Keywords

1 Introduction

1.1 Brief Explanation of Digital Health and Its Significance

Digital health can be defined as the use of technology, such as mobile devices, software, and sensors, to improve health outcomes and healthcare delivery (Ronquillo et al. 2022). These technologies can include a range of applications, from remote patient monitoring and Telemedicine to health information systems and electronic health records (EHR) (Ronquillo et al. 2022).The main goal of digital health is to improve access, advance and enhance the quality of healthcare services and lower any incurred costs. Electronic health records also aim to develop patients’ personalized healthcare plans (Hermes et al. 2020). In this regard, the Kingdom of Saudi Arabia (KSA) offers a mature example that can be highlighted as a success story, both in terms of the outcomes to the patients as well as in terms of developing an integrated, digital healthcare ecosystem.

1.2 Historical Context of Digital Health Adoption in Saudi Arabia

Saudi Arabia has made vast advancements in digital health adoption (Fig. 1). Digital health implementations started as early as the mid-1990s, but these projects were mainly isolated initiatives by a few governmental hospitals (Ministry of National Guard Health Affairs 2022; KFSHRC 2023). During the early 2000s, a more structured and unified approach emerged, leading to numerous collaborations among health institutions in Saudi Arabia and the formation of the healthcare reform committee (Altuwaijri 2010). In 2002, the healthcare reform committee established an information technology (IT) strategic plan for healthcare, which aims to further enable the management of similar digital tools (Altuwaijri 2010). Concepts in Telemedicine were tested as early as 2008 (Al-Kadi 2012), and in 2009, implementations of Telemedicine solutions were offered to assist in diabetes management (Al-Kadi 2012; Dawood and AlKadi 2023).

Fig. 1
A timeline of milestones in digital health adoption in Saudi Arabia. The eHealth implementation in hospitals in the mid-1990s, the launch of the M O H eHealth strategy in 2010, the introduction of Saudi Vision 2030 in 2016, and the digital health transformation plan and strategy in 2018.

Key milestones in Saudi Arabia’s adoption of digital health

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The Ministry of Health (MOH) first launched its eHealth strategy in 2010 (Ministry of Health Saudi Arabia 2018). Health in Saudi Arabia was revolutionized in 2016 with the introduction of the Saudi Vision 2030, a comprehensive plan for economic and social development, including the launch of the National Transformation Program (NTP) (Vision 2030 2016). In this plan, healthcare was classified as a top priority, and a commitment to adopt digital health technologies to improve healthcare delivery and outcomes was issued (Vision 2030 2016; Nation Transformation Program 2022). In 2018, the MOH launched its new Digital Health transformation plan, which outlined a roadmap for adopting digital health technologies across the country. The strategy aims to improve the overall healthcare quality. The goal of this plan is to create a modern, efficient, and integrated healthcare system that meets the population’s needs. Furthermore, the plan seeks to improve access to healthcare, reduce costs, and improve patient outcomes (Ministry of Health Saudi Arabia 2018). Between 2019 and 2021, the COVID-19 pandemic caused the expedited adoption of digital health technologies in Saudi Arabia, leading to the expansion of digital health infrastructure and the introduction of many population-level applications by the government (Alharbi et al. 2022; Unified National Platform 2022; Butcher and Hussain 2022; Ministry of Health Saudi Arabia 2023a, b)

1.3 Overview of the Population Structure in Saudi Arabia

According to the General Authority for Statistics, the total population in Saudi Arabia was 34.1 million in 2021, with an expected increase of up to 39.4 million by 2030, in which males accounted for 56.8% of the total population (General Authority for Statistic 2021). The Saudi citizens accounted for 63.6% of the total population, with non-Saudis accounting for 36.4% (General Authority for Statistics 2021). The country is witnessing an accelerated level of population growth at an annual rate of 2.43%. A major demographic shift is predicted in the next decade, with an increase in the growth rate of the elderly population (over the age of 60) of 3.2% to reach 4.63 million by mid-2030 (Health Sector Transformation Program 2021). This shift in the structure of the population is accompanied by an increase in the burden of non-communicable disease that requires high sub-specialized medical and surgical care (Alasiri and Mohammed 2022). This will undoubtedly increase the demand for long-term healthcare services capable of serving an aging population. The Health Transformation Plan has considered the burden of non-communicable diseases among several factors as core challenges and has worked to set priority initiatives to address them (Health Sector Transformation Program 2021). As a response, the MOH announced a reconstruction of the healthcare system. The MOH’s plans will not only focus on improving therapeutic and preventive healthcare services, but it will also attempt to reduce any created financial strains (Nation Transformation Program 2022; Alotaibi et al. 2022; Ministry of Health Saudi Arabia 2023a).

1.4 Overview of Saudi Arabia’s Healthcare System

Healthcare services in Saudi Arabia are provided through both the government and private healthcare providers. The leading governmental provider is the MOH, which provides a network of hospitals and primary healthcare centers, distributed throughout the country, representing over 60% of healthcare services. The remaining 40% are provided by other governmental healthcare providers, as well as private healthcare providers (Young et al. 2021). The healthcare system in Saudi Arabia is mainly governed by the MOH, as they issue the strategies and policies that guide health services throughout the country (Sebai et al. 2001; Unified National Platform 2022). The MOH institutes healthcare as a right of the entire population, providing free healthcare for all Saudi citizens and non-Saudis working in the public sector (Mufti 2002). The MOH’s health services liability for the holy Mosques’’ pilgrims and visitors further distinguish the Saudi healthcare system (Walston et al. 2008). Historically, the expenses associated with healthcare were solely financed by the Saudi government, taking up 6–8% of the country’s annual budget (Ministry of Health Saudi Arabia 2023c). Financial burdens combined with population growth, encouraged the Saudi Arabian government to move towards privatization (Rahman and Alsharqi 2019; Nation Transformation Program 2022). The first steps were taken in 2003 when the Cooperative Health Insurance recommended that mandatory employment-based health insurance should be implemented (Alkhamis et al. 2014).

