinhardt, 2019). The study by Luciano, Mahmood, and Mansouri Rad
(2020) confirmed that telemedicine adoption is influenced by policies, culture and security and privacy.
Li (2020) emphasized on perceived interactivity, perceived personalization and privacy concerns and
confirmed that these have significant impacts on users' perceptions of ease of use, usefulness and trust
towards mobile medical treatment services. Dhagarra et al. (2020) propounded that health care is not only
a universally used and complex phenomenon but also very personalized and expensive service, and
hence, building and maintaining trust and ensuring privacy are essential for the continued participation of
patients in a health care delivery system (Shashi et al., 2020). For any system to run smoothly and to be
able to provide effective solutions, it requires well-defined rules and regulations and standard operating
protocols. The study by Bali (2018) has highlighted that definite policies and procedures at both central
and state levels are imperative for the development as well as the smooth implementation of any system.
On the basis of the above discussion, the following hypothesis has been framed: 130 BAKSHI AND
TANDON H1. PR is a multidimensional construct significantly predicted by security risk and privacy
risk, technology risk, financial risk, time risk and social risk.

 Financial risk
Financial risk has been defined as ‘the potential monetary outlay associated with the initial purchase price
as well as the subsequent maintenance cost of the product’ (Featherman & Pavlou, 2003, p. 455).
Financial risk has been a dominant barrier due to late compensation and capital disbursement for
telemedicine technology. Instituting and operating a ‘telemedicine unit’ entails not only purchase and
maintenance of equipment but also training and compensating health care professionals (Bali, 2018).
High maintenance cost has led to failure on numerous telemedicine projects (Bali et al., 2016). Due to
low level of awareness, restricted exposure to infrastructure and technology in health care professionals as
well as patients, the cost of telemedicine is high in developing countries (Endeva & Hazarika, 2017;

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Levine et al., 2014). ‘For installation, and maintenance of telemedicine and communication equipment
cost is usually high and ROI is comparatively less, so there are limited economic benefits to the private
hospitals, which may lead to -bankruptcy and further extension of telemedicine in rural areas needing
specialized services’ (Levine et al., 2014). Many hospitals perceive telemedicine a costly solution thereby
avoid implementing it. Therefore, based on the above discussion, the following hypothesis has been
posited:
H2. : Financial risk shall negatively impact behavioural intention (BI).

 Social risk
Social risk can be defined as ‘potential loss of status in one's social group as a result of adopting a product
or service, looking foolish or untrendy’ (Featherman & Pavlou, 2003, p. 455). The social and cultural
environment of the people residing in the vicinity, peers, colleagues and people of a country create
several barriers in adjusting, employing and maintaining telemedicine services. Having role models and
enhancement of social status encourages people to implement new technologies and absence of the same
acts as a barrier. This finds support in a study by Alghatani (2016), who proposed the need of project
champions to implement the telemedicine programme once it has been deployed. The three prominent
champions are clinical champion (physicians), IT champion (tele-technicians) and paraclinical champion
(nurses) (Bali et al., 2016). The success of any telemedicine programme relies on these champions, but
the problem is the rarity of these champions in developing countries, so most of the planned telemedicine
programme wither out very soon after their deployment. There are also discrepancies in the training and
job orientation of these champions. The studies by Robben et al. (2012) and Young et al. (2011) also
confirmed social risk as one of the major barriers in adoption of any technology. The following
hypothesis has been framed to support the above discussion: H3. Social risk shall negatively impact BI.

 Time risk Time

Risk has been defined as ‘loss of time while learning and using a particular technology’ (Featherman &
Pavlou, 2003, p. 455). ‘Many emerging countries have inadequate provision of ICT infrastructure such as
computers, printers, printers, and even electricity for proper execution of telemedicine program. Internet
access and power supply are common and significant issues related to failure of telemedicine network in
rural locations’ (Bali, 2018; Sorwar et al., 2016; Stanberry, 2000). Poor internet connectivity is still a
prominent barrier in developing economies leading to wastage of time (Bali et al., 2016). Further,
majority of the applications need consistent and steadfast internet bandwidth to function hassle-free. A
few examples are the following: tele-surgery, tele-ophthalmology, real-time tele-radiology and others
(Hassibian & Hassibian, 2016). Unreliable and low internet speed are the vital barriers in adoption of
telemedicine. Therefore, the related hypothesis is as follows:
H4. : Time risk shall negatively impact BI.

