Hindawi Publishing CorporationInternational Journal of Telemedicine and ApplicationsVolume 2010, Article ID 357156, 7 pagesdoi:10.1155/2010/357156

Research Article

Tile-Ippokratis: The Experience of an EhealthPlatform for the Provision of Health Care Services inthe Island of Chios and Cyprus

Homer Papadopoulos

Department of Applied Technologies, National Center for Scientific Research “Demokritos”, 15310 Attiki, Greece

Correspondence should be addressed to Homer Papadopoulos, homerpap@dat.demokritos.gr

Received 2 November 2009; Revised 2 May 2010; Accepted 19 July 2010

Academic Editor: Tasos Dagiuklas

Copyright © 2010 Homer Papadopoulos. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Tile-Ippokratis proposed an integrated platform for the provision of low-cost ehealth services to citizens in southeastMediterranean area (Island of Chios and Cyprus). The aim of the paper is to present the architecture, the design, and theevaluation results of this platform. The platform based on already evaluated state-of-the-art mobile ehealth systems and usingwireless and terrestrial telecommunication networks is able to provide the following health care services: (i) telecollaboration andteleconsultation services between health care personnel and between health care personnel and patients and (ii) ehealth servicesfor “at risk” citizens such as elderly and patients with chronic diseases (Island of Chios) and postsurgery patients (Cyprus). Theehealth systems supported capabilities for vital signal measurements (ECG 1 lead, SPO2, HR, BP, weight, and temperature), anElectronic Patient Record (EPR) infrastructure, and video conference, along with communication gateways for data transmissionover ADSL, GPRS, and WLAN networks.

1. Introduction

Ehealth is an umbrella term which refers to the use ofinformation and communication technologies (ICTs) forthe provision of health services from distance. Ehealth,distinguished into eCare, eLearning, eSurveillance, andeGoverment/eAdministration [1], is one of the most rapidlygrowing areas of health. According to a global survey of theWorld Health Organization (WHO) there is a significantdemand for the provision of generic tools to support theclinical (elearning tools, access to digital libraries, databasesto support evidence-based medicine, telemedical systems,remote diagnostic systems, electronic patient records, deci-sion support systems, etc.) and administrative (e.g., financialsupport systems, patient referral systems, etc.) functionsof health care services in WHO member states [2]. Theabove is in line with the latest attempts, which have shownthat the use of ICT for the provision of healthcare servicesacross geographic, temporal, social, and cultural barriers

gave a great promise to help people in isolated and remoteregions to gain access in health care services [3].

The evolution on ehealth systems supported by advancedalgorithms, high performance computers, sensors, moni-toring devices, and telecommunication networks permitsthe provision of good quality of medical care even toremote/isolated regions, the information exchange, andthe distribution of medical knowledge among health careprofessionals [3].

Ehealth applications have been successfully used for theprovision of emergency ehealth in understaffed areas like,among others, rural health centers [4, 5] as well as forhome monitoring and home care [6, 7], whenever is needed.Recent studies have shown that the home monitoring ofelderly patients, as well as patients with chronic diseases,increases the individual’s comfort, enhances quality of life,and encourages the patient empowerment while it reducesthe number of needless transfers at hospitals and the cost ofprovided health care services [7–9].

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Furthermore several projects deal with elderly chronicdisease management as CONFIDENCE [10], ATTENTIANE[11], ENABLE [12], and K4Care [13].

This paper presents the architecture of the Tile-Ippok-ratis ehealth platform. The platform covers a wide range ofservices:

(i) support the collaboration and consultation betweenremote located health care personnel,

(ii) enable the electronic monitoring of “at risk” citizens,elderly, and patients with chronic diseases, in the areaof Island of Chios,

(iii) home telemonitoring of post-surgery patients whohad been provided intensive care medicine in theIntensive Care Unit of the Nicosia General Hospital;these patients were having Home Ventilation Carewithin their residents.

The main objectives of the project are considering:

(i) the collaboration between doctors and citizenslocated in Greece and Cyprus with different healthcare systems, different technology infrastructure, anddifferent needs, in order to enhance the quality ofhealth care services in the region South Mediter-ranean,

(ii) the improvement of the self-management skills ofthose patients with minimum ICT skills (the ehealthplatform and their electronic personal record couldbe accessed by them through a web browser),

(iii) the efficient monitoring and health management ofchronic and post-surgery patients by their doctorsand the early response to emergency incidents usinglow-cost state-of-the-art web-based technology,

(iv) the evaluation of the usability and acceptability of theproposed ehealth services in the pilot areas.

