The key findings of this study were that 70% of health professionals surveyed across three levels of HF were either aware of or had used (41%) telemedicine. However, over 40% of HWs at HC-IV and RRH were telemedicine naïve. All doctors who had used telemedicine were impressed with it. ‘Telemedicine user’ and ‘telemedicine aware’ respondents showed core, clinical, and e-learning readiness for telemedicine. Patients were also generally aware of telemedicine but identified barriers to its use. For technology readiness, although all respondents reported knowledge about telemedicine, only the RRH in District 3 and the national referral hospital appeared to be technology ready for telemedicine. The quality of service, equipment and budget for ICT is still a challenge, especially at the lower HF levels.
Relatively few eHealth or telemedicine readiness studies have been conducted in the developing world. Whilst every country is different, with different health systems, burdens of disease, health needs, infrastructure and political agendas, the key findings of such studies are quite similar. For example, in Palestine mHealth approaches were regarded a promising strategy for mental health treatment interventions  while an assessment of telemedicine readiness at public health facilities in Addis Ababa, Ethiopia, showed a degree of readiness for telemedicine rating varied from a weak rating for technology readiness to strong rating for Organizational readiness .
It is generally acknowledged that eHealth readiness assessment should be undertaken before implementing an eHealth solution , in this case telemedicine. A recent review of eHealth readiness frameworks identified 13 papers covering eight readiness domains , whilst another systematic review of 63 papers identified 7 differently phrased eHealth readiness domains . There is much confusion and inconsistency in the field of eHealth readiness assessment. No generic framework or underlying unified theory has been reported. Some frameworks address specific issues, with different target audiences assessed, in environments with different degrees of eHealth exposure and experience. Additionally, different tools have been used to score readiness assessment. The review noted that different survey tools will be needed for different groups such as managers, funders, technical staff, doctors, nurses and patients . The tools will also have to differ depending on the proposed eHealth solution, with assessment of readiness for synchronous videoconference based telemedicine being different to that for deployment of a hospital information system.
In part, this study addressed some of these issues. The readiness of three sectors of stakeholders was assessed each using specific tools and methods: health workers at different levels of health facility; management, IT and technical experts; and patients. The large sample size of health workers surveyed (406 participants) provided unusual insight of readiness for telemedicine, primarily because three groups were identified based on their use and / or awareness of telemedicine (telemedicine user, telemedicine aware, and telemedicine naïve), and compared. The responses of those who were unaware of telemedicine prior to the survey (telemedicine naïve) are based solely on their perception, and can be likened to the opinions of participants in a Technology Acceptance Model (TAM) study; TAM refers to an information systems theory that models how users come to accept and use technology, based on their perception of its usefulness and ease of use . The group aware of telemedicine but not using it (telemedicine aware) is also of interest. Although not specifically asked, their reasons for not using telemedicine or their failure to use telemedicine may reflect concerns over legal and regulatory issues, the quality of care provided by telemedicine, or may merely reflect lack of access to technology. Based on their responses the latter is most likely.
Patient readiness for telemedicine was unclear, since patients in this study seemingly equated telehealth to use of the mobile phone. Attempting to understand patient readiness is uncommon but important, because as availability increases it is likely patients, even the general population, will be primary users. Certainly in developed countries the importance of a citizen-centric focus, and empowering citizens as change agents, has been embraced (3). The insight gained from this study will facilitate the development of a tool for determining population readiness.
A recent eHealth readiness study in Mauritius found that 80% of respondents were aware of eHealth or had used telemedicine . Khoja et al.’s eHealth readiness tool was used with managers and healthcare professionals already involved in an eHealth project . In South Africa, the same tool was found to be problematic when used with district managers and hospital managers who were not involved in an eHealth project . Saleh et al. , assessed health provider readiness on computer literacy, use, and access to computers at work in the Lebanon. Readiness for eHealth implementation was based on Holt’s Readiness for Organizational Change scale (appropriateness, management support, change efficacy, personal beneficence  and showed that eHealth implementation is dependent on readiness of the health providers for change.
All groups (users, aware and naïve) showed a positive attitude for core readiness and integration of telemedicine. Process workflow has been defined as all activities related to patient care and can refer to clinical and administrative workflows and integrated IT solutions are considered critical to optimizing workflows in healthcare . As noted earlier, the user and aware groups averaged over 80% positive responses for all but process workflow, a domain in which low scores for changes to work flow and practice indicate a positive attitude to telemedicine. The respondents showed readiness to integrate telemedicine at the HFs, especially among those who had used telemedicine in the delivery of healthcare.
Both telemedicine users and non-users showed clinical readiness for telemedicine integration at the public health facilities. Health workers see the potential benefits of telemedicine but do not yet have access to the infrastructure necessary to take advantage of it. The willingness to use ICT for health may reflect growing use of social media platforms and comfort with using computers and mobile phones.
This study has further demonstrated that e-learning is being used, and that the majority feel it would be of benefit and are ready to use it. These findings also align with the literature, which provides many examples of the use of e-learning to educate, train, or maintain the skills of the health and social care workforce in both developed (NHS eLearning; https://www.elearning.nhs.uk/), and developing countries [26, 30].
While this study did not comprehensively survey all HF sites, the likelihood is that most facilities will not have adequate infrastructure. While many HWs were either aware of and / or using telemedicine, the HC-IVs lacked infrastructure and the RRH’s lacked secure Internet and Web access for communication, prerequisites for both asynchronous (store and forward) and synchronous (real time) telemedicine. If the necessary technology and user training is not available, successful telemedicine cannot ensue. The introduction of 3G/4G networks offering unlimited Internet data packages  presents an opportunity for technology innovations for sites with limited connectivity and bandwidth.
The study also supported the literature which shows not only the need for eHealth readiness assessment, but the need for consistent terminology and description of a limited number of discrete readiness types, and the need for standardised tools for readiness assessment of different user groups (e.g., managers, funders, technical staff, doctors, nurses, patients, policy makers). Future research should focus on the latter two requirements.
Overall, the study findings can guide policy- and decision- makers in the health sector when designing, implementing, and scaling-up telemedicine services in Uganda and similar developing countries. It is recommended that eHealth readiness assessment be conducted for a specific intervention, and for specific groups in a particular healthcare setting using appropriate group specific readiness assessment tools, and not be generalised across all levels of HF. This will ensure evidence-based implementation and integration of telemedicine solutions relevant to the beneficiaries.
Strength and limitations
A major strength for this paper is that eHealth readiness was addressed using the critical domains and sub-domains identified from the literature as relevant to the Ugandan and developing country context. In addition, this is believed to be the largest and most disparate sample surveyed regarding readiness. Thus the total sample size was 534 participants, and study participants were diverse (ranging from patients, nurses/midwives, district health teams, public health professionals, consultants, doctors and physicians in-charge). Also, both users and non-users of telemedicine services were included in the analysis to ascertain core, clinical and e-learning readiness to integration of telemedicine. Limitations of the study were that the readiness of the private healthcare sector has not been investigated and that respondents’ perceptions of, and understanding of, telemedicine varied.