Health professionals' readiness and its associated factors to implement Telemedicine system at private hospitals in Amhara region, Ethiopia 2021.

INTRODUCTION: In resource-limited settings incorporating the Telemedicine system into the healthcare system enhances exchanging valid health information for practicing evidence-based medicine for the diagnosis, treatment, and prevention of diseases. Despite its great importance, the adoption of telemedicine in low-income country settings, like Ethiopia, was lagging and increasingly failed. Assessing the readiness of health professionals before the actual adoption of telemedicine is considered the prominent solution to tackle the problem. However, little is known about Health professionals' telemedicine readiness in this study setting.
OBJECTIVE: Accordingly, this study aimed to assess health professionals' readiness and its associated factors to implement a Telemedicine system at private hospitals in North West, Ethiopia.
MATERIALS AND METHODS: An institution-based cross-sectional study was conducted from March 3 to April 7, 2021. A total of 423 health professionals working in private hospitals were selected using a simple random sampling technique. Multi-variable logistic regression was fitted to identify determinant factors of health professional readiness after the other covariates were controlled. RESULT: In this study the overall readiness of telemedicine adoption was 65.4% (n = 268) [95% CI:60.1-69.8]. Knowledge (AOR = 2.5;95% CI: [1.4, 4.6]), Attitude (AOR = 3.2;95% CI: [1.6, 6.2]), computer literacy (AOR = 2.2; 95% CI: [1.3, 3.9]), computer training (AOR = 2.1;95% CI: [1.1, 4.1]), Computer skill (AOR = 1.9;95% CI: [1.1, 3.4]), computer access at office (AOR = 2.1;95% CI: [1.1, 3.7]), Internet access at office (AOR = 2.8; 95% CI: [1.6, 5.1]), Own personal computer (AOR = 3.0; 95% CI: [1.5, 5.9]) and work experience (AOR = 3.1; 95% CI: [1.4, 6.7]) were significantly associated with the overall health professionals readiness for the adoption of telemedicine using a cut point of p-value lessthan 0.05. CONCLUSION AND RECOMMENDATION: Around two-thirds of the respondents had a good level of overall readiness for the adoption of telemedicine. The finding implied that less effort is required to improve readiness before the implementation of telemedicine. This findings implied that respondents who had good knowledge and a favorable attitude toward telemedicine were more ready for such technology. Capacity building is needed Enhance computer literacy, and computer skills building their confidence to rise ready for such technology. Building their capacity through training, building good internet connection, and availability of computers, where the necessary measures to improve Telemedicine readiness in this setting. Additionally, further studies are recommended to encompass all types of telemedicine readiness such as organizational readiness, technology readiness, societal readiness, and so on. Additionally, exploring the healthcare provider opinion with qualitative study and extending the proposed study to other implementation settings are recommended to be addressed in future works. The study has a positive impact on the successful implementation and use of telemedicine throughout hospitals at countries level by providing pertinent information about health professionals' preparedness status. Therefore, implementing telemedicine will have a significant contribution to the health system performance improvement in terms of providing quality care, accessibility to health facilities, reduction of costs, and creating a platform for communication between health professionals across different health institutions for providing quality patient care.

Introduction

Information and Communication Technology (ICT) is being used to improve health care quality and allow patients to access primary healthcare through digital technologies modality, in different countries in the world [1]. Digital technologies including telemedicine have plenty of benefits to healthcare delivery with the help of good telecommunication infrastructures, information technology infrastructures, medical terminologies, and trained health professionals it helps to provide health services and manage patients at distance [2]. In the era of covid-19 pandemics, telemedicine have a great role in controlling the pandemics by using different communication modalities including, online consultation, telemonitoring/screening and chatbox and sensors, and geographic position system to avoid potentially dangerous location [3].

Introducing a telemedicine system to the healthcare system provides a platform for health professionals to exchange valid and quality health information about diagnosis treatment and management of patients and to apply evidence-based practice and its saves both health professionals and patients time and costs [4, 5]. Despite the potential of telemedicine to improve the quality of patient care significant proportion fails to support patient management in low-income countries [6].

Different countries in the world introduced telemedicine to their health systems to improve the health quality of their populations and modernize their health system, however many of them were not successfully implemented [7].

More than 75% of telemedicine system projects failed without significant contributions to the health system globally [8]. However developed countries are better to implement telemedicine as compared with low-income nations, 76% of united states of America health institutions full function the system [9]. 75% of Norway’s health institutions successfully implement telemedicine system, But in low-income countries only 10%of their health institutions provide health service through telemedicine [8, 10].

To successfully implement a telemedicine system readiness assessment is a significant factor for the adoption and utilization of telemedicine system health institutions and is fundamental [11, 12].

Readiness assessment finds outs existing conditions of health institutions and health professionals’ preparedness for a new system.

Preparedness evaluation refers to the preparedness of healthcare systems and health professionals to adopt changes that have been brought about by the implementation of computerized systems [13]. The readiness assessment of healthcare providers has been identified as a critical success factor in the implementation of electronic systems [14].

Research done in Lebanon on health professionals’ readiness toward electronic health reported that the majority of study participants were ready to implementation of electronic health [15]. A study conducted in Uganda on health professionals’ readiness toward telemedicine found that 64.7% of health professionals were ready to implement telemedicine [16]. Another study conducted in Mauritius on health professionals’ readiness to implement telemedicine showed the readiness of health professionals for Telemedicine system implementation was 64.5% [17].

Multiple reasons are given for low adoption of telemedicine systems such as resistance to change, lack of pre-implementation preparation, lack of organizational readiness, unavailability of information technology, and lack of technical skill of personnel [18-21].

The successful introduction of a telemedicine system into healthcare organizations requires the study of different technical, organizational infrastructures, and human factors [15]. The study revealed that health professionals’ readiness is fundamental for launching a telemedicine system in healthcare [22]. Examining readiness is an inclusive measurement to know about possible reasons for telemedicine adoption failure and provide pertinent information on existing conditions and the preparedness of health care organizations to change.

