Telemedicine solutions for remote healthcare delivery in Greece

Information Technology: Telemedicine Solutions Offered to Remote Places in the Country of Greece

The term 'telemedicine' derives from the Greek 'tele' meaning 'at a distance' and the present word 'medicine' which itself derives from the Latin 'mederi' meaning 'healing'." (Mavengere, nd) The American Telemedicine Association defines Telemedicine as "...the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth." (in Kodandaram, 2009) Roth, Carthy, and Bendek (1996) state that telemedicine can be defined "broadly...as the use of telecommunication in an organized system to provide medical information and health care. While telemedicine systems, which are typically characterized by their particular application, have been in existence since the early 1960s, their evolution from being a research tool to being a practical tool for everyday use by physicians and other medical service personnel has only recently begun."

Objective & Aims of the Study

The objective of the present study is to examine 'Telemedicine' both in terms of its ideology and the benefits identified as arising from increased use of telemedicine by today's healthcare professionals and organizations.

Significance of the Study

The significance of the study reported herein is the additional knowledge that will be added to the already existing knowledge base in this area of study.

Background of the Study

In the work entitled "History of Telemedicine it is states that Radio News magazine, in April 1824 featured a drawing "of a physicians viewing his patient over the radio which include a TV screen; TV was not invented until 1929. First cross state demonstration of telemedicine probably occurred in 1951 New York World's Fair. In 1957 Albert Jutras started doing teleradiology in Montreal and in 1959 Cecil Wittson started at the Nebraska Psychiatric Institute a tele-education and telepsychiatry program." (Universidad de Las Palmas de Gran Canaria, 1997) It is written in this work that the first quotations of the use of Telematic services in the ancient world are those in the work of Homer and specifically Odysseia where the "use of frictories was described i.e. fires whose controlled smoke was used to transfer information about the progress of the Trojan War. The system was extended from Troia in Asia Minor and along the Greek coast line to Argos and Mycene." ((Universidad de Las Palmas de Gran Canaria, 1997)

It is related that Professor Skevos Zervos (1975-1958) of the School of Medicine of the University of Athens, in more recent times "has developed a system allowing him to examine a patient from distance. The examination was concerning auscultation and cardiac pulses. The data could be transmitted in any place around the globe. The virtues of the system were demonstrated in several experiments conducted in plenary sessions of the Athens Medical Society at the National University of Athens, at the National Technical University of Athens and at the Athens Academy during which the signals were transmitted from several Athens hospitals and various Greek cities." (Universidad de Las Palmas de Gran Canaria, 1997) This innovation has received publication in the Annals of the Athens Medical Society (1946-1956).It has been proposed by Professor Zervos that the system be used "...on board of the Greek ships that were offering regular service between Piraeus and New York. The communication host could not be afforded at that time and the system was not used." (Universidad de Las Palmas de Gran Canaria, 1997)

It is reported that cardiologist George Papakonstantimou in 1976 with the National Technical University of Athens providing technical support 'developed a system allowing the transfer of EKG using dial up PSTN lines. The system is in use even today." (Universidad de Las Palmas de Gran Canaria, 1997) The Medical Physics Laboratory of the University of Athens began a new era in their provision of Telemedicine Services in 1987 through a convincing demonstration of the advantage that the capture of transmission of X-ray pictures of high resolution to a hospital provides to the primary healthcare units. It is related that the EKG traces "are transmitted via the dial-up PSTN network in 3-30 seconds to the Cardiology Clinics of the Onassis Cardiac Surgery Centre for evaluation and support. Onassis CSC has also developed a medical protocol allowing the administration by the remote physicians a thrombolytic factor APSAC to patients suffering from acute myocardial infarction. The TALOS network is not expanding very rapidly but the Cardiology Clinic of the Tzmeron General Hospital in Yhaeus is ready to act as a support centre for the Aegean Islands. A similar network is going to be introduced in the immediate future in all primary healthcare units of the Kavals Prefecture in Macedonia in Northern Greece." (Universidad de Las Palmas de Gran Canaria, 1997)

Research Questions

The questions addressed in the following research include those of: (1) What are the requirements of successful telemedicine health care services; (2) What are the challenges of telemedicine in health care services? (3) Where does Greece stand in its offering of telemedicine health care services?

Methodology

The methodology of the study reported herein is one of a qualitative nature and one that has been conducted through an extensive review of literature in this area of study. Qualitative research is interpretive and descriptive in nature. Literature reviewed will be comprised of journal articles, books, and other professional or academic works that are in the nature of peer-reviewed works in writing.