 Technology risk
Technology risk has been defined as ‘technology failure that disrupts business’ (Spacey, 2016). An
important assertion by Bali (2018) is that technology itself is a significant barrier in the development of
telemedicine in under-developed countries across the world. ‘Literature is replete with studies that show
that despite the inherent risks in a technology, organizations as well as individuals adopt technology when
the benefits outweigh the costs (Davis, 1989). The study by Cambre and Cook (1985) highlighted that on
using a particular computer-based BAKSHI AND TANDON 131 technology, people have an

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apprehension regarding the usage of the technology. This apprehension in the minds of people slows
down the adoption of any technology. Firms attempt to increase technology adoption by assuring them of
various safety features that reduce risk in technology adoption (Xu, Teo, Tan, & Agarwal, 2009) such as
encryption and authentication. Similarly, in order to alleviate risks, firms focus on adopting proper legal
framework and certification that certify the solution to be secure. Poor understanding of the technology
and their application in delivering health care thus can be the biggest stumbling blocks in usage of
telemedicine (Bali, 2018). Even physicians lack ICT know-how and thus show resistance to adopt
telemedicine. Older physicians are uncomfortable working with computers and modern gadgets, and
therefore, have apprehensions about telemedicine (Bishop et al., 2013; Endeva & Hazarika, 2017). Thus,
we propose the following hypothesis:
H5. : Technology risk shall negatively impact BI.

 Security and privacy risk

Security and privacy risk can be defined as ‘loss of personal information and stealing some operational
information or data’ (Featherman & Pavlou, 2003, p. 455). Telemedicine systems mainly entail doctor-to-
doctor (D2D) and doctor-to-patient interactions (D2P). D2D interactions are considered as most crucial as
these require sharing as well as monitoring of significant health-related information. This also requires
high level of cybersecurity thereby incorporating remote consultations and providing prescriptions (Bali,
2018). ‘Therefore, in such a milieu, the telemedicine environment is prone to an array of security threats
like telemedicine app forgery/alteration, MITM attacks, illegal access etc. Various other security threats
like device use errors, altering of prescriptions, data leakage, wire-tapping etc., also create apprehensions
in the minds of doctors regarding telemedicine adoption’ (Bali, 2018). Issues surrounding the patient as
well as physicians, privacy, security and confidentiality also play vital roles in telemedicine adoption
(Combi et al., 2016). Therefore, the related hypothesis is as follows:
H6. : Security and privacy risk will negatively impact BI

2. RESEARCH METHODOLOGY
2.1. Survey instrument and Sample
For demographic behavior-Telemedicine patient survey data was collected by Centiment, an independent
survey provider. Centiment solicited input from a patient panel that included 578 recent
US telemedicine patients. Recent patients were defined as patients receiving telemedicine services in the
past year. Telemedicine patients provided responses to a questionnaire that was created by the authors.
The patients were required to provide consent before they participated in the survey.
For problem identification- The target population in this research was doctors practising telemedicine in
India. More specifically, this study was conducted in the North Indian states of Jammu and Kashmir,
Himachal Pradesh, Punjab, Haryana, Delhi and Uttar Pradesh. Measurement items suggested by
Featherman and Pavlou (2003) were used to measure different facets of PR. Items for technology risk
were measured using an ad hoc scale of measurement. An ad hoc questionnaire model incorporates
involving respondents in making the questionnaire linked with their experiences regarding the product
(Masuda & Hara, 2017, p. 183). For developing an ad hoc questionnaire, threestep approach was
followed. We conducted interviews from a group of 27 doctors located at various hospitals based on
convenience sampling technique. Their apprehensions regarding telemedicine before adoption as well as
after providing a few teleconsultations helped us to frame items of technology risk (Appendix A).