1.5 Overview of the Digital Health Transformation Landscape

Saudi Arabia’s digital health transformation plan is committed to creating an ambitious goal of an economically conscious and modernized healthcare system that meets the entire population’s needs. The plan’s fundamental goals are to improve access to care and patient outcomes, increase efficiency, improve care quality, and strengthen health information systems. To mobilize these goals, the plan has built initiatives that expand Telemedicine services, introduce EHRs and develop a National Health Information Exchange (HIE) platform (Ministry of Health Saudi Arabia 2018; Health Sector Transformation Program 2021). Additionally, the plan seeks to bridge the gap between public and private sector organizations to facilitate their communication and delivery coordination (Health Sector Transformation Program 2021).

2 Current State of Digital Health in Saudi Arabia

2.1 Digital Health Solutions and Technologies in Saudi Arabia

Saudi Arabia has made significant investments in digital health infrastructure, enabling Telemedicine, mobile health (mHealth) applications, remote monitoring, Artificial Intelligence (AI), and Blockchain technology (Health Sector Transformation Program 2021). In the first quarter of 2023, 26% of the country’s annual budget, which accounts for $50,491 million, was dedicated to the health and social development sector. This amount is actually an increase of 31% from the previous year (Ministry of Finance Saudi Arabia 2023). By improving access to care, enhancing patient outcomes, and reducing the cost associated with traditional healthcare delivery models; these technologies work towards addressing goals set by the digital health transformation plan (Ministry of Health Saudi Arabia 2018, 2023a). Nevertheless, effective integration of these efforts into the healthcare system is still developing, as discussed in the proceeding sections.

One of the first digital health technologies to be adopted worldwide was EHR (Evans 2016; Graber et al. 2017). Saudi Arabia started implementing EHR in the early 2000s to provide a digitalized alternative that allows quick access, backup and recovery of patient data (Sebai et al. 2001; AlSadrah 2020).The MOH adopted an EHR system (the Unified Health File) to improve clinical performance, reduce errors in patient history records, and provide a national database of patient records (Ministry of Health Saudi Arabia 2023d). The use of EHRs improved patient care by equipping doctors to make more informed decisions based on accurate and real-time data (Yousef et al. 2020). Studies conducted in Saudi Arabia found healthcare providers to be knowledgeable of EHR systems (Hasanain et al. 2015; AlSadrah 2020; Otaybi et al. 2022; Alsahafi et al. 2022; Alharbi 2023). Electronic Health records’ role in aiding and controlling noncommunicable diseases has also been assessed and found to be a valuable tool (Hazazi and Wilson 2021). The use of EHR can be seen not only within MOH institutions, but also in many of the medium-large private hospitals in Saudi Arabia (Aldosari 2014).

As indicated earlier, EHRs were developed to preserve patients’ vital information, from basic demographic data to details of medical diagnosis and management plans. Accessing those data through online portals or mobile applications represents the potential impact of patient engagement and improvement in healthcare delivery (Dendere et al. 2019; Lyles et al. 2020). A successful initiative within the Saudi digital health transformation plan is the implementation of patient portals. Patient portals are a service offered by many healthcare institutions, both private and government, to empower patients to become active stakeholders regarding their health. Patient Portals are secure platforms that provide the patient’s access to health-related information. They also provide open channels that allow patients to communicate with their healthcare provider. The potential benefit of the patient portal relay on improving the quality of health services provided and facilitating the work of health practitioners and improving healthcare delivery (Lyles et al. 2020; Yousef 2021; KFSHRC 2023a; Ministry of National Guard Health Affairs 2023). Positive results reported from studies indicated enhancement of preventative behaviors and management of chronic conditions through those portals (Hazazi and Wilson 2021). In addition, evidence has shown that patient portal use in the primary care setting has enhanced patient engagement, improved communication, and cut costs (Amante et al. 2014; Hazazi and Wilson 2021). The next step is to progress to the Unified Health File system aimed at preserving all patient information and eliminating duplication of patient’s data throughout various healthcare organizations (Young et al. 2021; Ministry of Health Saudi Arabia 2023d).

Telemedicine entails utilizing digital communication as well as technology in diagnosis, evaluation, and medical assessment by facilitating the interaction between patients and their healthcare providers (Ministry of Health Saudi Arabia 2022a). Telemedicine is a part of the countries’ digital health strategy (Ministry of Health Saudi Arabia 2018). The COVID-19 pandemic required a contact-free solution, which drove the world towards Telehealth (Keesara et al. 2020; Omboni et al. 2022). Saudi Arabia embraced the use of Telemedicine through the adoption of the Sehhaty application to face the demands of the growing population (Alharbi et al. 2021). Sehhaty is an MOH developed unified platform that offers multiple health services. It encompasses the delivery of Telemedicine, health monitoring services, booking of appointments and vaccinations, in addition to health information and other health services offered to the public (Ministry of Health Saudi Arabia 2023e). Governmental and private hospitals, in addition to Telehealth startup Cura have also adopted Telemedicine platforms, including Telepharmacy services (Cura 2023; KFSHRC 2023b; Ministry of National Guard Health Affairs 2023; Dr.Sulaiman Alhabib Medical group 2023). Similarly, hospitals have implemented Telepharmacy services that provide remote prescription, medication management and home-delivery of prescriptions (Algarni et al. 2022). Furthermore, physicians are able to prescribe medication remotely using the Wasfaty or Anat applications. The Wasfaty application serves as a gateway between the patient and a network of pharmacies both governmental and private, enabling them to fill prescriptions or refill regular medications (Wasfaty 2021; Ministry of Health Saudi Arabia 2023f). While the Anat app is a platform designed for health practitioners, it offers services that make their job easier and improve the quality of care provided to patients such as e-prescriptions (Ministry of Health Saudi Arabia 2015, 2023f).