The platform, which had been developed during theInterreg IIIA “Tile-Ippokratis” project: An INTEgrated pilotehealth-platform for enhancing health care provisionbetween Greece and Cyprus, has been tested and validated inthe pilot sites in Greece and Cyprus (Figure 1). The platformand the provided services have been assessed by patients andphysicians in the aforesaid sites.

The platform (Server Software, EPR, Web Viewer-en-abling Internet access to patient measurements) has beeninstalled within the premises of the National Center forScientific Research, “Demokritos”.

In the Island of Chios the platform has been usedby the Skylitsio General Hospital of Chios and the ruralmedical peripheral health centers residing in Chios Prefec-ture Municipalities of Volysos, Kardamyla, Oinouses andPyrgi supporting elderly citizens and patients with chronicdiseases. The patients were receiving support in the ruralhealth centres.

In Cyprus the platform has been used by the IntensiveCare Unit of the Nicosia General Hospital supporting post-surgery patients in the municipalities of Nicosia, Larnaca and

Athens

Cyprus

Nicosiageneralhospital

NCSR

2.5 Gbps

155 MbpsChios island

“Skylitsio”generalhospital

“Demokritos”

Figure 1: Tile-Ippokratis pilot sites.

Limassol. The patients were receiving support in their ownhomes.

A summary of the various services provided per pilot siteand transmitted data is presented in Table 1.

The paper describes the Tile-Ippokratis architecture, thedesign of the entire platform, the provided services, the usedsystems, and the platform infrastructure (Section 2) andpresents the protocol of the trials (Section 3). In Section 4,the evaluation results of the validation phase are discussedwhile the conclusions are presented in Section 5.

2. Platform Description

The description of the platform is divided into three parts.The first part describes the teleconsultation systems andthe patients’ peripheral systems that entail the acquisitionof the patients’ biosignals and their transmission to thecentral database server, the second part describes the remotecentralized database itself, and the third part describes thenetwork technology selected for the uploading of the data tothe database.

2.1. Teleconsultation Systems and Patients’ Peripheral Systems.The Tile-Ippokratis platform provides a series of services,which have been supplied through the combined use ofalready evaluated systems (off the self-systems as well assystems coming out of EU-funded projects) as presented inthe following paragraphs.

(1) Teleconsultation Systems. The teleconsultation serviceshave been mainly provided by the Wavelet-based INteractiveVideo Communication System (WinVicos). WinVicos is ahigh-end, interactive video conference system providing real-time video, still images, and audio transmission [14]. Thesystem has been designed mainly for medical applications,like intraoperative teleconsultation, in various EU-fundedprojects. WinVicos supports communications via satellite,Local Area Network (LAN), Internet, ATM, xDSL, and soforth.

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Table 1: Services provided per pilot site.

Connected end-points Services Data transferred between end-points

NCSR (server)EPR,

Web services

Incident data: personal info, contacts, medicalinfo (diseases, medication), medical data (vitalsigns)

Skylitsio General Hospital (monitoringstation)

Teleconsultation,ehealth

Medical data (vital signs), images

Rural medical peripheral health centersresiding in Chios Prefecture Municipalitiesof Volysos, Kardamyla, Oinousses, and Pyrgi“at risk” citizen (client)

Teleconsultation,ehealth

Incident data: personal info, contacts, medicalinfo (diseases, medication), medical data (vitalsigns), real-time video conference

Intensive Care Unit of the Nicosia GeneralHospital (monitoring station) postsurgerypatients in the municipalities of Nicosia,Larnaca, and Limassol (client)

Teleconsultation,ehealth

Incident data: personal info, contacts, medicalinfo (diseases, medication), medical data (vitalsigns), real-time video conference

The teleconferencing scenario was realised with the use ofa web camera connected to the computer, a set of speakers,and a microphone for the audio signal and the WinVicossoftware. In some cases commercially available teleconfer-encing software such as adobe connect (http://www.adobe.com/products/acrobatconnectpro/) has been adopted inthose cases where the patients had to have routine telecon-ferencing sessions with their carers (Cyprus pilot). A framerate of at least 25 fps at a resolution of 640× 480 pixels was apreferred one for the real-time teleconferencing sessions.