Like other countries, Ethiopia’s ministry of health recognized the importance of information technology to the health system is indicated and tried to implement telemedicine pilot projects at some selected hospitals, but failed without net contribution to the health system. To fully implement electronic health at the national level electronic health strategy was developed including five domains including telemedicine, mobile health, electronic learning, electronic medical records, and health information system. The government of Ethiopia has made different efforts to implement an electronic health information system including a district health information system version2 for reporting system and electronic medical records and telemedicine for a few hospitals as a pilot and plans to scale up in the future.

To researcher knowledge limited research is done in Ethiopia, assessing health professionals’ readiness towards telemedicine has paramount significance to the health system.

These findings help input for policymakers, program managers, and local health administrators to launch a full system and sustain it for the future.

Therefore, this study aimed assessed health professionals’ readiness toward telemedicine and its associated factors working at private hospitals Amhara region, North West Ethiopia.

Materials and methods

The Institutional Review Board of the University of Gondor, College of Medicine and Health Sciences, Institute of Public Health, issued an ethical clearance with the reference number (RfNo/IPH/1493/2013). Verbal consent was obtained, and study subjects were told that they were able to complete the questionnaire suggested as their contract to engage in the study. During previous research, we found that many of the study subjects were unwilling to sign a written authorization form. This factor, along with the overwhelming number of respondents, led us to resort to verbal consent. The ethics procedure clarified this, and the ethics board precluded the signed consent requirement. As a result, rather than offering written approval, we chose to read and describe the consent form to respondents during data collection.

Study design and settings

An institution-based cross-sectional quantitative approach was conducted from March 3 to April 7, 2021. The study was conducted at private hospitals in the Amhara region of North West Ethiopia. The capital city of the Amhara region is bahirdar.

Source and study population

Private hospitals found in the Amhara region of Ethiopia are general hospitals.gamby general hospital has 205 health professionals and about 165 beds. Adinas general hospital has about 73 health professionals and 45 beds. Dream care general hospital has 67 health professionals and 38 beds. Afilias general hospital has about 38 health professionals and 23 beds. Ibex general hospital has about 34 health professionals and 22 beds.ayu general hospital has 41 health professionals and 25 beds. Bati general hospital has 58 health professionals and 26 beds. Selam general hospital has 81 health professionals and 35 beds.yifat general hospital has 41 health professionals and 21 beds. Ethio general hospital has 61 health professionals and 29 beds.

In this study source and study population are the same because ten private hospitals were included in the study. All health professionals who were working at ten private Hospitals in the Amhara Region of Ethiopia were considered as the source and study of the population.

Inclusion criteria

Private hospitals found in the Amhara region of Ethiopia are general hospitals.gamby general hospital has 30 specialists. Adinas the general hospital has 23 specialists. Dearm care general hospital has 20 specilialist. Afilias general hospital has 12 specialists. Ibex general hospital has 15 specialists.ayu general hospital has 11 specialist.bati general hospital has 13 specialists.selam general hospital has 19 specialists. Yifat general hospital has 10 specialists. Ethio general hospital has 9 specialists. All Health professionals who were working at ten private Hospitals and available at the time of data collection were included in the study.

Exclusion criteria

Health professionals who were seriously ill and those who have less than six months of working experience in clinical practices were excluded from the study. Because they are new to the work environment and may not have knowhow the application of telemedicine technology for healthcare delivery.

Study participants, sample size, and sampling procedure

Health professionals working at private hospitals found in the Amhara region of northwest Ethiopia were eligible for this study. The sample size was calculated by using the single population proportion formula by considering 50%with a 95% level of confidence, a 5% margin of error a 10% non-response rate. Finally, a minimum sample size of 423 was obtained.

The following formula was used to calculate the total sample size of the study.

proportional allocation was done for each hospital and study participants were recruited by a simple random sampling technique (Fig 1).

Fig 1

Sampling procedure for selecting study participants at private hospitals in Amhara region, Ethiopia 2021.

Data collection tool and procedures

Data were collected using a pretested and structured self-administered questionnaire adapted from [13]. The first part of the questionnaire contents, demographic information, individual, technical, and organizational access to basic technologies variables were included in the questionnaire and it includes yes and Likert scale questions. The second part includes questions on core and engagement readiness. Core readiness was examined by health professionals’ dissatisfaction with the current paper-based system(four items), while engagement readiness was assessed by health professionals based on the potential benefits and willingness to use the telemedicine system (eleven items). These two readiness domains were measured s in a five-point Likert scale with one denoting strongly disagree to five indicating strongly agree. The English version of the questionnaires is translated to the local language Amharic The local language is also translated to English. The reliability was also checked using Cronbach alpha’s coefficient (overall Cronbach alpha for health professionals readiness = 0.81).

Health informatics professionals were recruited as supervisors and eight health information technician professionals participated in data collection. To control the quality of data, two days of training were given to data collectors and supervisors on the objective of the study, data collection procedures, data collection tools, respondents’ approach, data confidentiality, and respondents right before the data collection date. Before the actual data collection, pretesting of the questionnaire was conducted for about 10%of the study participants.

Measurements

In this study, core readiness and engagement readiness were assessed using a set of composite scores that included four core questions and eleven engagement questions. The realization of needs and expressed dissatisfaction with the current way of working, such as inefficient documentation, patient privacy, and data confidentiality, is defined as core readiness [1]. Engagement Readiness is defined as an active willingness to implement telemedicine and volunteer to receive telemedicine training [23].

In this study, we used the mean and median scores to dichotomize our variables such as Telemedicine readiness, knowledge, attitude, computer literacy, and computer skill. If the variable was normally distributed, we computed the mean score. On the other hand, we used the median score if the variable was not normally distributed.