In several nations, mHealth applications are becoming an increasingly significant instrument for the delivery of healthcare (Consolvo et al. 2008). mHealth aims to improve healthcare practitioners’ outreach by overcoming distance, time zones, and cost barriers to deliver accessible and low-cost therapeutic services (Vaghefi and Tulu 2019). The MOH introduced several mHealth applications, such as Mawid, to improve the patient experience. Mawid is a free smartphone application that allows users to book, cancel, and/or reschedule appointments at primary care clinics, as well as manage referral appointments to general and specialized hospitals (Alanzi et al. 2022; Ministry of Health. E-Services) eReferrals were shown to be effective in lowering wait times, enhancing access to secondary care, and improving referral patients’ information accuracy (Tian 2011). During COVID-19 Mawid helped the users determine the risk of COVID-19 contamination by encouraging them to submit their symptoms and travel information into the application for the risk assessment test. It also assists users in raising awareness about COVID-19 and provides preventative instructions to be followed (Alanzi et al. 2022).

As the Saudi Arabian government is keen on protecting the health and safety of its citizens and residents from the risk of the spread of novel coronaviruses, the Saudi Data and Artificial Intelligence Authority (SDAIA) developed the Tawakkalna application to aid government efforts to combat COVID-19 (Dawood and AlKadi 2023). The Tawakkalna application was developed in collaboration with the MOH and all relevant authorities during the curfew period to facilitate the electronic issuance of movement permits for government and private sector employees, as well as any individual, assisting in containing the spread of the pandemic in the Kingdom (Binkheder et al. 2021b; Dawood and AlKadi 2023). As we return to regular life, Tawakkalna continues to assist in’ displaying users’ health status and other services. In addition, as part of encouraging social responsibility, Tawakkalna allows individuals to report breaches to the MOH in the event of a suspected case (Saudi Data and AI Authority 2023).

Saudi Arabia has been a pioneer in the use of remote monitoring technology to enhance patient outcomes. For example, the remote monitoring of chronic diseases such as diabetes and hypertension allows for the promotion of daily treatment and lowers the risk of hospitalization (Alanzi 2018; Alessa et al. 2021). The use of smartphone applications to help with hypertension self-management is becoming increasingly common. However, few commercially available applications have the potential to be useful and have acceptable security and privacy measures in place. A recent study in Saudi showed that commercial application use for self-management of hypertension is effective, usable and acceptable by patients (Alessa et al. 2021). Diabetes mellitus is one of the chronic health conditions that can benefit from self-management education utilizing mHealth applications. A Little research has been undertaken in Saudi Arabia to explore the efficiency of mobile technologies in diabetes management. Nevertheless, studies on the use of mobile applications for disease management and healthcare delivery have shown positive results (Alanzi et al. 2014, 2016). To date, no clinical trial demonstrating the efficiency of these methods for diabetes treatment in the Kingdom has been published. An application referred to as “SAED” was evaluated in a pilot study by Alotaibi et al. (2016). The SAED application was found to positively influence the innervation group by significantly decreasing HbA1c levels and enhancing diabetes awareness (Alotaibi et al. 2016). This application is used for diabetes monitoring, a helpful tool in improving the diabetes care of Saudi patients. The SAED application can also give healthcare professionals vital medical information about each patient. Easing the process of decision-making in their diabetic treatment plan. Incorporating an instructional tool can give diabetic patients pertinent information for better diabetes control. This is especially crucial in distant areas of Saudi Arabia, where healthcare facilities are still poor and lack specialized diabetes care. Adopting such an application will ensure appropriate medical intervention and treatment can be provided (Alotaibi et al. 2016).

Like the rest of the world, wearable health monitoring technologies in Saudi Arabia are increasingly being used. Smart watches or wristbands can track a variety of physiological characteristics and wirelessly transmit data to smartphones (Torres-Huitzil and Alvarez-Landero 2015; Yeh 2016). Wearable devices are used to monitor and collect information on people's health issues, such as glucose levels, blood pressure and heart rate (Vijayashree and Sultana 2018). While wearable devices have become a world norm, Saudi Arabia has also joined in the development of wearable sensors due to the growing demand from health consumers. For example, a real-time pilgrim tracking and health monitoring system was utilized using Arduino. Each pilgrim is given a wearable sensor that detects their location and primary health information. This sensor is linked to the control room to take fast action in case an alarm is received from the device (Rajwade and Gawali 2016). Also, a wearable personalized medicinal platform has been developed, where a wearable device can dispense medication and vitamins at varying doses depending on the individual needs (KAUST Innovation 2016). Another example is Qawam, a headwear addition capable of monitoring posture. The goal is to prevent neck and back pain that results from incorrect posture during computer and smartphone usage (Qawam 2021).

In various medical professions, Virtual Reality (VR) has been utilized to improve health outcomes (Alanazi 2022; Bayahya 2021; Bruno 2022). Further, VR in education and training allows medical students to virtually enter the human body to gain a comprehensive understanding while simulating real-life therapies (Eddy 2021; Dhar et al. 2023). Employing VR in medical education allows students to train in a simulated scenario for comprehensive surgical education at a significantly lower cost. In Saudi Arabia, the application of VR versus conventional methods in teaching has shown promising results in undergraduate medical education (Sultan et al. 2019). Augmented reality (AR) is also being used to give students hands-on learning experiences, such as simulating patient and surgical encounters, so that medical interns can practice emerging techniques (Bhugaonkar et al. 2022). A study evaluated the efficacy of AR among patients undergoing orthodontic treatments in Saudi Arabia. Patients who underwent education through AR displayed higher levels of knowledge retention of oral hygiene instructions than patients who received information from leaflets (Aljabry et al. 2023).