Teleconferencing has been introduced for two reasons: toimprove the patients’ confidence to the treatment creating afeeling of safety for the patient and to support the collabo-ration and consultation between remote located health carepersonnel.

(2) Patients’ Peripheral Systems. For the ehealth services thefollowing low-cost systems have been used for the provisionof telemedical services in Chios Island and Cyprus. It consistsof the following components:

(i) personal computer (PC) or laptop,

(ii) biosignal acquisition module (Wrist ClinicTM (http://www.telcomed.ie/allinone.html)) which is respon-sible for biosignal collection (Figure 2); more specif-ically, this lightweight and mobile module is able tocollect, record, store, and wirelessly transmit 1 leadECG, SpO2, HR, BP, and TEMP up to 250 m; thedevice can store data if there is no connection,

(iii) fully wireless weight scale (http://www.telcomed.ie/scale.html) which allows untethered operation (nocommunication or power cords); the patient canuse the weight scale anywhere within coverage area(250 m communication range in open space),

(iv) software (client) for communication with the centraldatabase (Cyprus pilot),

(v) application (client) for medical monitoring in publicenvironments allowing multiple patients to use asingle device (Chios pilot),

(vi) two-way radio USB-based communication device(automatic data accumulation and transmission)which connects via ordinary internet connection; thedevice has 200 m communication range (open space),uses reliable data communication protocol, and has aunique digital ID for system identification. The dataare transmitted from the monitoring devices to thehome computer using a wireless connection (WiFi).

There is wireless connection between USB device(onboard the PC), the biosignal acquisition module, and thewireless weight scale. The selected data are stored to the PC,while an asymmetric digital subscriber line (ADSL) internetline is used for uploading data from the PC or laptop to thedata base.

2.2. Remote Centralized Database. The EPR has been storedin an SQL-type database. The EPR information includedpatient details, medical info (diseases, medication), and themedical data (vital signs) acquired from the monitoringdevices deployed. The data were structured in an efficientway. The medical and care personnel were able to utilizea standard web browser to login on a webpage to view apatient’s record and search for readings that fall within agiven range or from a specific time and date. This abilityassisted medical personnel to reassure themselves aboutpatient’s condition providing the patients with an extrafeeling of safety.

2.3. Network Description. The broadband telecommunica-tion network integrated two types of networks, terrestrialand wireless. The network has been based on nodes ofresearch institutes (National Center for Scientific Research“Demokritos”—NCSR), hospitals (Nikosia General Hospitaland Chios Skylitsio Hospital), and the four rural peripheralmedical centers in Island of Chios. Each node is connected toits appropriate router via an Ethernet link running TCP/IPprotocol. The network provided broadband coverage to allthe partners in Greece and Cyprus thus ensuring communi-cation between different and remote parties allowing for data

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Internet

PC gateway

Ethernet

Monitoringdevice

WirelessUSB

Data server -EPR

Figure 2: The system operation process.

transmission and bidirectional communication by means ofaudio-visual content transmission.

Through the platform clinical data have been exchangedwhich were collected by distributed nodes (e.g., regionssupported by low-bandwidth earth network, such as ruralareas in Chios Island). The uploading of the measurementsdata from the patients’ premises to the database have beenachieved either by wireless technologies—General PacketRadio Service (GPRS) data cards for PC have been usedor wired technologies—Asymmetric Digital Subscriber Line(ADSL) depending on the availability of ADSL connection.ADSL was selected to be the primary technology for use inthe patients’ premises as well as in the Peripheral HealthCentres due to the low overall cost of usage compared to theother technologies available and the provision of high speedswhich can support the teleconferencing scenario as requiredin the project. Depending on the availability of ADSL lines,the patients’ Peripheral Health Centres were connected withspeeds of 1.024 Mbps download and 512 kbps upload whichwere sufficient for monitoring and teleconferencing. In thecase of the patient’s premises, these were connected withspeeds of at least 512 kbps download and 128 kbps uploadwhich were sufficient for monitoring.

Security issues in health care information systems are ofgreat importance. Our major objective was to allow doctorsquickly access patient data when and where they needed itwithout compromising security. In the proposed integratedehealth platform security, mechanisms are incorporated inorder to protect the information during the transmissionand storage as well as at the system level (logical accesscontrol, legitimate, and availability). For each network typean efficient security policy has been deployed, in order toprotect data from unauthorized use or alteration/damageand legal issues that concern the exchange of medical databetween the two countries.