Health professionals’ readiness

In this study health professionals’ readiness was measured by a set of 15 questions and participants who scored median and above were considered ready, and participants who scored below the median were considered as not ready [24].

Knowledge

Respondents’ level of knowledge of telemedicine was assessed by questions to be answered in either “Yes” or “No.” A score of “1” will be given for “Yes” and “0” for “No.” One can score a minimum of 0 and a maximum of 18 in this section. In this study, the average score of 9 (50%) from the 18 questions was used as a cutoff point to determine the level of knowledge of telemedicine. The mean knowledge score of less than 9 (50%) was labeled as poor knowledge of telemedicine and the more than average score of 9 (50%) was labeled as good knowledge of telemedicine [25].

Attitude

The respondents’ attitude was assessed by questions answered by rated on a 5-point Likert scale that ranged from “1 = strongly disagree” to “5 = strongly agree. In this study, a mean score of less than 2.5 (50%) is labeled as poor attitude, and 2.6 and more (51%)–3.0 (60%) is labeled as favorable attitude [26].

Data processing and analysis

Before entry to Epi info and exported to SPSS The data were manually checked for completeness and consistency. The data were entered into the Epi info version7.2 and exported to SPSS version 20 for analysis. Descriptive statistics were used to describe the characteristics of study participants in terms of socio-demographic and other variables. Categorical variables were presented in form of a frequency table to describe study subjects. Study subjects’ preparedness was measured by calculating the overall scores readiness level. The median scores for each readiness component were evaluated to find the overall readiness levels, and respondents who scored below or above the median overall readiness score were regarded as not ready (No) or ready (Yes) for Telemedicine implementation, respectively. to determine the association between independent variables such as gender educational status, work experiences, knowledge, attitude, computer literacy, etc, the dependent variable readiness was analyzed by multivariable logistic regression. Multicollinearity was also checked to manage the confounding effect of each variable. In multivariable logistic regression model analysis, model fitness was checked by the Hosmer-Lemeshow test (0.052) Variable’s significant association was determined based on the adjusted odds ratio (AOR), with 95% Cl and variables with (p<0.05) were considered as determinant factors for health professional readiness towards the implementation of Telemedicine.

Result

Socio-demographic characteristics of study participants

In this study, a total of 423 health professionals from ten private hospitals were approached, out of them, 410 responded with a response rate of 96.9%. More than half 226 (55.1%) of the study participants were males. The majority (44.6%) of the respondents were within the age group 25–29 years (Table 1).

Table 1

Socio-demographic characteristics of health professionals working in all private hospitals Amhara region 2021 (N = 410).

Variables	Categories	Frequency (N)	Percentage (%)
Sex	Male	226	55.1
	Female	184	44.9
Age	20–24	29	7.1
	25–29	183	44.6
	30–34	128	31.2
	> = 35	70	17.1
Professions	Medical Doctor	90	22.0
	Nurse	165	40.2
	midwifery	40	9.8
	pharmacy	46	11.2
	Medical laboratory	57	13.9
	Other	12	2.9
Work experiences	<2years	66	16.1
	2–3 years	58	14.1
	4–5 years	67	16.3
	>5 years	219	53.4
Educational status	Diploma	82	20.0
	Degree	202	49.3
	Masters and above	126	30.7

Technical related factors

Of the total study participants, More than half 240 (58.5%) of health professionals were computer-literate. About 245 (59.8%) of study participants had computer skills (Table 2).

Table 2

Technical factors towards telemedicine readiness among health professionals at private hospitals in the Amhara region 2021.

Variables	Category	Frequency (N)	Percent (%)
Computer literate	Yes	240	58.5
	No	170	41.5
Computer skill	Yes	245	59.8
	No	165	40.2

Organizational related factors

About 245 (59.8%) of study participants have had computer access at their offices. Regarding, internet access at the office nearly two-thirds of 251 (61.2%) of the health professionals had internet access at their office (Table 3).

Table 3

Organizational factors for health professionals’ readiness towards telemedicine in private hospitals Amhara region 2021 (N = 410).

Variables	Categories	Frequency (N)	Percent (%)
Computer access at the office	Yes	245	59.8
	No	165	40.2
Internet access at the office	Yes	251	61.2
	No	159	38.8
Available IT support	Yes	252	61.5
	No	158	38.5
Computer Training	Yes	168	41.0
	No	242	59.0
Backup power generator	Yes	334	81.5
	No	76	18.5

Behavioral related factors

In this study, more than two-thirds of 281 (68.5%) of the study participants had good knowledge. Similarly, half of 217 (52.9%) of the study participants had a favorable attitude toward Telemedicine (Fig 2).

Fig 2

Knowledge and attitude towards telemedicine among health professionals working at private hospitals in Amhara region, Ethiopia, 2021.

Health professional readiness to ward telemedicine system

Of a total of study participants, 244 (59.5%) and 222 (54.1%)of study participants have had core and engagement readiness respectively. The result of this study indicated that two-thirds of 268 (65.4%) with 95% CI: (60.1–69.8) study participants were ready for telemedicine adoption (Fig 3).

Fig 3

Core and engagement and overall readiness of health professionals’ towards telemedicine at private hospitals in Amhara region Ethiopia, 2021.

Factors associated with telemedicine system readiness

As shown in (Table 4) variables in multivariable logistic regression like Knowledge, Attitude, own personal computer, internet access at the office, Computer skill, computer literacy, computer training, Work experiences, educational status, gender, and computer access at the office were positively associated with health professionals’ readiness towards telemedicine.

Table 4

Bi-variate and multivariate analysis on factors associated with readiness of health professionals for telemedicine system in private hospitals, Amhara region, 2021.