Literature Review

The work of Doukas, Maglogiannis and Kormentzas (2006) entitled: "Advanced Telemedicine Services Through Context-Aware Medical Networks" states that remote patient care and telemedicine platforms have been proven to be significant tools for "the optimization of patient treatment in isolated areas. " (Doukas, Maglogiannis and Kormentzas, 2006) Not only does telemedicine reduce costs associated with "transport, accommodation, and medical-professional related costs" but as well a "full time 24 hours per day, 7 days per week patient status monitoring is provided." (Doukas, Maglogiannis and Kormentzas, 2006)

Doukas, Maglogiannis and Kormentzas state that there are many implementations and proposals for telemedicine and e-health platforms however "only a few works include context awareness." (2006) Stated as the primary goal of context aware computing is the acquisition and utilization of information concerning the "context of a device to provide services that are appropriate to particular people, place, time, events, etc." (Doukas, Maglogiannis and Kormentzas, 2006) Doukas, Maglogiannis and Kormentzas state that the "Network Broker" is a "special software agent, which monitors network resources and activities. Its intelligence enables it to take decision regarding services and network usage leading this way to optimum network utilization. Doukas, Maglogiannis and Kormentzas state that given a specific conventional service, the corresponding active service constitutes the outcome of the application to the conventional service. Taking into account that the particular format of the services functions depends on the underlying networking environment, an active service can have various instances according to the particularities of the defined functions." (2006)

It is related that the actives services are comprised by the "patient monitoring tools" that have the capability of adapting the coding of the data that is generated to both underlying network conditions and the patient status itself." (Doukas, Maglogiannis and Kormentzas, 2006) The architecture of the context-aware medical networking framework as proposed in the work of Doukas, Maglogiannis and Kormentzas is shown in the following illustration.

Figure 1

The Context-Aware Medical Networking Framework Architecture

The proposed framework is comprised by the following modules: (1) the network monitoring module that determines the current network interface used and the corresponding status; (2) (2) the patient status monitoring module that collects patient data and makes the determination of the status of patients; (3) the data coding module which is responsible for properly coding the transmitted patient data, according to instruction given by the medical broker usually a repository containing predefined or dynamically defined threshold values for determining patient and network status. (Doukas, Maglogiannis and Kormentzas, 2006) Several health sensors along with vital signals are that determining the patient status. It is related that the architecture of the framework is open and not dependent on the monitoring applications used, the underlying networks or any other issues regarding the telemedicine system used." (Doukas, Maglogiannis and Kormentzas, 2006)

It is stated that for this reason Web Services have been utilized as a mechanism for communication between "the major framework components and the external patient monitoring applications used." The message exchanged is stated to have been implemented "through SOAP, a simple yet very effective and flexible XML-based communication mechanism." (Doukas, Maglogiannis and Kormentzas, 2006) The following illustration shows the message exchange between the framework's modules.

Figure 2

Message Exchange Between the Framework's Modules

It is reported that the primary components that comprise the platform are the biosensors which are attached to the patient as well as a PDA for collection of corresponding signals, a software module installed on a laptop or desktop computer that determines the data coding depending on the patient and network status, a network infrastructure for data transmission and the monitoring units." (Doukas, Maglogiannis and Kormentzas, 2006) The following illustration shows the evaluation Platform Architecture.

Figure 3

The Evaluation Platform Architecture

Doukas, Maglogiannis and Kormentzas (2006) state that the patient state vital signs are monitored through a PDA device attached to the patient and transmitted to a computer for evaluation through wireless access or Bluetooth. Additionally the patient site is monitored through use of a camera. The software that has been developed is used to monitor the patient status as well as the network status and determines the proper coding of the data collected on the patient. Doukas, Maglogiannis and Kormentzas states that two patient states have been identified as (1) normal; and (2) urgent. (2006) Sensors used to monitor patient data include those of: (1) ECG, BP (non-invasive blood pressure); (2) PR (Pulse Rate); (3) HR (Heart Rate) and (3) Sp02 (Hemoglobin Oxygen Saturation). (Doukas, Maglogiannis and Kormentzas, 2006) The following illustration lists the data level thresholds which indicate the status of patients.

Figure 4

Patient Data Coding According to Network Quality and Patient Status

When patient status is normal there is no transmission of real time data unless otherwise ordered by the physicians. Information containing vital signs average values are included in daily status reports. In the event of an emergency it is stated that "the real time data transmission mode is activated, alerting the monitoring physicians regarding the patient status and allowing thus efficient remote care (e.g., medication advise, urgent patient transfer to hospital, etc.)." (Doukas, Maglogiannis and Kormentzas, 2006)

The work of Kodandaram (2009) entitled: "Telemedicine: Healthcare for the Future" states that many countries including the country of India are short of 600,000 doctors, 1 million nurses, and 200,000 dental surgeons to achieve 1:10,000 doctor-patient ratio." (Kodandaram, 2009) It is reported that 72% of India's population still live in rural locations, 75% are dispensaries, and 60% of hospitals are located in urban areas. However, the government of India reports having launched a national health insurance scheme and one in which the home clinic has been integrated. States is that the idea of being treated from one's home is "very comforting and is proving to be cost effective." (Kodandaram, 2009)