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Reliability analysis was performed on these items, and after getting suitable results, the scale was
administered to normal population along with other constructs. Furthermore, items of BI were measured
using a scale adapted from 132 BAKSHI AND TANDON Bali et al. (2016). All the items were measured
using a 5-point Likert scale with the anchors varying from 1 (strongly agree) to 5 (strongly disagree)
(Appendix A).
For knowing my area behavior: The data has been collected from a mixture of students studying in
Centurion University of Technology and Management, Bhubaneswar, Hi-Tech Medical College &
Hospital, Bhubaneswar and Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar.

2.2. Data collection procedures

For demographic behavior: Prior to collecting data, the authors obtained approval for human subject
research from an ethics review board at Arkansas Tech University. Survey data was obtained in April
2021. The data was stored with the lead author and per Institutional Review Board approval regulations is
not publicly available. Patient participation was voluntary, and respondents were required to provide
participation consent. Respondent anonymity was accomplished by not allowing responding patients the
ability to share personally identifiable information. To prevent duplication of respondents, Centiment
assigned a custom variable to each respondent entering the survey.
For problem identification: In order to improve the clarity of the survey questionnaire, a preliminary
version of the questionnaire was distributed to a pilot group of 27 doctors (Appendix B) as well as faculty
members of a university. The pilot group answered each question and suggested minor modifications in
the wording of items to improve clarity and conciseness. Their suggestions were taken into account,
where relevant, throughout the questionnaire. Some questions were added, others amended, whereas a
few items were deleted due to repetition in the wording. As a part of National Knowledge network (NKN)
one national resource centre and seven regional resource centres are designated to ensure pan-India
connectivity to achieve the target of universal outreach of health care in an affordable manner. Post
Graduate Institute of Medicine and Research (PGIMER) is the regional resource centre for the north zone
of India, and it caters to five states, 24 hospitals and three medical colleges (National Health Portal,
2019). And that is the reason North region has been selected for this study. In North India, although
PGIMER has been identified as Nodal centre for North India, even then the awareness, diffusion and
adoption of telemedicine is quite low. One hundred and fifteen districts have been announced as
aspirational districts by the government of India under NITI Aayog (RRC Report, 2017–2018). According
to Niti Aayog, ‘the National Health Stack (NHS) is a virtual digital platform for healthcare in the country.
NHS study aims to make digital health records for all the citizens by 2022 to facilitate telemedicine and e-
health easy’. PGIMER being Regional Resource Centre (RRC) has identified six districts in North India.
This initiative by PGIMER requires active research into factors which deter health care professionals to
adopt telemedicine as well as the factors which will motivate health care professionals to adopt
telemedicine in their daily routine. Therefore, this study has been carried out in the northern states of
India. Further, considering the mixed methodology approach (both field and online survey), a survey was
carried out in private and government hospitals of North Indian States. Only doctors who were posted in
hospitals of North Indian states were contacted. In the field study, different hospitals located in North
Indian states were visited. Based on convenience sampling, doctors were approached to take part in the
survey. Subsequently, using purposive sampling method, respondents were recruited from websites of
hospitals for an online survey. Authors visited online pages of hospitals available on Facebook, Instagram
and YouTube and those individuals who had recommended, liked, disliked and commented on these
pages as well as shared their experiences regarding telemedicine were considered as potential respondents

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for this study. Authors sent detailed messages on their social media accounts to invite them to take part in
the survey. Next, the questionnaire was sent to those individuals who were willing to take part in the
survey. Lastly, respondents were recruited using snowball sampling methods from social
groups/networks, and questionnaires were distributed using both online and offline modes as per
convenience. According to de Leeuw, Dimman, and Hox (2008), the use of mixed methods reduces the
bias caused by the single method, saves time and improves the survey response rate. A total of 250 filled
up responses were received in return. However, 35 were found incomplete or unengaged responses, and
therefore, only 215 valid responses were analysed. Kline (2010) suggested that a sample of 200 responses
or larger is suitable for a complicated path model. Among these valid responses, 92 belong to the field
survey, 75 belong to the online survey, and 48 were recruited from Facebook, Instagram and others.
Further, the dataset received was divided into three groups (field survey and online survey, field survey
and social network groups, and online survey and social network group). All these groups were compared
by one employing t-test to evaluate differences among responses (Groves & Lepkowski, 1985; Sakshi et
al., 2020). No statistically significant difference among responses was BAKSHI AND TANDON 133
found thereby eliminating the bias arising from mixedmode survey (Groves & Kahn, 1979)
For knowing my area behavior- A questionnaire was prepared which was circulated to different
institutions in Bhubaneswar and a total of 57 responses were taken to calculate the behavior of different
students involved in online doctor consultations in Bhubaneswar. The data is fresh and is taken between
5th May to 6th July 2022.