Variables	Readiness		Crude OR (95% CI)	Adjusted OR (95% CI)	p-value
	Ready	Not ready
Knowledge
Good	221 (78.6%)	60 (21.4%)	6.43 (4.1, 10.2)	2.5 (1.4, 4.6)*	0.002
Poor	47 (36.4%)	82 (63.6%)	1.0
Attitude
Favorable	186 (85.7%)	31 (14.3%)	8.1 (5.1, 13.1)	3.2 (1.6, 6.2)*	0.001
Unfavorable	82 (42.5%)	111 (57.5%)	1.0
Personal computer
Yes	223 (71.5%)	89 (28.5%)	2.96 (1.85, 4.71)	3.0 (1.5, 5.9)*	0.002
No	45 (45.9%)	53 (54.1%)	1.0
Computer skill
Adequate	188 (76.7%)	57 (23.3%)	3.5 (2.3, 5.4)	1.9 (1.1, 3.4)*	0.025
Not adequate	80 (48.5%)	85 (51.5%)	1.0
Computer literacy
Adequate	186 (77.5%)	54 (22.5%)	3.7 (2.4, 5.7)	2.2 (1.3, 3.9)*	0.007
Not adequate	82 (48.2)	88 (51.8%)	1.00
Computer Training
Yes	140 (83.3%)	28 (16.7%)	4.5 (2.8, 7.2)	2.1 (1.1, 4.1)*	0.022
No	128 (52.9%)	114 (47.1%)	1.0
Work experience
<2 years	35 (53%)	31 (47%)	1.0
2–3 years	32 (55.2%)	26 (44.8%)	1.1 (0.5, 2.2)	0.9 (0.4, 2.4)
4–5 years	32 (47.8%)	35 (52.2%)	0.8 (0.4, 1.6)	1.1 (0.4, 2.7)
>5 years	169 (77.2%)	50 (22.8%)	3.0 (1.9, 5.3)	3.1 (1.4, 6.7)*	0.004
Internet access
Yes	200 (79.7%)	51 (20.3%)	5.3 (3.4, 8.2)	2.8 (1.6, 5.1)*	0.001
No	68 (42.8%)	91 (57.2%)	1.0
Computer access
Yes	186 (75.9%)	59 (24.1%)	3.2 (2.1, 4.9)	2.1 (1.1, 3.7)*	0.017
No	82 (49.7%)	83 (50.3%)	1.0
Sex
Male	171 (75.7%)	55 (24.3%)	2.8 (1.8, 4.2)	1.5 (0.74, 2.9)
Female	97 (52.7%)	87 (47.3%)	1.0
Educational status
Diploma	39 (47.6%)	43 (52.4%)	1.0
Degree	124 (61.4%)	78 (38.6%)	1.7 (1.0, 2.9)	1.3 (0.58, 2.8)
Master and above	105 (83.3%)	21 (16.7%)	5.5 (2.9, 10.4)	1.6 (0.7, 3.9)

The odds of readiness are 2.3 times high among health professionals who had good knowledge as compared with their counterparts. Respondents who had a favorable attitude toward Telemedicine were 3.2 times more likely ready for the Telemedicine system than those who have an unfavorable attitude. Having a personal computer was positively associated with health professionals’ readiness for telemedicine adoption.

Computer skill was found significantly associated with respondents’ readiness for telemedicine implementation. Computer literacy was statistically significant with health professionals’ readiness for telemedicine adoption. Computer training was found positively associated with respondents’ readiness for telemedicine adoption.

Discussion

The study assessed health professionals’ readiness in private hospitals in Ethiopia for the planned national adoption of telemedicine. health professionals were targeted due to key determinants adoption and successful implementation of telemedicine depends on health professionals’ readiness [27]. The readiness of healthcare professionals is a helpful component for the implementation successfully Telemedicine [28, 29]. To the best of our knowledge, no studies have been undertaken in Ethiopia on health professionals’ readiness for telemedicine system adoption.

In this study, the readiness of health professionals for the Telemedicine system in ten private hospitals that were frontline to implement the Telemedicine system was assessed. Our assessment indicated that the overall readiness of health professionals for the telemedicine system was 65.4%(with 59.5% of core readiness and 54.1% engagement readiness).

Nearly 59.5% were deemed ready for core readiness, while 54.1% were deemed ready for engagement readiness. This implies that health professionals may have expressed discomfort with paper record systems and recognized the necessity of Telemedicine (core readiness), as they were seen as highly actively engaged with Telemedicine and willing to use it. assessing the core and engagement readiness of health professionals will help to know the advantage and disadvantages of telemedicine risk and the applicability of the system in healthcare institutions.

Health professionals’ readiness in this result was consistent with readiness assessments done in other resource constraint settings in Uganda [16]. This is also consistent with a study conducted in Mauritius [17]. However slightly higher than another study done in Uganda [1]. This substantial difference could be due to infrastructure differences as well as differences in measurement methods used in the studies. Furthermore, higher education institutions in Ethiopia have currently integrated a generic health information system course for all health science students into their curriculum, which can provide information about the telemedicine system.

In this study health professionals who had good knowledge of Telemedicine, were about 2.5 times more likely to be ready for a Telemedicine system as compared to their counterparts. This finding is consistent with the previous study conducted in Mauritius [17]. Moreover, consistent with a study conducted in Iran [30]. This might be due to, health professionals with prior knowledge that may have helped their motivations to use the Telemedicine system. the speculation is per evidence suggested by another study [31], which confirmed that having a concept about Telemedicine improves readiness for the telemedicine system.

Health professionals who had a favorable attitude toward telemedicine were 3.2 more likely ready for the telemedicine system than their counterparts. This result is consistent with the study done in Saudi Arabia [32]. The reason is due to having a favorable view of telemedicine helps health professionals ready to adopt the telemedicine system.

This study showed that participants who owned personal computer were found to have telemedicine readiness.this is in line with a study done in Ethiopia [15, 33].

