Abstract
Background Remote online assessment (ROA) systems gained prominence in undergraduate medical education during the COVID-19 pandemic. This study describes a uniquely phased implementation of an ROA system in a resource-limited setting, guided by an analysis of student satisfaction and perceptions. Methodology This observational study presents data from the implementation of ROAs at a private medical school in Lahore, Pakistan. Four principal activities were conducted on five undergraduate medical and four dental program classes, including two mock and two summative assessments. The ROA system utilized open-source, web-based software to administer the assessments. Primary outcomes included the rate of uninterrupted exam completions and student satisfaction (measured on a five-point Likert scale) during the first three activities. Secondary outcomes examined perceptions of educational impact, perceived usefulness, and the effectiveness of anti-cheating measures. Results Over 800 students participated in the ROA implementation process. Clinical-year students reported significantly higher levels of satisfaction compared to preclinical students (mean ranks = 443.18 vs. 372.81, 454.31 vs. 409, and 435.50 vs. 380.13, p < 0.05), while female students consistently reported lower satisfaction. One-on-one online training sessions conducted in small groups and mini-mock exams significantly improved overall satisfaction (p < 0.005). Key challenges included insufficient exam time (n = 614, 73.9%) and internet connectivity issues (n = 470, 57%). Although live proctoring effectively deterred cheating, it also heightened exam-related anxiety (n = 313, 77.9%). Despite perceiving ROAs as inferior to traditional examinations, students acknowledged their value in supporting course completion and preparation for summative assessments. Conclusions A phased, adaptive approach is essential for implementing ROAs in resource-limited settings. Repeated mock exams, small-group training, and targeted support for preclinical and female students can improve satisfaction and program outcomes. Addressing technical and psychological barriers is critical to successfully integrating online assessments into undergraduate medical education.