In Saudi Arabia, VR and AR have also been utilized in settings related to clinical psychology. A randomized control trial in Najran, a city southwestern of Saudi Arabia examined the effect of applying VR for patients undergoing cesarean sections. It found that use of VR glasses channeling 3D natural videos with sounds such as Quran (the holy book of Islam) or soft music during anesthesia resulted in a reduction of stress and anxiety levels among patients undergoing cesarean sections (Almedhesh et al. 2022). Others have proposed the use of AR as an alternative to Cognitive Behavioral Therapy (CBT) in patients with attention deficit hyperactivity disorder (ADHD) through the design of an AR-therapist (Alqithami et al. 2019). The AR-therapist incorporates gaming and utilization of AR to engage the patient and facilitate the treatment of ADHD patients. Although this model has been implemented and has shown efficacy in a single patient. The comparison of the AR-therapist to traditional CBT for the treatment of ADHD still needs to be evaluated with a cohort of human subjects (Alqithami et al. 2019).

Another important development in the field of digital health is the growing interest in Artificial Intelligence (AI). Although AI implementations in healthcare started as early as the 1950s, the full potential has only been witnessed in the past two decades, with the advancements in machine learning and language/image recognition algorithms (Kaul et al. 2020; Roser 2022).With the COVID-19 pandemic quickly straining healthcare services early in 2020, the Saudi Arabian government, led by SDAIA, utilized the use of AI to face the growing demands of the healthcare sector.

Artificial intelligence can also be used as a ‘Phenotype tool’ assisting in a preventive approach style of healthcare, commonly used in the field of public health. Using predictive analytics can help identify patients at a higher risk of developing chronic diseases such as diabetes (Alshammari et al. 2021a, b). By also examining patient long-term information, such as medical history, lifestyle habits, and genetic information, AI algorithms can analyze this and determine which patients may develop a particular disease (Alshammari et al. 2021a, b). These preventive approaches can assist healthcare decision-makers in identifying tools for early intervention, leading to a healthier population and reduced healthcare costs. However, AI implementations still have a long way to go, and Saudi Arabia recognizes the potential of AI and the role it will have in the healthcare sector (National Strategy for Data & AI 2020). In particular, the advancements in diagnosing various diseases, including cancer, diabetes and cardiovascular disease (Jiang et al. 2017). During the Riyadh Digital Health Summit (2022), a panel of 13 key experts identified 7 priorities recommended for adoption in order to face future pandemics. Artificial intelligence landed third on this list, indicating the potential it possesses (Al Knawy et al. 2020).

Blockchain is another technology being used worldwide in many industries, including Finance and Healthcare. It is used to securely transmit and store data. This is an important aspect when dealing with digital health due to the sensitive nature of patient data and the strict privacy rules (Shi et al. 2020). Hence, the incorporation of Blockchain technology into the Saudi healthcare sector, taps into its capabilities to ensure patient confidentiality. (Alsufyani et al. 2020), and to improve the healthcare system’s efficiency, security, and transparency (Alharthi et al. 2020). The Saudi Food and Drug Authority (SFDA) is currently exploring the use of blockchain to trace products’ journeys. That will allow the two parties, the supply chain entities and consumers to enhance their transparency and security, that will feed into establishing trust (Saudi Food and Drug Authority 2023).

Finally, the Seha Virtual Hospital is an innovative digital technology that has been introduced to the Saudi digital health market. It is considered a specialized healthcare virtual facility that can accommodate up to 400,000 patients annually. It employs advanced technologies that offer specialized services. It also has the capacity to assist around 152 hospitals throughout the Kingdom, in addition to 15 primary specialized health services and 34 sub-specialized services (Ministry of Health Saudi Arabia 2023g). The Seha Virtual Hospital has embraced a patient-centric approach to healthcare delivery, improving patient outcomes and experiences. The hospital utilizes all the advancements already well established in the Kingdom such as; EHRs, Telemedicine and AI, and remote monitoring technologies (Alsufyani et al. 2020; Ministry of Health Saudi Arabia 2022b). These technologies have helped bridge the gap between patients and providers. Overall, Saudi Seha Virtual Hospital’s adoption of digital health solutions and technologies has had a significant role in offering digital health services in the governmental sector (Ministry of Health Saudi Arabia 2018, 2023g) . A list of available digital health solutions and technologies are summarized in table 1 (Table 1).

Table 1 Summary of digital health solutions and technologies in Saudi Arabia
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2.2 Assessment of the Level of Digital Health Adoption and Awareness

Early research indicated a low percentage (approximately 30%) of use of digital health among healthcare organizations and negative attitudes from the healthcare workers relating to health information security and lack of sufficient training in using digital health applications (El-Mahalli et al. 2012; Albarrak et al. 2021). However, recently the perception and belief about the benefit of digital health implementation in a practical setting have changed (Thapa et al. 2021). Many reports indicated that digital health in Saudi Arabia is evolving steadily due to many factors including, but not limited to good network infrastructure across the country, a high percentage of internet users among the population that reached 98% in 2021, the launch of health information system in numerous governmental hospitals since the early 2000s, (Shouli and Mechael 2019; World Bank 2021; Al-Kahtani et al. 2022a). This has been evident during the COVID-19 pandemic, emphasizing the importance of digital health as an indispensable resource for patient care (Alghamdi et al. 2021). For example, Telemedicine emerged in some of the healthcare settings prior to the pandemic, but the adoption of Telemedicine has been moved forward during the pandemic with improvement in healthcare providers and patients’ awareness, and willingness to use such resources (Omboni et al. 2022). Similar observations have been reported in many health-related fields, including medical students, pharmacists, and the dental profession (Alsahali 2021; Chaudhary et al. 2022; Al-Kahtani et al. 2022a).