Computer skill was found to be significantly associated with telemedicine readiness. Participants who had good computer skill were 1.9 times more likely ready for telemedicine than their counterparts. This is consistent with studies done [1, 17, 33].

This might be because being familiar with computer technologies and having technical skills helps health professionals to be active adoption of telemedicine, not such difficult to adapt to new technology. Readiness to accept information systems is affected by the level of computer skill.

Computer literacy was found positively associated with telemedicine readiness. Respondents who had good computer literacy were 2.2 times more likely ready for telemedicine than their equivalents. This result is comparable with other studies done [34, 35]. The possible explanation might be knowing how to use computer technologies in day-to-day activities increase to use of advanced technologies.

Computer-related training was found significantly associated with telemedicine readiness. Health professionals who had taken computer-related training were about 2.1 times more likely ready for telemedicine systems than as compared with those health professionals who had not taken computer training. This is in line with a study done in Australia [35].

A possible reason for this could be computer training is more likely to increase participant familiarity with using technologies. Additionally, the explanation might be training and education usually changes people’s views, and upgrade knowledge levels, and perceptions. Knowing the updated technology passionate for upcoming in their institution.

In this study internet access at the office was positively associated with telemedicine readiness. Health professionals who had internet access at their office were about 2.8 times more ready for the telemedicine system as compared with those health professionals who did not have internet access at the office. Consistent with a study done in [36]. This might be because the internet influences access how new advanced technologies applications in the health system. Internet exposure can impact humankind’s daily life.

Health professionals who had computer access at their office were about 2.1 times more ready for the telemedicine system as compared with those health professionals who did not have computer access at the office. This finding is supported by a previous study done in Lebanon [15]. This could be attributed to the availability of computer-enabled individuals to practice digital tools. Furthermore, computer access allows for a daily practice of Telemedicine technologies, which improves skill and confidence in engaging in Telemedicine [37].

Study participants who had more than years of work experience were about 3.1 times more ready for the telemedicine system as compared with those study participants who had less than five years of work experience. This is in line with a study done in Nigeria [38]. The possible reason might be that more working long years in the health care system might have the probability of sharing new knowledge with other partners in the workplace. The finding of this study could be generalizable to other private hospitals in Ethiopia.

This could be explained by the fact that those individuals, as new staff, might not have understood the context of the healthcare setting and the tiresome process flow imposed by paper-based records.

The study’s strengths and limitations

This is Ethiopia’s first study to assess health professionals’ readiness levels before Telemedicine implementation. It also highlighted some of the Measurements to be taken before the introduction of telemedicine in low-income countries. However, Because the study was cross-sectional, causality does not infer. The study did not triangulate with qualitative findings. Furthermore, this does not address organizational readiness.

Conclusion and recommendation

Around two-thirds of the respondents had a good level overall of readiness for the adoption of telemedicine. The finding implied that less effort is required to improve readiness before the implementation of telemedicine. This finding implied that respondents who had good knowledge and a favorable attitude toward telemedicine were more ready for such technology. Capacity building is needed to enhance computer literacy, and computer skills build their confidence to rise ready for such technology. Building their capacity through training, building good internet connection, and availability of computers, where the necessary measures to improve Telemedicine readiness in this setting. Additionally, exploring healthcare providers’ opinions with qualitative study and extending the proposed study to other implementation settings are recommended to be addressed in future works. The findings will help policymakers improve and expand the implementation of telemedicine technology across the country. The study has a positive impact on the successful implementation and use of telemedicine throughout hospitals at countries level by providing pertinent information about health professionals’ preparedness status. Therefore, implementing telemedicine will have a significant contribution to the health system performance improvement in terms of providing quality care, accessibility to health facilities, reduction of costs, and creating a platform for communication between health professionals across different health institutions for providing quality patient care.

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5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

6. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

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9. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

10. Please include a separate caption for each figure in your manuscript.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Page 9: Paragraphs 1 and 2 which deal with the benefits of Telemedicine, should be more comprehensive and holistic

Page 9, lines 59-60: Some of these sentences are repetitive

Page 9, lines 65-66: A few words appear to have been missed.

Page 10: Cited studies from Lebanon, etc., lack sufficient details

Page 10: lines 86-90: This paragraph should be moved to the next page and merged with lines 108-113

Page 11. Lines 91-94: The sentence has no verb

Page 11, lines 108-109: Identify all five domains

Page 12, lines 112: what is the mean of dhis2? Is it a typo? Or is an abbreviation? If yes, it must be capitalized

The introduction is long and has repetitive sentences. The connection between the paragraphs and their logical order is not well established. The introduction needs a major rewrite. In addition, despite conducting the study during the Covid 19 pandemic, the Covid 19 pandemic and its impact on the spread of the use of telemedicine is not mentioned anywhere.

Line 136: Provide general information about ten hospitals, including number of beds, general or specialized, etc.

Page 13, line 141: Mention the number of specialists

Page 13, lines 151-162: In this part, too, information and repetitive sentences have been used a lot

Page 14, line 169: Specify which dimensions of health professional readiness are examined. In which part of the questionnaire is this dimension addressed and how many questions each part of the questionnaire have. The different parts of the questionnaire and the number of questions as well as the Likert scale used should be specified. Summarize the information presented in lines 197-211 and move to this section.

Page 15, line 176: what is the mean of" Three-degree holder health professionals"?

Line 178: It is better to explain in the introduction about the geographical extent of the study setting to show the importance of work.

Line 184: Reporting variables is not common in e-health studies.

Line 257: what is core and engagement readiness?

Line 244: Based on the data of which part of the questionnaire, this result was obtained?

Line 247: Are organizational factors just access to computers and the Internet? Numerous other factors had to be considered.

Figures 2 and 3 have no title and are not presented respectively

Line 264: Among the demographic variables, gender and educational status also had an effect on the level of readiness.