2.3. Demographic profile and characteristics of respondents

For problem identification: In the sample, there is a reasonable presence of respondents across gender—
57.32% males and 42.67% females—and decent depiction of each age group and employment status.
Table 1 reports the characteristics of respondents in more detail.

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For my area behavior: In the sample, there is a reasonable presence of respondents across gender- 50.9%
males and 49.1% females of age group between 20-25.

3. DATA ANALYSIS
3.1. For problem identification
 Structural equation modelling analysis
Structural equation modelling (SEM) (AMOS 20) was used to analyse the data. SEM was preferred over
other techniques, because it integrates many standard methods such as correlation, multiple regression
and factor analysis into one single software (Gaskin & Lowry, 2014). Furthermore, SEM enables the
comparison between conceptual model and data. This comparison results into fit statistics assessing the
matching of model and data (Gaskin & Lowry, 2014). SEM also validates the theoretically driven model
while there was no model implemented in regression. Bollen and Pearl (2013) have argued in this context
that the primary goal of regression analysis is mere prediction (i.e., fit a regression plane into a
multidimensional scatter of Y values). SEM/path analysis in contrast is based on strong and weak causal
assumptions (Merchant et al., 2013; Musil et al., 1998). The most important difference it that the structure
(with its assumptions) implies testable implications (in contrast to regression). Authors further argued that

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the basis for a regression can be a causal model (with causal assumptions), but in this case, the actual
model (behind the regression) is indeed a SEM and the regression is just a tool to control for confounders
and not a model in itself. Additionally, a study by Rijnhart et al. (2017, p. 130) highlighted upon that
‘since OLS regression, SEM, and the potential outcomes framework yield the same results in three
mediation models with a continuous mediator and outcome variable, researchers can continue using the
method that is most convenient to them’. Because this study analyses and compares the cause and effect
of various facets of risks, SEM has been preferred over regression. The methodology for data analysis
followed two steps. The first step confirmed the factor structure of measurement items, that is, the
validity, reliability and model fit. The second step investigated the path relationship between the
constructs and proposed hypotheses.

 Reliability and validity

To assess the reliability and validity of the proposed measurement model, a confirmatory factor analysis
(CFA) was carried out with items pertaining to different facets of PR and dependent variable, namely, BI.
The results of the CFA (see Table 2) indicated that the standardized loadings of all the included variables
are significant. Few items of technology risk such as Type of information available on template, Unsure
about the diagnosis without physical examination, Fear of asynchronous communication with the
frontline health-worker, Quality of consultation (audio as well as video) depends on technology support,
and Lack of adequate training programmes for usage of telemedicine equipment were suggested by
experts and were included in the scale. For the purpose of clarity, these items have been italicized in
Appendix A. One item of Time risk TMR4 ‘Unstable internet connection does not allow me to complete a
teleconsultation’ was deleted, to low factor loadings. The same has been added up in Appendix A and put
in italics. The constructs further demonstrate evidence of validity (significant and high standardized
loadings as well as average variance extracted >0.50 in all occasions), composite reliability (values >0.70
in all occasions) and discriminant validity (AVE estimate of each construct is larger than the squared
correlations of this construct to any other construct; Fornell & Larcker, 1981).