The platform maintained the security of the datathroughout all the communication stages, data storage, anduser access to the data. More specifically the followingsecurity actions have been adopted:

(i) access control/single sign-on,

(ii) authentication,

(iii) authorization—user Access rights,

(iv) session control,

(v) activity log—audit,

(vi) data protection,

(vii) encryption—HTTPS SSL,

(viii) network firewalls,

(ix) application security—application Firewall.

3. Protocol for the Trials

During the six-month trial phase, general practitioners andspecialized doctors supported the chronic and postsurgerypatients from distance, minimizing routine transportation ofpatients from and to hospitals. The recruitment process wasbased on willingness, ability, and commitment of the patientsreferenced by medical personnel in charge. A training processwas conducted concerning the use of devices and the proto-col of the monitoring program. Regular followup with usersby the project partners involved scheduled reassessment,reassurance of the case management program compliance,corrective actions, reinforcement of the pilot patients andmedical personnel.

Particular attention has been paid to ethical issues.

(i) The respect of their privacy: an internal ConsortiumAgreement regulated all the operations involvingthem with basic rules imposing the respect of theirhabits, their environment, and their times.

(ii) The respect of an ethic code, ensuring a correctbehavior and the respect of the patients’ rhythms andattitudes. Signs of discomfort or uneasiness on theuser’s part during the evaluation activities have beentaken into consideration.

(iii) The collaboration with their family members: peoplesurrounding the end users have been involved in theevaluation process. The patients have been providedwith information about the purpose of the researchactivities, duration of their participation, and whichprocedures are followed.

Sixteen patients suffering from chronic diseases partici-pated in the trials in Chios Island:

(i) four hypertensive patients were monitoring their HRand BP,

(ii) four individuals with chronic pulmonary disease(chronic asthma or chronic obstructive pulmonarydisease) were monitoring their SpO2 and ECG daily,

(iii) eight individuals with chronic cardiovascular diseasewere monitoring their ECG, BP, and weight.

According to the rural health center scenario (Islandof Chios) and the protocols that have been applied bythe four General practitioners of the rural health centerstogether with two specialized doctors in Skylitsio GeneralHospital, the selected patients were measuring their vitalsigns frequently (2-3 times per week) in the rural healthcenters. Although the sixteen patients were using only

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Table 2: Overview of technical metrics of Tile-Ippokratis services.

Connectivity with networks Ease of data transmission

Home care Low rate of failures (∼< 1%) No problems reported

Rural health centre Low rate of failures (∼< 1%) No problems reported

Quality of data transmission Interference to other medical equipment

Home care Excellent None

Rural health centre Excellent None

User friendliness Wrong findings

Home care Users satisfied, amendments asked No wrong alarms

Rural health centre Users satisfied, amendments asked No wrong alarms

four sets of devices, the vital signs through a softwareapplication for medical monitoring in public environmentswere automatically transmitted and saved to their electronicpersonal records maintained by NCSR “Demokritos”. Thesedata were accessed frequently, at least once per week, bythe medical personnel of the Skylitsio General Hospitalof Chios, who were able to provide remote consultations.Based on the monitoring data and on the direct sight ofthe patient through the videoconference facilities the doctorsfrom the Skylitsio General Hospital of Chios provided asecond opinion to the local doctors of the rural health centerswhen needed.

Six postsurgery patients in Cyprus participated in thetrials in Cyprus (home care trial) conducting daily fromtheir home a full set of measurements: HR, SpO2, BP,1 lead ECG, Temp, and weight where possible. In thisscenario each patient owned one set of ehealth systems. Thevital signs through the home gateway were automaticallytransferred and saved to their electronic personal recordsmaintained by NCSR “Demokritos”. The medical personnelof the intensive care unit (two specialized doctors) of theNikosia General Hospital accessed at least once per week theElectronic Patient Records providing remote consultationswhere necessary. The patients were able to contact theirdoctors via video/audio to seek medical advice. Furthermorean admin support and medical help desk has been integratedinto the service concept in Cyprus pilot to motivate thepatients to adhere the planned protocol.