Lines 266-284: There is no need to duplicate table data in text format.

The Result section is not well organized because the method section does not specify the exact dimensions of the study and the questionnaire, and therefore the logical order of the findings is not clear to the reader.

Figures 2 and 3 have no title and are not presented respectively

Line 368: " Furthermore, another study also supports this study" how? Needs further explanation

The Discussion section needs to summarize comparisons to similar studies and place more emphasis on reasoning and inference.

There are several typos in reference section, for example references number 30 and 39

Reviewer #2: This work imed to assess health professionals' readiness and its determinant factors to adopte Telemedicine system at ten private hospitals in North West, Ethiopia. It would be interesting if they explained the rate between public and private hospitals in Ethiopia. Mainly for knowing the representativeness of the study among total professionals, both public and private.

They contend that those findings are not representative of the scenario in low-income countries due to differences in digital technology penetration and it needs several behavioral changes in the workplace for health workers and also knowing how to use computer technologies in day-to-day activities increase to use of telemedicine applications.

The results could be presented in a more summarized and less repetitive way.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Victoria Ramos

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

8 Aug 2022

Dear Editors of PLOS ONE :

It has been recalled that we the authors of the manuscript entitled “Health Professionals' readiness and its associated factors to implement Telemedicine system at private Hospitals in Amhara Region, Ethiopia 2021” submitted our manuscript for publication in your journal and received reviewer comments for the betterment of the manuscript before its publication. In line with this, all authors are very happy with the constructive and valuable comments given by reviewers. Accordingly, we have considered all the comments and provided a point-by-point response and explanations for all the questions raised. Finally, we have submitted all the required documents in their revised form. We hope that we have addressed all the questions and if you have any points for further clarity, let us know.

All the authors would like to thank the editorial team and reviewers

Editor(s)’ comments to the authors

Comment1: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

Answer: Thanks dear editor for your nice comments and suggestions. We, the authors

of this study, have attached the necessary files and a detailed rebuttal letter according to

your suggestion and the journal format.

Comment2: A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

Answer: Thank you, the track changes and cleaned document have been prepared and labeled as revised manuscript and attached

Comment 3: An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Answer: thank you very much, dear editor, unmarked version of the revised manuscript was prepared without track change labeled as the manuscript was uploaded.

Journal Requirements:

Comments: When submitting your revision, we need you to address these additional requirements.

Answer: thank you dear editor we authors of this study agreed with your comments and suggestions. We have addressed the following requirements accordingly Plos one journal standards.

Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

Answer: thank you for the insightful comments, we authors accepted all your comments and suggestions forwarded to our manuscript. Accordingly, the manuscript was prepared based on the Title, Author, Affiliations, and Manuscript body formatting guidelines of PLOS ONE journal.

Comment 2: In the ethics statement in the Methods, you have specified that verbal consent was obtained. Please provide additional details regarding how this consent was documented and witnessed, and state whether this was approved by the IRB.

Answer: thank you very much, we authors gladly accept your comments and suggestions. Before we collected the data, we inform the study participants about the objective of the study and study do not harm them when they participate and there are no incentives during participation in the study. After they give us their voluntarism to take part in the study we began collecting the data. This study was approved by an institutional review board of the University of Gondar college of medicine and health sciences institute of public health.

Comments 3. Thank you for stating the following financial disclosure:

no.

Answer: thank you very much

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

Answer: thank you for the interesting suggestions, there are no specific funds for this study

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.”

Answer: thank you very much, no specific funding for this study

c) If any authors received a salary from any of your funders, please state which authors and which funders.

Answer: thank you no specific funding

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Answer: thank you, we the authors of this study received no specific funding for this work.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Answer: thank you, our authors included amendments made in the cover letter

Comment 4: Thank you for stating the following in your Competing Interests section:

no competing interest

Answer: thank you very much, the authors have declared that no competing interests exist."

Comment 5: In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

"Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Answer: thank you very much, dear editors, we authors of this study agreed on uploaded the dataset used in this study. We have uploaded additional supplementary materials.

Comment 6: PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

Answer: thank you very much, the corresponding author has ORCID ID and is validated by the editorial manager.

Comment7: Please ensure that you include a title page within your main document. You should list all authors and all affiliations as per our author instructions and indicate the corresponding author.

Answer: thank you, dear editors, for your interesting comments and suggestions and we authors of this study included title pages, a list of author’s affiliations, and corresponding authors accordingly to the PLoS one journal instructions.

Comment 8: Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical.

Answer: thank you for your insightful comments and suggestions, we agreed on the identity of the abstracts and .accordingly revised the abstracts online.

Comment 9: Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Answer: thank you very much, we authors of this study are grateful for the comments and suggestions forward. we revised accordingly and the ethics statement was put in method sections.

Comment 10: Please include a separate caption for each figure in your manuscript.

Answer: thank you, we have given separate captions for each figure that appears in the revised manuscript.

Review1 Comments to the Author

Reviewer #1: Page 9: Paragraphs 1 and 2 which deal with the benefits of Telemedicine, should be more comprehensive and holistic.

Answer: thank you very much for the interesting suggestions and comments, we authors agreed with your fantastic comments. Accordingly revised in the main manuscript is shown in track change.

Reviewer #1:Page 9, lines 59-60: Some of these sentences are repetitive

Answer: thank you for the interesting and constructive comments and suggestions; we authors of this study gladly accepted all comments and suggestions. Thus all repetitive sentences were removed in manuscript track changes.

Reviewer #1: Page 9, lines 65-66: A few words appear to have been missed.

Answer: thank you very much, we authors of the study accepted all your comments and suggestions. In addition, we have added missed words in the revised track change manuscript.

Reviewer #1: Page 10: Cited studies from Lebanon, etc., lack sufficient details

Answer: thank you, dear reviewer, we agreed on your advisable comments and suggestion forwarded to us .accordingly we try to write more clearly and in detail in the track change manuscript.