The available literature assessing the level of digital health adoption and awareness highlighted the importance of providing proper training to healthcare workers and education to the general population (Al-Kahtani et al. 2022b). Many qualitative studies highlighted the issue of understanding the cultural perspective in terms of application of and adoption of health technologies. Based on a qualitative study, cultural factors such as the language and communication of patients and the electronic literacy of healthcare providers are considered the main factors that potentially influence the adoption and awareness of digital health (Alodhayani et al. 2021). However, there is still insufficient data on the level of awareness of the implementation of digital health for both healthcare providers and patients. This can be attributed to the context and setting of those studies (Alodhayani et al. 2021; AlSalloum et al. 2023). A recent study examined patients’ awareness and satisfaction with four main MOH e-services (Seha, Moed, 937 Services, and Wasfati.). The study reported that 77% of participants were aware of such services where the demographic characteristics and level of education played key roles in the awareness of e-health.

2.3 Measuring the Digital Health Implementation in Saudi Arabia

The advancements in digital health development and implementation necessitates a comprehensive evaluation for their effectiveness and long-term impact on population health outcomes (WHO 2021). Understanding the healthcare landscape and the population’s needs is the first step in evaluating and implementing digital health technologies (Soobiah et al. 2020). Some studies indicated that the digital health efforts within the Saudi healthcare system have been efficient in reducing time, cost, and efforts of the healthcare providers to provide care (Otaibi 2019). However, the available literature that discussed a framework for monitoring and evaluating digital health implementation and progress is lacking. Some of those studies were formative evaluations, which assesses the readiness for digital health transformation at different hospitals. Other studies evaluated the effectiveness of specific eHealth applications (Alharbi et al. 2021; Al-Kahtani et al. 2022a). For example, one study examined the effectiveness of the Seha, an eHealth app, in improving healthcare delivery and efficiency and indicated that adopting digital or eHealth technologies would address some of the problems in the health system related to low patients’ satisfaction and limited resources (Alharbi et al. 2021).

In 2013, the World Health Organization (WHO) issued a global strategy on digital health that calls for developing and maintaining digital health infrastructure. And since 2015, the MOH has made remarkable progress in implementation of digital health; however, the status of the digital health implementation has not been unified by providers across the country (Alharbi 2018). In an effort to highlight the importance of digital technology for the global health and care system, the Riyadh Declaration on Digital Health in 2020 was formulated. This landmark forum emphasizes the role of digital and data technologies in promoting local and global resilient healthcare systems through the articulation of seven key priorities and nine recommendations for data and digital health (Al Knawy et al. 2020). The fact that Saudi Arabia hosted this forum is a showcase that the country is taking leading steps and a prominent position in the realm of digital health. Still, further research with appropriate measures and high-quality data on the evaluation of digital health efforts and outcomes and their impact is essential to support the implementation of further digital technologies. In addition, evaluations are expected to provide justification to further promote investment in the field (Al Knawy et al. 2020; WHO 2021).

3 Digital Health Ecosystem in Saudi Arabia

3.1 Overview of the Digital Health Ecosystem in Saudi Arabia

A digital health ecosystem is a health-centered environment that encompasses all individuals, governmental and private entities, innovations, technologies, data and resources, key players necessary to advance the digital health program (WHO 2021). The digital health ecosystem in Saudi Arabia is an evolving and developing sphere. The maturity of digital health in the Kingdom has been captured through Global Digital Health Index (GDHI). This measure assessed components of advancement in digital healthcare such as leadership and governance; strategy and investment; legislation policy and compliance; workforce, standards and interoperability, and infrastructure services and applications (Global Digital Health Monitor 2023). Currently, the GDHI in Saudi Arabia reached a maximum maturity (phase 5), an improvement from previous years where it was placed at the phase 4 level of maturity (Al Shouli and Mechael 2019; Global Digital Health Monitor 2023). These improvements are attributed to government and private sector collaborations to promote and embrace digital health technologies. The success and sustainability of digital health in Saudi are also reliant on an influx of investment, support, and continued cooperation (Ministry of Health Saudi Arabia 2018).

3.2 Overview of the Key Stakeholders in Saudi Arabia

To ensure that the goals of the digital health transformation plan are met, all stakeholders should be involved in its implementation process. Encouragement of innovation and intersectoral collaborations is a priority in the Kingdom (Ministry of Health Saudi Arabia 2018). This section will highlight some of the key stakeholders in digital health in the Kingdom. This includes; patients and providers, regulatory bodies, academic and research institutes and other governmental initiatives. This section will outline their roles and contributions to developing the digital health arena.

The experience of a patient with digital health in Saudi Arabia is now further enhanced by the changes in healthcare reform (Ministry of Health Saudi Arabia, Digital Health Strategy 2018). The patient’s acceptance and proper utilization of these solutions are vital for better health outcomes (Lupton 2014). This is why user-centered designs have been adopted (Calvillo-Arbizu et al. 2019). The national strategy places the health consumer at the center of the health model. Focusing on patient-centered care, which includes patient involvement in the decision-making process for improving their health outcome (Amin et al. 2020; Alotaibi et al. 2022).

The healthcare provider also plays a critical role in digital health adoption (Petersen et al. 2015). As the primary users of digital health technologies, healthcare providers are responsible for the successful implementation and adoption of these technologies (Petersen et al. 2015). Primary healthcare providers in Saudi Arabia comprehend the benefits of EHR, which include; the efficiency, the accuracy of documentation, and the availability of information when it is required (Hazazi and Wilson 2021). The government also supports their education and advocates to increase their knowledge in digital heath (Hassounah et al. 2020).