 Structural model
After attaining the satisfactory results witnessed in the measurement model, the hypothesized model was
then estimated with all the independent variables and the dependent variable (see Table 4 and Figure 1).
All the fit indices showed an appropriate fit. These results suggest that the hypothesized model is a logical
representation of the structure underlying the observed data. Social risk had the highest loadings (β =
−0.217, p = 0.008) and emerged as the strongest barrier of PR in adoption of telemedicine, thereby
confirming H3. Social risk was followed ex-aequo by time risk (β = −0.163, p = 0.047) and security and
privacy risk (β = −0.124, p = 0.014), thereby lending support to H4 and H6, respectively. Albeit less
impactful, technology risk was nonetheless significantly related to behavioural intention to adopt
telemedicine (β = 0.12, p = 0.017), supporting H5. Surprisingly, financial risk only marginally predicts
behaviour intention (β = −0.074, p = 0.366), thereby rejecting H2.

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  Discussion of the results
This research provides significant inputs to the practitioners as well as to the policymakers that can be
applied to health-related literature. The study offers significant insights into various facets of PRs
considered as a major hindrance in successful implementation of telemedicine in a developing country
context. As these risks in Indian telemedicine context still remain unexplored, the study therefore will
help in framing policies to overcome these risks, thereby improving the overall health scenario in India as
well as similar other settings. Indian government has undertaken the challenge of providing accessible,
affordable and quality health care, which could be overcome only if the risks highlighted in the study
could be TABLE 3 Correlation matrix of variables TER TMR SCR SPR FNR BII TER 0.734 TMR
0.518** 0.834 SCR 0.354** 0.325** 0.793 SPR 0.447** 0.428** 0.409** 0.711 FNR 0.571** 0.518**
0.542** 0.531** 0.803 BII 0.163* 0.198** 0.191** 0.107 0.070 0.912 Abbreviations: BII, behavioural
intention; FNR, financial risk; SCR, social risk; SPR, security and privacy risk; TER, technology risk;
TMR, time risk. **Correlation is significant at the 0.01 level (two-tailed). Items in italics represent square
root of AVE. TABLE 4 Results of hypotheses testing No. Hypothesis Estimates (β) C.R. Sig. Remark H2
Financial risk shall negatively impact BI −0.074 −0.905 0.366 Not supported H3 Social risk shall
negatively impact BI −0.217 −2.668 0.008 Supported H4 Time risk shall negatively impact BI −0.163
−1.658 0.047 Supported H5 Technology risk shall negatively impact BI −0.12 −1.363 0.017 Supported
H6 Security and privacy risk shall negatively impact BI −0.124 −1.464 0.014 Supported Note: Goodness-
of-fit statistics CMIN/df = 4.503, GFI = 0.898, NFI = 0.891, RFI = 0.901, TLI = 0.911, CFI = 0.906,
RMSEA = 0.076. FIGURE 1 Path relationships 136 BAKSHI AND TANDON minimized. As these risks
serve as impediments in successful implementation of telemedicine, the time has arrived to minimize
these barriers for the hassle-free expansion of telemedicine network across the country for the benefit of
humanity. More specifically, the study analysed wide array of facets of PRs for which extant literature
has found mixed results (Bali et al., 2016). Besides, the study also validates their impact on intention to
adopt telemedicine. The study proposed and validated a comprehensive model covering various facets of

15
PR to predict their relationship with behavioural intention to adopt telemedicine. The study is the first
attempt to validate PRs in the Indian context and their association with intention to adopt PRs. The study
results provide a deep understanding of roles of different facets of PRs experienced by doctors in
adoption of telemedicine in India. Overall, in line with the past research which showed that social risk
hampers the adoption of any technology (Robben et al., 2012; Young et al., 2011), the research confirms
the prevalence of a significant impact of friends, peers and other opinion leaders. This is not so surprising
because the results confirmed that the opinion of ‘consumer's family, extended family, neighbours, work
groups and other wider social networks that the consumer has some affiliation towards adopting
telemedicine’. Moving further, technology risk and security and privacy risk were other significant risks
and depicted negative relationship with behavioural intention to adopt telemedicine. This finding provides
more substantial and empirically grounded evidence for the presupposed importance of technology risk
and security and privacy risk, as suggested in past research (Cherney & Van Vuuren, 2012; LeRouge &
Garfield, 2013; Mohammadzadeh et al., 2013). Because technology risk and security and privacy had a
strong impact on adoption of telemedicine, this option should not be dismissed by hospitals, and adequate
training programmes need to be imparted to the doctors so that apprehensions regarding these could be
minimized. Lastly, the absence of significant effect of financial risk on BI albeit providing lack of support
to one of our hypotheses is good news. It shows that perception of financial risk does not inhibit the
adoption of telemedicine. Research suggests that it is because doctors perceive that the practicality
inherent to other risks such as social risk, technology risk, security and privacy risk overweighs financial
risk. This finding goes against the study of Levine et al. (2014) where financial risk emerged one of the
significant factors inhibiting adoption of telemedicine by doctors of public as well as private hospitals