Reviewer #1:Page 10: lines 86-90: This paragraph should be moved to the next page and merged with lines 108-113

Answer: thank you very much, we authors of this study accepted all your comments and suggestions. According to your suggestions, we have moved the paragraphs and put them in the appropriate place in the track change manuscript.

Reviewer #1: Page 11. Lines 91-94: The sentence has no verb

Answer: thank you for the insightful suggestions and comments forwarded to our manuscript. Our authors accepted all comments and revised accordingly in the track change manuscript.

Reviewer #1:Page 11, lines 108-109: Identify all five domains

Answer: thank you very much, we accepted all comments and suggestions. Accordingly, the five domains were added in the rack change revised manuscript.

Reviewer #1: Page 12, lines 112: what is the mean of dhis2? Is it a typo? Or is it an abbreviation? If yes, it must be capitalized

Answer: thank you very much, we authors accepted comments and suggestions. Accordingly revised in the track changes manuscript. it was an abbreviation for district health information system version 2.

Reviewer #1: The introduction is long and has repetitive sentences. The connection between the paragraphs and their logical order is not well established. The introduction needs a major rewrite. In addition, despite conducting the study during the Covid 19 pandemic, the Covid 19 pandemic and its impact on the spread of the use of telemedicine is not mentioned anywhere.

Answer: thank you very much for your insightful comments and suggestions, we gladly accepted suggestions and comments. According to suggestions we try to reduce repetitive and long sentences and establish logical order between paragraphs. in the era of covid-19 pandemics, we try to show the importance of telemedicine.

Reviewer #1: Line 136: Provide general information about ten hospitals, including the number of beds, general or specialized, etc.

Answer: thank you very much, we authors of this study accepted all suggestions and comments. Accordingly, we incorporate basic information about private hospitals in the revised track change manuscript.

Reviewer #1: Page 13, line 141: Mention the number of specialists

Answer: thank you dear reviewers for the insightful constructive comments and suggestions; we gladly accepted all comments. We try to incorporate the numbers of specialists working in each hospital in the revised track change manuscript.

Reviewer #1: Page 13, lines 151-162: In this part, too, information and repetitive sentences have been used a lot.

Answer: thank your comments and suggestions forwarded to our manuscript development are very interesting and advisable for us. We tried to reduce too much information and redundancy appeared in this part in the revised tracked change manuscript.

Reviewer #1: Page 14, line 169: Specify which dimensions of health professional readiness are examined. In which part of the questionnaire is this dimension addressed and how many questions does each part of the questionnaire have. The different parts of the questionnaire and the number of questions, as well as the Likert scale used, should be specified. Summarize the information presented in lines 197-211 and move to this section.

Answer: thank you, we accepted all comments and suggestions. in this study, we try to assess core and engagement readiness of telemedicine among health professionals .likert type questions were used to assess readiness. A total of 15 questions four questions for core readiness and 11 questions for engagement were used. This information is summarized and presented accordingly to the suggestions in the revised track change manuscript.

Reviewer #1: Page 15, line 176: what is the meaning of" Three-degree holder health professionals"?

Answer: thank you for the comments and suggestions we authors of this study agreed on the issues raised. We mean that data collection supervisors were bachelor's degree health informatics professionals. Try to revise in track change revised manuscript.

Reviewer #1: Line 178: It is better to explain in the introduction about the geographical extent of the study setting to show the importance of work.

Answer: thank you for your insightful comments and suggestions, we authors are happy to accept comments and based on your recommendation try to remove them from this part in the track change manuscript.

Reviewer #1: Line 184: Reporting variables is not common in e-health studies

Answer: thank you for the comments forwarded to our manuscript improvement. We put the study variables assuming for clarification purposes. However if not necessary we tried to remove Based on your recommendation on track change manuscript.

Reviewer #1: Line 257: what is core and engagement readiness?

Answer: thank you reviewer the comments given us to improve the scientific writing of our manuscript. We try to give clear information about core and engagement readiness in the methods section in the track change manuscript.

Reviewer #1:Line 244: Based on the data which part of the questionnaire, this result was obtained?

Answer: thank you very much interesting comments on the advancement of our manuscript quality and readability. Accordingly, the result was obtained by technical-related factors questions. we tried to add a table for this result look (table4).

Reviewer #1: Line 247: Are organizational factors just access to computers and the Internet? Numerous other factors had to be considered.

Answer: thank you for the constructive comments and suggestions forwarded to us to advance the manuscript writing and understandable. We accepted all your comments, internet, and computer access are not the only organizational factors that have positive or negative impacts on health professionals' readiness we try to incorporate the availability of technical personnel and power generator but internet and computer access were significantly associated with health professionals readiness.

Reviewer #1: Figures 2 and 3 have no title and are not presented respectively

Answer: thank you very much, we authors of this study accepted all your comments and suggestions to improve our manuscript scientific writing. Accordingly, we tried to give a full name for figure 2 and figure 3 in the revised track change manuscript.

Reviewer #1: Line 264: Among the demographic variables, gender and educational status also affected the level of readiness.

Answer: thank you, reviewer, for constructive comments, we accepted all raised suggestions and comments to clarify our manuscript readability and scientific writing .accordingly we tried to incorporate the missed socio-demographic variables including gender and educational status of health professionals in the revised track change manuscript.

Reviewer #1: Lines 266-284: There is no need to duplicate table data in text format.

Answer: thank you very much for the interesting comments forwarded to our manuscript improvement. We accepted all your comments. The table data was converted into meaningful information for readers’ understandable concept .but your recommendation is that duplication, so we tried to reduce the text information written in an articulated manner in the revised track change manuscript.