The MOH manages and regulates digital healthcare services in the Kingdom, it oversees the healthcare industry and formulates regulations governing both the public and the private health sector (Ministry of Health Saudi Arabia 2018; Al-Kahtani et al. 2022b; Alqahtani et al. 2022). The MOH’s efforts are outlined as the National Standards for eHealth in the Kingdom, which is the roadmap for the digital health transformation plan (Ministry of Health Saudi Arabia 2018). In addition, the MOH sets the necessary guidelines for data sharing, privacy, and it overlooks all ongoing digital health initiatives in the country (Digital Government Authority 2023a). An example of the MOH’s regulation of digital health services is its governance of the interoperability of e-prescriptions (Ministry of Health Saudi Arabia 2015). Another regulatory body involved in digital healthcare services is the Saudi Data & Artificial Intelligence Authority (SDAIA). The SDAIA was established in August 2019, by a Royal Decree aiming to facilitate the transition in achieving Vision 2030’s goals. SDAIA’s responsibilities lie in advancing the data and AI agenda (Memish et al. 2021). Global investment in the health sector is seeked out and regulated by the Ministry of Investment Saudi Arabia (MISA),formerly known as the Saudi Arabian General Investment Authority (SAGIA) (Ministry of Investment Saudi Arabia 2023). The MOH, SDAIA and MISA are all governmental entities that align their efforts to achieve national goals within the Kingdom towards Vision 2030 targets and initiatives.

Digital health care services are also regulated by the Saudi Health Council (SHC) (Saudi Health Council 2023).The SHC’s role, among other things, is to ensure enhancement of healthcare services between different stakeholders. It acts as a liaison that properly bridges the different entities together allowing proper collaboration to take place without any duplication of efforts (Saudi Health Council 2023). Another regulator is the Council of Health Insurance (CHI) previously known as Cooperative Health Insurance. The CHI is concerned with insurance companies and service providers. Their mission is to advance the health outcome of beneficiaries by enabling the use of transparency and equity value-based care among stakeholders (Invest Saudi 2017; Council of Health Insurance 2023). In addition, the SFDA is responsible not only for drug and food regulation but also for regulations concerned with medical devices. For example, the SFDA ensures necessary guidelines are present for medical devices marketing authorization for AI and machine learning. A crucial step that will facilitate adoption of medical devices into the Saudi market (Invest Saudi 2017; Saudi Food and Drug Authority 2022).

The growth and development of the digital health profession in the country is also a priority. Although research and development in the field is fostered at multiple universities in the Kingdom, these efforts only started in the 2000s (Al-dossary et al. 2021). There are 16 identified Universities that offer degrees in a variety of programs in Health Information Management, spread out at different geographical locations in the Kingdom. The majority (10) are public programs, and the rest are private programs (Al-dossary et al. 2021). All 16 Universities offer bachelor’s degrees in health informatics. However, only five provide a master’s degree. The earliest program started around 2003, at the Imam Abdulrahman bin Faisal University (Al-dossary et al. 2021). Most of these Universities have a set pathway to pursue a Doctor of Philosophy (PhD) scholarship opportunities in Health Informatics supported by the Ministry of Education (MOE). This will ensure further research and development in the field (KSAU-HS 2023). Furthermore, the Saudi Commission for Health Specialties guarantee proper classification and registration of these scholars and provides opportunities for further professional development (Invest Saudi 2017).

The Saudi Association for Health Informatics (SAHI) aims to improve efforts for further development by promoting research and engaging professionals in conferences, exhibitions, and networking opportunities (Saudi Association for Health Informatics 2023). In 2018, The Misk digital health accelerator program was launched to support startups and entrepreneurs in the digital health sector, through mentorship, fundraising, and networking (Misk 2022). The NHIC also works to advance the field of health informatics through the introduction of initiatives (Public consultation Platform 2022) In addition, the Saudi Electronic University (SEU) has recently collaborated with the MOH. This collaboration offered professionals in the field access to blackboard licenses from SEU to be utilized for training purposes. Ultimately, this collaboration is expected to build capabilities and strengthen online health practices among professionals (Saudi Electronic University 2022).

3.3 Analysis of the Key Players in the Ecosystem

In Saudi Arabia, family ties and values are very important (Al-Khraif et al. 2020).The patients’ caregivers or family members’ role as a stakeholder cannot be overlooked, as family members are usually in charge of supporting elders (Al-Khraif et al. 2020; Petersen et al. 2015). Elders usually seek help from a family member when accessing information from the mobile internet (Xiong and Zuo 2019). Digital literacy, level of education, as well as necessity for technology access, are aspects that dictate if older adults actually adopt certain technologies (Neves and Amaro 2012). Usage of user-centric designs in the developmental process of digital health technologies or eGovernment services can help increase adoption within young and adult populations (Alanezi et al. 2012; Calvillo-Arbizu et al. 2019; Khan and Lutfi 2021). The eGovernment services can only be considered for adoption when the quality is up to the consumers ‘standard (Choudrie and Alfalah 2016).

Health providers in Saudi Arabia have expressed digital literacy (Hasanain et al. 2015). In spite of all offered support, providers lack reliable infrastructure, resources, and training act as major challenges in digital health adoption (Alshahrani et al. 2019). Satisfaction and improvement in their experience with digital health technologies became evident after the COVID-19 pandemic (Alsaleh et al. 2021). The COVID-19 pandemic has provided a push to help accelerate this digital transformation (Alharbi et al. 2022; Alkhalifah et al. 2022). For this reason, the rush of digital health technologies into the Saudi Market was accompanied by numerous tactics to empower and educate the health consumer (Hassounah et al. 2020). The MOH scheduled live television broadcasts of the official spokesperson presenting up-to-date information daily. The MOH also utilized its social media platforms, Twitter in particular, to support this goal. In addition, it collaborated with a number of health entities to establish the Prevention Ambassador Initiative web-based course, to address health rumors on social media platforms (Saudi Press Agency 2020; Hassounah et al. 2020) . Other efforts included the provision of new laws by the Saudi Public Prosecution for sharing misleading or inaccurate electronic information (Riyadh Daily 2020).