3.2. For demographic influence

 Statistical Analysis
Multivariate analysis of variance (MANOVA) was used to consider the impact of patient gender,
level of income, and education on telemedicine patient satisfaction dimensions. Individual
analysis of variance (ANOVA) was used to test for differences within the examined dimensions of patient
satisfaction, namely the health benefits, patient-centered care, monetary costs, and non-monetary costs.
Additionally, linear contrasts were used to examine the impact of appropriate patient demographics
on telemedicine satisfaction dimensions. SAS statistical software was used to conduct all analyses.

16
17
 3.3. For my area behavior:
 Analysis of the data
The ratio of male and female who attended the survey are

18
The no of participants who has consulted a doctor online

No of male and female who has consulted online

consultation

5 5

Male Female

19
20
 4. Conclusion
 For my area behavior:
In the above charts the maximum people who has attended a online doctor consultation is 10 out of 57
participants.
The age group of people is taken from 18-30.
It was observed that the number of active participants is very less which indicates there is some problems.
 After handling a telephonic conversation with most of the participants I came to find the major
problems that are;
Lack of awareness: Most of people are not aware of the particular platform to access telemedicine. As
there is not much advertisement by different healthcare services because of the financial cost of
maintaining a server and keeping engineers to maintain the platform.

21
Basic belief: Whenever the term doctor comes to our mind, one would always think to meet a doctor in
person as it is a belief that online consultation would never give them the satisfaction they needed.
Further, some are just not interested to consult a doctor online.
 Who are the potential customer?
The potential customer are those who are basically having friends or relatives working in a healthcare
service. Those group of people are aware of the online platforms and as they have someone who is able
guide them and make them aware and convince them to consult a doctor online. This is the sole reason
why they are the potential customer.
 Is this behavior permanent or temporary?
No this behavior is not permanent and they usually visit a online doctor when there is some problems
like; Transportation problem, doctor is busy or far, the person is busy and don’t have the time to travel
and meet a doctor, the disease according to him is very minor.

 For demographic behavior

Telemedicine patient satisfaction is a salient construct that impacts patient medical treatment adherence,
thus patient health. In addition, satisfied telemedicine patients may be inclined to use
future telemedicine services or recommend them to others, thus leading to sustainable revenues for
providers. The study highlights the benefits of measuring telemedicine patient satisfaction as a multi-
dimensional construct to identify where targeted improvements are needed. The findings also highlight
the need for telemedicine providers to customize services according to their patients’ demographic
profiles. Findings also underscore the importance of measuring telemedicine patient satisfaction as a
multi-dimensional construct. For example, patient gender was found to moderate satisfaction with health
benefits, patient-centered care, and monetary costs. Patient income was found to moderate satisfaction
with health benefits and patient-centered care. Finally, patient education was found to moderate patient-
centered care, monetary costs, and non-monetary costs. Variations in satisfaction across the observed
demographics provide a nuanced understanding of the drivers of patient satisfaction.