For the home care scenario, emergency events at homehave been planned as possible to happen. The scenarioconcerned a patient who collects vital measurements when-ever he/she does not feel well. In case abnormal situationsoccur and the measurements exceed set levels for a givenpatient, alarms triggered and doctors, family members, andemergency services automatically were notified. It has to bementioned that during the pilot phase this scenario has beenrarely conducted.

4. Platform Evaluation and Discussion

The evaluation of the Tile-Ippokratis ehealth platform hasbeen primarily technical in order to verify that the systemscan operate in reliable way and end users’ oriented (usingquestionnaires and interviews) in order to investigate howthe system can be embedded in everyday clinical practice.

During the trials the users from both server and client siteswere asked to evaluate the system, in order to evaluate notonly the one-way use of the system but also capture theimpressions of ICT-mediated interaction.

Taking into account the inherent variety in the project,Tile-Ippokratis consortium opted for an evaluation approachwhich collects data from a variety of sources in order toensure the integrity and generalisability of the results. To thisend, data were collected through the following methods:

(i) Technical metrics deriving from monitoring theehealth system during the pilots,

(ii) Users’ acceptance metrics collecting quantitative andqualitative data pertaining to the usability of thesystem and its users’ overall experience.

4.1. Technical Evaluation. Tile-Ippokratis was evaluated on anumber of critical technical factors which were identified asimportant by desk research and discussions with computerengineers and physicians. These factors guided the collectionof data showing the performance of Tile-Ippokratis duringits operation in the various scenarios tested during the trials;the overall results from these tests are shown in Table 2.

More specifically the first critical factor is connectivitywhich is defined as the capability of the ehealth system totransmit data between client and server units without anydisruptions. This is the basis for the operation of any ehealthsystem which aims at providing continuous support to itsusers. Tile-Ippokratis scored high in this area having lowfailure rate less than 1% in the “home care” and “rural healthcentre” scenarios.

Ease of data transmission was the second evaluationfactor. It accounts for both the ease of data transmissionof biosignals and all other necessary data (e.g., video) foreffective diagnosis over the network as well as the ease ofdata entry by users into the Tile-Ippokratis system. Giventhe trial results in the above-mentioned technical factor(connectivity) the outcome of ease of data transmissionfollows the same pattern. In the “home care” and “ruralhealth centre” scenarios there were no problems with ease ofdata transmission. Data were transmitted successfully duringeach repetition of the trials.

The third factor quality of data transmission examinesa parameter of paramount importance in telemedicineas suggested by relevant literature [15]. Data transmitted

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Table 3: Perceived benefits of Tile-Ippokratis services.

Type of users

Physicians Patients

Scenario

Home care

Good alternative for avoiding frequentvisits to the hospitalLong term-appreciation of patient’ssituation—useful in cases of emergencyShifting of the location of care, out ofhospitals

Increased sense of safetyAvoidance of unnecessary visits to thehospitalIncreased sense of “always connected”with their doctors

Rural health center

Sense of “team” work between remotelocated medical personnelTime savings from patients’transportation to Skylitsio GeneralHospital and other large hospitalsIncreased sense of safety because of thesecond opinion choiceLow-cost ehealth services. One ehealthsystem for many patientsEnsuring continuity of healthcare andpatient followups

Larger number of patients own theirelectronic personal recordIncreased positive attitude against ICTtechnologiesPromotion of behavioural modification,goal setting, prevention rather thantreatment and adjusting to living with achronic disease improving patients’feeling of safetyAssist patients to self-manage theirchronic condition and enhancesupportive measures to promoteself-management in the long term

through ehealth equipment must maintain its integrityduring transmission for the receiver (usually a doctor ormedical personnel) to be able to produce an informed andvalid opinion on the patient’s condition. In both “home care”and “rural health center” scenarios, which were examinedduring the same trial, there were two major types of medicaldata transmitted through the applied network.

(i) Numerical data which are essentially the biosignalsrecorded by the system (weight, 1 lead ECG, BP, HR,SpO2, and temperature).

(ii) Video-conferencing files. These were recordings au-tomatically captured by the video-conferencing soft-ware which could be stored for subsequent review.

According to the data recorded by the project servers, inboth these cases there has been no problem with the qualityof data transmitted. Data was of excellent quality, and therewere no complaints from both client and server units. Giventhe stable connectivity among the client and server sites therewere no failures in the transmission of data.