The digital health market has witnessed rapid growth that requires the personal data protection law (PDPL) to oversee privacy policies and procedures. Accordingly, SDAIA and National Data Management Office (NDMO) released guidelines and rules for Personal Information Protection and Sharing of Data (National Data Management Office 2020; Digital Government Authority 2023b). The main objective of this law is to govern the process by which digital technology is utilized in healthcare while maintaining the necessity of protecting the privacy and security of personal information. (Digital Government Authority 2023b).

The maturation in protection laws allowed MISA to open the doors for local and international investments (Unified National Platform 2023). To add to the appeal of investing in Saudi’s HealthCare and Life Sciences (HCLS) sector, MISA has granted foreigners 100% ownership of their investments (Ministry of Investment Saudi Arabia 2021).This has lead to the direct investment of foreign companies such as Roche in Saudi’s HCLS sector with the aim of unlocking investment opportunities including digital health solutions (Ministry of Investment Saudi Arabia 2021). Additionally, the MOH has signed Memorandums of Understanding (MoUs) with international as well as local companies to support the National Transformation Plan for the healthcare sector. An example of an international collaboration is the MoU with General Electric (GE) to provide digital health solutions to the Kingdom (GE 2018). Locally, an MoU with Inma to provide and implement Telesurgury services (Alturki Holding 2022). The advancement of the digital health strategy also includes partnership and MoUs between private companies such as cloud solution and Dell technologies to provide technology solutions for the health care sector (Cloud Solutions 2021).

4 Future Outlook and Opportunities

4.1 Discussion of the Challenges of Digital Health Solutions in Saudi Arabia

Digital health implementation in Saudi Arabia can provide sustainable solutions and improve access to healthcare with higher levels of consumer satisfaction. Moreover, it offers many other benefits in improving patient health outcomes. This is evident through streamlining the delivery of care, improving communication between patients and healthcare providers, providing personalized treatment plans based on individual needs and preferences, as well as increasing access to quality care for underserved populations (Kuwabara et al. 2019; Haleem et al. 2021), moving away from silos and towards a greater integration of the healthcare ecosystem.

The Health Sector Transformation Program (Ministry of Health Saudi Arabia 2018) identified a number of challenges that can be addressed through digital health implementations. Concerns such as premature death, an accelerated level of population growth, the burden of non-communicable disease (mainly diabetes) as well as the burden from road traffic injuries are all areas that need immediate interventions to improve the quality of health services currently provided.

Other challenges that face the healthcare sector include lack of awareness among stakeholders, privacy concerns, cultural factors, regulatory challenges, and cost considerations (Al-Jumaili et al. 2015; Alnemary et al. 2017; Ministry of Health Saudi Arabia 2018; Alkhateeb and Alhadidi 2018; Almubark et al. 2019; Alnaim 2019; Alakhali 2020; Alodhayani et al. 2021; Alsahafi et al. 2022; Alahmadi 2023). The somewhat overlapping roles of the regulatory bodies and the health or financial service providers may lead to a conflict of interests. Thus, inconsistencies in primary and specialized healthcare, rehabilitation, long-term, and home care services, and patient care may affect the quality of treatment plans monitoring of patient’s outcomes (Vision 2030 2016; Khan and Iqbal 2020; Nation Transformation Program 2022). Furthermore, there is a lack of robust, consistent, and integrated digital information systems across all hospitals, which could enable better resource management, activity levels, product quality, and performance (Health Sector Transformation Program 2021).

With an increasing population, including a growing elderly population, and a considerable number of expatriates and international visitors, the healthcare system must modernize its approaches in order to meet growing demands (Vision 2030 2016). It should be noted that this challenge has been identified and been taken into consideration within the health sector transformation program initiatives. Adding to this, many of the initiatives within this program set outcome evaluation to follow up the projects with defined performance indicators, especially those initiatives that related to improved performance of MoH hospitals and medical centers (Health Sector Transformation Program 2021). Furthermore, Saudi Arabia is the custodian to the two holy mosques attracting more than seven million Umrah visitors during 2022, including four million worshipers with Umrah visas (Alarabiya 2023). Ensuring their safety and disease control is an ongoing challenge facing the healthcare system.

Acknowledgement of these challenges requires collaboration between government agencies, healthcare providers, technology companies, and other stakeholders to ensure that the population benefit from these transformative technologies and that the right capabilities are being built (Al-Kahtani et al. 2022b). Challenges are prioritized according to national goals and population needs (Alshuwaikhat and Mohammed 2017).

Another trending issue is the health literacy level among the Saudi population, with 46% considered health illiterate (Alahmadi 2023). Although access to health information is available, the amount, accuracy, quality, and reliability of it might not be suitable (Alsahafi et al. 2022), resulting in a misinformed, confused and often overwhelmed health consumer. The wide access to social media networks among a generally tech-savvy younger population has led to another more trending concern facing health consumers which is the spread of misinformation (Infodemic) on the Internet. Misleading information on digital platforms can negatively impact population health, spreading anxiety and fear which leads to health consumers adopting unhealthy behaviors (Pian et al. 2021). Furthermore, the internet contains an immense amount of health information. However, the majority of it is in English, not Arabic, the main language in Saudi, thus compounding the potential for misinformation (Al-Jumaili et al. 2015; Alnemary et al. 2017; Alkhateeb and Alhadidi 2018; Almubark et al. 2019; Alnaim 2019; Alakhali 2020; Alahmadi 2023).

Overall, the implementation of digital health provides sustainable solutions (Thapa et al. 2021). It improves patient outcomes by streamlining the delivery of care, improves communication between patients and healthcare providers, provides personalized treatment plans based on individual needs and preferences, as well as increases access to quality care for underserved populations (Kuwabara et al. 2019; Haleem et al. 2021; Alodhayani et al. 2021; Alsahafi et al. 2022).