 For problem identification

Complete observations from 440 telemedicine patients were obtained, resulting in a seventy-six percent
survey response rate. Sixty-three percent of the patients received primary care, twenty-four percent
received specialty care, and seven percent had emergency care. In addition, six percent of the patients
indicated that they received some other type of telemedicine care.
Patients were evenly divided with fifty percent male and female, respectively. Patient education levels
varied with approximately sixty percent holding a least a bachelor’s degree. The median annual
household income for participating patients was in the fifty to seventy-five thousand per year range.
Overall, the sampled telemedicine patients were consistent with the
demographics of telemedicine patients in the US, thus a fairly representative sample [49].
The overall telemedicine patient satisfaction mean observed was 5.1 on the 7.0 scale, where 7 represents
the highest possible satisfaction. Thus, the patients’ overall satisfaction observed was consistent with
other studies of telemedicine patient satisfaction [50,51]. However, the MANOVA results demonstrated
that satisfaction differed across gender, income, and education demographic characteristics.

22
The MANOVA analysis results are summarized in Table 1. The four commonly used multivariate
statistics, Wilks’ lambda, Pillai’s trace, Hotelling-Lawley trace, and Roy’s greatest root were used to test
demographic effects on patient satisfaction. All four multivariate tests showed that gender,
level of income, and level of education significantly moderated telemedicine patient satisfaction.
To further explore these differences, separate analysis of variance (ANOVA) results are given for the
examined dimensions (see Table 2). Patient gender had highly significant effects on patients’ satisfaction
regarding health benefits and patient-centered care (p < 0.01 for both) and a marginally significant impact
on patients’ satisfaction with telemedicine monetary costs (p = 0.06). Likewise, patient income had
marginally significant effects on patient satisfaction concerning health benefits (p = 0.07) and patient-
centered care (p = 0.06). Additionally, the effect of patient income on patient satisfaction
with telemedicine monetary costs showed some indication of significance (p = 0.107). The ANOVA
results demonstrated that patient education level significantly impacted satisfaction with monetary and
non-monetary costs (p < 0.01) and may be related to patient-centered care (p = 0.13), however, education
level was not found to impact patient health benefits satisfaction.
Linear contrasts were used to test linear trends in patient income and education levels on each of the four
dimensions of patient satisfaction (see Table 3). Patient income level had a significant impact on
two of the satisfaction dimensions: health benefits and patient-centered care. In addition, patient
education level significantly moderated patent satisfaction with telemedicine patient-centered care as well
as with monetary and non-monetary costs, respectively. Additionally, patient education level had a
marginally significant effect on patient health benefits satisfaction (p = 0.097).
The satisfaction means for gender, level of income, and level of education for each of the dimensions are
summarized in Table 4, Table 5 and Table 6, respectively. Patient gender significantly
moderated telemedicine patient satisfaction; however, the direction of those differences varied by the
dimension of patient satisfaction (see Table 4). Overall, females expressed
higher telemedicine satisfaction than males. More specifically, female patients had significantly higher
satisfaction concerning the health benefits, patient-centered care, and monetary costs
dimensions of patient satisfaction. Female patients also had higher satisfaction with the non-monetary
costs of telemedicine, although the satisfaction difference was not significant.
Likewise, dimensions of patient satisfaction significantly varied by patient income levels (see Table 5).
Patient satisfaction with telemedicine health benefits and patient-centered care were more favorable as the
patient’s level of income increased. However, patient income did not significantly moderate satisfaction
with the monetary costs and non-monetary costs of telemedicine.
The level of education obtained by patients significantly moderated their satisfaction for select
dimensions of telemedicine patient satisfaction. As shown in Table 6, patient education level had a
significant impact on patient satisfaction with patient-centered care, monetary costs, and non-monetary
costs. Specifically, while patients with the lowest education level were an anomaly, an examination of the
overall linear trends revealed that higher satisfaction with telemedicine patient-centered care, monetary
costs, and non-monetary costs were observed for patients with lower educational levels. Significant
differences in telemedicine patient satisfaction for telemedicine health benefits were not found to be
related to the patient’s level of education.

5. Supplementary Materials
The following supporting information can be downloaded at: 

23
https://www.mdpi.com/article/10.3390/healthcare10061029/s1, Survey Questionnaire.

https://docs.google.com/forms/d/19xX0WQsmsJm9mHH7SWvbN9G_pNKmqMan9AEfdyU7P2k/
edit#responses

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