The fourth factor was interference to other medicalequipments. There were no recorded problems regarding theinterference of the equipment with other medical devicesmainly in the rural health centers scenario. Users from bothserver and client units expressed a positive opinion on theinterface and data entering procedures of the devices used byTile-Ippokratis.

4.2. Evaluation of User Acceptance of the Ehealth Platform.Following the technical evaluation, a small-scale evaluationof the users’ acceptance of the systems was performed.Whitten et al. [16] point out that users see the ehealthsystems primarily as services provided to them and not asnew technologies. Having this in mind and the fact thatthe success of every system relies on the user acceptance

and user opinion must be taken into serious account aswell. The evaluation of the users’ acceptance of the systemsincluded collection of data on perceived benefits for theservices provided. Users were asked to fill in questionnairesregarding their experience with the interaction with thesystem. Interviewing them allowed us to clarify hiddenattitudes and beliefs. Their views, from both server and clientperspective, are summarised in Table 3.

The proposed platform was surprisingly welcomed bypatients and carers because of its simplicity and functionalityalthough most of the patients were not comfortable withusing video communication and pc technology (especiallythe elderly one). The whole service has been viewed asan early warning mechanism which helps prevent frequenthospital visits. But although the regular user’s followup andthe scheduled reassessment and reinforcement of the pilotpatients and medical personnel were taking place and theservice was free of use for the duration of the validationphase (the project covered the communication cost togetherwith the cost of the devices), it was observed a drop inusage rates although this was not the case according tothe specified protocol. More specifically the usage rates asregistered in the data base revealed that almost for thefirst month the users conformed to the specified medicalprotocol and their measurements were taken frequently asasked. But after that period the number of measurementsstarted to gradually reduce. This behavior, mainly comingfrom the postsurgery patients, makes us conclude that theusers are not willing to use frequently/daily and for long timeperiods ehealth monitoring devices even if they are askedto do it. According to Papadopoulos [17] this attitude canbe explained by the fact that the patients do not perceiveimmediately the benefits of the mobile health applicationssince these services provide preventive medicine rather thancure.

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Finally, evaluation showed that Tile-Ippokratis servicesare reliable, from a technical perspective. No technicalproblems were recorded. Users considered their interactionwith the system as a positive experience which makes themconsider adoption of such a system in the future. Ofcoursemaking this platform sustainable is a real challenge especiallyin low-resource settings such as the Greek context. Issuessuch as facilitation and maintenance of communicationinfrastructure, payment of license fees, communicationcosts, and others are considered to be the problem forsustainability of such services. Maybe local authorities couldundertake the responsibility to exploit and disseminate thelong-term potentiality of Tile-Ippokratis services.

5. Conclusion

The concept and realization of integrated low cost andease of use ehealth platform for the provision of ehealthservices for both patients with chronic diseases and patientswho have been served by an intensive care unit have beenpresented in this paper. The platform based on the useof terrestrial and wireless communication infrastructuressupported teleconsultation and ehealth service. The platformensured bidirectional communication between specializedmedical personnel and civilians. The platform providedequal opportunities to all citizens to have heath care servicesand familiarize them more with information technology.

The overall architecture of the platform has beentechnically tested while well-prepared scenarios have beenevaluated. The evaluation results showed the feasibility of theproposed platform to be successfully used by physicians andcivilians. Encouraged by these results the optimization of theplatform for a wider delivery of telemedical services in thenear future is under consideration. It is expected that theuse of such platform will effectively improve the provisionof health care services, reduce the related costs in terms oftime and unnecessary transfers, and increasingly enhancethe quality of life of individuals living in remote/isolatedregions.

The results proved the functionality and utilization ofthe platform in Greece and Cyprus and the positive impacton psychological health of the participants. However, furtheractions are needed in order to enable the local health caresystems and the different group population to be familiarizedand use in their everyday live mature technological solutionsfor the provision of health care services.

Acknowledgments

The Tile-Ippokratis is an integrated pilot ehealth platformfor improving health care provision between rural healthcenters in the island of Chios and the Nikosia GeneralHospital/intensive care unit and is founded by INTERREGIII Greece-Cyprus fund. The author wishes to thank theproject partners and the researchers, for their contributionand fruitful collaboration. The work they performed inthese projects has provided valuable insight into some issuesaddressed in the present paper.

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