Reviewer #1: The Result section is not well organized because the method section does not specify the exact dimensions of the study and the questionnaire, and therefore the logical order of the findings is not clear to the reader

Answer: thank you very much reviewer, we accepted all your comments and suggestions given to us to advance scientific writing in the manuscript. We tried to revise the method sections information to make the logical order of the manuscript clear for readers in track change manuscript

Reviewer #1: Figures 2 and 3 have no title and are not presented respectively

Answer: thank you very much, we authors of this study accepted all your comments and suggestions to improve our manuscript scientific writing. Accordingly, we tried to give full names for Figures 2 and figure 3 in the revised track change manuscript.

Reviewer #1: Line 368: “Furthermore, another study also supports this study" how? Needs further explanation

Answer: thank you very much for your insightful comments on our manuscript development, we authors accepted all comments forwarded to us. Accordingly, we tried to revise and modify the section in the track change document.

Reviewer #1: The Discussion section needs to summarize comparisons to similar studies and place more emphasis on reasoning and inference.

Answer: thank you, reviewer, we accepted all your comments and suggestions forwarded to our manuscript improvement. Accordingly, we revised the discussion section thoroughly in the track change manuscript.

Reviewer #1: There are several typos in the reference section, for example, references number 30 and 39

Answer: thank you for your insightful comments on our manuscript development, we accepted all comments. we tried to correct typos in the reference section in the revised track change manuscript.

Reviewer2 Comments to the Author

Reviewer #2: This work aimed to assess health professionals' readiness and the determinant factors to adopt the Telemedicine system at ten private hospitals in North West, Ethiopia. It would be interesting if they explained the rate between public and private hospitals in Ethiopia. Mainly for knowing the representativeness of the study among total professionals, both public and private.

Answer: thank you very much for your insightful comments on our manuscript improvement readability and scientific writing. We authors of this study accepted all comments, unfortunately, this study examined the proportion of health professionals who are working at private hospitals. Due to this public hospitals' health professional’s proportion of readiness is not examined.

Reviewer #2: They contend that those findings are not representative of the scenario in low-income countries due to differences in digital technology penetration and it needs several behavioral changes in the workplace for health workers and also know how to use computer technologies in day-to-day activities to increase to the use of telemedicine applications.

Answer: we thank you reviewer for your interesting comments and suggestions, we accepted all comments and suggestions given to our manuscript improvement.

Reviewer #2: The results could be presented in a more summarized and less repetitive way.

Answer: thank you very much for your insightful comments on this paper improvement, we accepted all comments and suggestions. Accordingly revised in the track change manuscript.

7 Sep 2022

8 Sep 2022

Dear Editors of PLOS ONE :

It has been recalled that we the authors of the manuscript entitled “Health Professionals' readiness and its associated factors to implement Telemedicine system at private Hospitals in Amhara Region, Ethiopia 2021” submitted our manuscript for publication in your journal and received reviewer comments for the betterment of the manuscript before its publication. In line with this, all authors are very happy with the constructive and valuable comments given by reviewers. Accordingly, we have considered all the comments and provided a point-by-point response and explanations for all the questions raised. Finally, we have submitted all the required documents in their revised form. We hope that we have addressed all the questions and if you have any points for further clarity, let us know.

All the authors would like to thank the editorial team and reviewers

Editor(s)’ comments to the authors

Comment1: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

Answer: Thanks dear editor for your nice comments and suggestions. We, the authors

of this study, have attached the necessary files and a detailed rebuttal letter according to

your suggestion and the journal format.

Comment2: A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes.

Answer: Thank you, the track changes and cleaned document have been prepared and labeled as revised manuscript and attached

Comment 3: An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Answer: thank you very much, dear editor, unmarked version of the revised manuscript was prepared without track change labeled as the manuscript was uploaded.

Journal Requirements:

Comments: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Answer: thank you dear editor we authors of this study agreed with your comments and suggestions. We tried to review the whole references cited in the manuscript are complete and correct. we ensured that all references are correct and complete no retracted papers are cited in our manuscript.

Reviewer 1 comment to the author

Comment#reviwer1: In conclusion, the macro view should be observed and the impact of this research on the successful use of telemedicine and the improvement of the health system should be mentioned.

Answer: thank you very much for your valuable comments ad suggestion for the improvement of our manuscript, we authors are happy to accept and agreed with the comments. Accordingly, we revised the conclusion section as recommended in the main revised manuscript.

Comment#reviwer1: To improve the validity of the sentence "In the era of covid-19 pandemics telemedicine have a great role in controlling the pandemics by using different communication …." in the introduction section (lines 66-69) on page 15, refer to the following reference.

Answer: thank you very much, dear reviewer, for your insightful comments and suggestion for our manuscript development. We authors of this study gladly accepted and agreed with your comments. We tried to cite the recommended reference in the introduction section lines66-69 in the revised manuscript.

Reviwer2 comments to the Author

Reviewer #2: The authors have adequately addressed my comments raised in a previous round of review and I believe that this manuscript is now acceptable for publication,

Answer: thank you very much dear reviewer for your insightful appreciation and recognition, we authors of this study gladly accepted and admiration for your constructive scientific comments forwarded to our manuscript improvement. Thank you very much again.

Submitted filename: Rebuttal letter.docx

Click here for additional data file.

12 Sep 2022

Health Professionals' readiness and its associated factors to implement Telemedicine system at private Hospitals in Amhara Region, Ethiopia 2021

PONE-D-22-16282R2

Dear Dr. Sisay wubante maru ,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jahanpour Alipour, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors properly addressed satisfactorily all of the concerns. Thus, the manuscript has now could be accepted for publication in the PLOS ONE journal.

Reviewers' comments:

15 Sep 2022

PONE-D-22-16282R2

Health Professionals' readiness and its associated factors to implement Telemedicine system at private Hospitals in Amhara Region, Ethiopia 2021

Dear Dr. Wubante:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr., Jahanpour Alipour

Academic Editor

PLOS ONE