Adding to this, the duplication of health service provision and financing for the same beneficiary, which results in unjustified variance, overuse, and underuse, leading to efficiency shortfalls (Trinh et al. 2008). Another identified challenge is related to the presence of a gap between supply and demand in the health workforce that has led to an increased dependence on foreign labor. Furthermore, there is a lack of robust, consistent, and integrated digital information systems across all hospitals, which could enable better resource management, activity levels, product quality, and performance (Health Sector Transformation Program 2021). Finally, there is a need to strengthen governance systems that contribute to reducing challenges to the health of the population and the quality of health services provided (Ministry of Health Saudi Arabia 2018; Chowdhury et al. 2021).

4.2 Discussion of the Future Opportunities for Growth of Digital Health in Saudi Arabia

The Saudi government’s commitment to digital transformation is evident. Through strategic programs such as the NTP, the government can act as a catalyst furthering the adoption of digital health strategies and initiatives (Vision 2030 2016; Health Sector Transformation Program 2021). The government is also committed to providing the right infrastructure for a prosperous digital health environment (Health Sector Transformation Program 2021). In 2021, the internet penetration rate in Saudi Arabia increased to 98.1% compared to 95.7% in 2019 (Communication, Space & Technology Commission 2021). Residents in Saudi Arabia are now offered high speed coverage from mobile networks, which consists of 4G and 5G coverage capabilities with wireless and fiber optic connectivity (Aldiab et al. 2022). The trust in digital solutions amplified with the adoption of health applications, such as Sehhaty, Tawakkalna applications, during the COVID-19 pandemic. The growing interest of citizen adoption and usage of e-services can have a ripple effect towards the development and innovation in more digital health technologies. Future opportunities lie in Saudi Arabia, given how it is becoming a market that capitalizes on investing in digital health solutions. This is evident through the Vision 2030 Privatization Program (launched 2018) which aims to improve the quality of services in 16 sectors within the country, including the health sector (Vision 2030 2022).

Furthermore, future opportunities in Saudi Arabia are also associated with the growing population of digital natives. Based on the total population estimation in 2021, more than 30% are between the ages of 15–35 years (General Authority for Statistic 2021). This age group is comfortably utilizing and navigating digital technologies, further enabling transformation of digital health and its development (Communication, Space & Technology Commission 2021). Capitalizing on this age group by educating and building their capabilities will help close the digital divide among elders and help increase satisfaction among users of digital technologies. Furthermore, building capabilities in Saudi Arabia will also facilitate advancements towards the Sustainable Developmental Goals (SDGs) in achieving indicator 4.4.1: “proportion with youth and adults with information and communications technology (ICT) skills” (United Nations 2022). Saudi Arabia intends to fulfill this SDG through attaining fundamental data and AI literacy skills by training 40% of its workforce by 2030 (National Strategy for Data & AI 2020).

Opportunities persist given the current deficiency of published literature surrounding digital health. The government recognizes the need to connect research with national development, especially with fields that support national programs such as health informatics. In order to understand existing publications Binkheder, Aldekhyyel and Almulhem (2021a) assessed the health informatics publication trends in Saudi Arabia between 1995 and 2019. The authors found that most of the published literature discusses clinical informatics (73.1%), and the rest covered consumer health informatics (22.3%) and 4% only covered public health informatics (Binkheder et al. 2021a). This emphasizes the opportunities that lie within furthering research and development in these fields.

In a global survey, Saudi Arabia was ranked second when answering “whether artificial intelligence products and services will make the lives of respondents easier.” Fully aware of the potential opportunities that lie within AI, SDAIA launched the National Strategy for Data and AI, a long-term plan aimed at implementing AI in five sectors in the country, including education, government, healthcare, energy, and mobility (National Strategy for Data & AI 2020). In order to facilitate the implementation of the strategy across the government entities four subsidiaries were created under SDAIA: the National Information Center (NIC), the National Data Management Office (NDMO), and the National Center for Artificial Intelligence (NCAI)(National Strategy for Data & AI 2020). According to the strategy, integration of Data and AI into healthcare will “increase access, enhance preventative care, and accommodate growing demand (National Strategy for Data & AI 2020). The opportunities in AI are endless and will continue to develop, attracting further growth and investments. The goal of the strategy is to reach $20 billion in local and foreign investments by 2030 (National Strategy for Data & AI 2020). A commitment to Saudi’s future as a global hub for Data and AI has been established, and with it the advancement of healthcare through digital health will continue.

5 Conclusion

The government of Saudi Arabia has been exploring the potential impact digital health can have on the healthcare sector since the late 1990s. Initiatives by government health entities quickly developed into national collaborations under the umbrella of the Saudi MOH. The past two decades witnessed digital transformations in the healthcare sector which improved the quality of health services, reduced medical errors, utilized health resources, and reduced costs. Alongside this transformation came national strategies, regulatory bodies and law, and public health campaigns to address health literacy within the population.

One of the main factors for success is the advanced mobile connectivity and stable country-wide coverage incorporating high-speed 5G networks. In addition, the majority of the Saudi population already uses the internet with a growing number of digital health users. This reliable infrastructure was evident during the COVID-19 pandemic when most healthcare services converted to a virtual form relying heavily on mobile health applications. As of 2022, over 68 million doses of the COVID-19 vaccine have been administered in Saudi Arabia indicating that 80% of the population (approximately 27 million) have booked and received the COVID-19 vaccines through the MOH mobile application Sehhaty. This suggests widespread use and acceptance of the Saudi population.

Vision 2030 has set objectives for the healthcare sector, and digital health can no doubt assist in achieving them. In particular, much focus has been on trends using technologies such as AI, Data mining, Genomics, and Bioinformatics. As technologies evolve and new devices develop, it is imperative that we continue to address critical issues related to data security and confidentiality. We also need to focus on patient satisfaction through a patient-centric approach to healthcare. Additional research is required to examine the impact of such technologies and identify potential areas for growth. Digital health has already had a significant impact on the healthcare sector in the Kingdom, and we expect to see further incorporation of future innovations, putting Saudi Arabia at the forefront of digital health adoption and utilization.