This idea is driven by the aging population of India and the increased demand in remote locations as well as by advancing technology with forecast to reach $18 billion by 2015. It is stated to telemedicine will soon play a role that is important. The different forms and uses of telemedicine are based on the type of service:

(1) Teleradiology: Provides primary diagnosis of medical images such as x-ray technology; (2) Teleconsultation: General practice consultation through an audio-video conference and exchange of patient information for routine chronic disease management like diabetes, high blood pressure, etc.) non-emergency review, and prescription refills;

(3) Telecardiology: Observation of a chronic heart patient through monitoring of blood pressure, electrocardiograms (ECG), pulse, etc.;

(4) A cardiologist can review the data and advice on the condition and initiate any emergency care if required; (5) Teledermatology: Remote diagnosis of a patient's skin condition;

(6) Teleophthalmology: Remote ophthalmology consultations and diagnosis of various eye conditions;

(7) Telepathology: Viewing laboratory specimens located at a remote laboratory through a camera-based microscope. (Kodandaram, 2009) Sensor drives used in telemedicine application include such as "...temperature sensors, blood pressure monitors, weighing machines, pulse oximeter (SPO2), ECG, etc."

Kodandaram (2009) states that a key requirement for consideration in telemedicine is the consideration of the need to provide a telecommunication technology that is both "reliable and cheap." (Broadband installations are reported to have grown and government and non-government organizations are stated to be "taking the lead by sponsoring satellite links."

Kodandaram (2009) states that bandwidth availability is "not a big challenge for other telemedicine disciplines involving images. Today, bandwidth availability is"... not a big challenge for other telemedicine disciplines involving images. To transfer patient information to the hospital server, applications have to be HL7 (health level seven) compliant. Being HL7 compliant, patient health records can be electronically maintained (electronic medical record -- EMR). It also allows for sharing of patient data across hospitals and systems, allowing interoperability of applications and systems. In addition, telemedicine solutions should allow for billing and connection to insurance systems. Under the RSBY healthcare scheme, the government has mandated that every person who is availing of the RSBY facility be issued a smart card that would track his/her vital health statistics and insurance cover utilization. Through the smart card, the insurance company can track utilization of the insurance coverage for billing." (Kodandaram, 2009)

Stated as another key consideration in the implementation of telemedicine is the deployment of solutions that are in compliance with the Health Industry Portability and Accountability Act (HIPAA) and that properly address "security and privacy issues of health records." (Kodandaram, 2009) According to Kodandaram "...this would mean that patient data has to be secure while at rest (stored in the telemedicine box) and while on the move (transmitted from box to a server or doctor). For images to be stored or transferred to the hospital server or doctor's office, the boxes also should be DICOM (digital image and communication) compliant. " (Kodandaram, 2009)

The equipment used should be very user friendly because making a technician available at remote locations is not stated to be feasible. Broadband width availability is stated to be needed for "dynamic data throttling" requirements in telecommunication initiatives because there is more to telemedicine than simple image transmission.

Interoperability and standards compliance requirements relate that adoption of standards such as HL7, DICOM and HIPAA become more prevalent in developing countries and that telemedicine equipment should "allow for upgrades without additional investment. Integration and interoperability between existing hospital applications could be a challenge." (Kodandaram, 2009) In regards to billing and accounting for the healthcare service it is stated that the integration of "government scheme and payment to service providers and hospitals could be a challenge." (Kodandaram, 2009) The telemedicine solution is stated to comprise of "a PC for Internet connectivity and data transfer, a web camera for video, an aggregator box to take sensor inputs, and a telephone for audio."

Kodandaram states that the telemedicine platform known as 'MindTree' is a single integrated aggregator box solution" and that a "variety of sensor devices can be connected to the box through the available USB or serial ports." (2009) Also reported to be integrated into the box are audio and video conferencing facility and Internet connectivity. This solution is one that is integrated and one that "enables the solution provider to configure the telemedicine setup with different sensors and interface devices based on the actual need of the community, thereby significantly reducing cost. It offers multiple variations of the platform. Variants can have smart card readers to address the RSBY requirement, built-in LCD/external monitor/TV, and Bluetooth connectivity. The solution also supports HL7, DICOM and HIPAA standards." (Kodandaram, 2009)

The platform is stated to be designed on a "...standard SoC which supports two processor cores -- an ARM core for application software and a DSP core for signal processing. The solution used open source software components to keep the product cost low. Application management is based on Linux operating system (OS). H.264 compression is used for video, which is an excellent choice as it enables more effective video compression than older standards. H.264 provides better flexibility for applications to operate in a wide variety of network environments, particularly considering the different use case scenarios of the telemedicine solution. Video is transmitted to the remote side using common intermediate format (CIF), which allows to easily convert to PAL or NTSC format. Also, depending on the available bandwidth, the application is able to throttle and tune the number of frames sent per second. The image type can be changed to quarter CIF (QCIF) if required. The DSP core in the SoC is used for audio and video conferencing and data processing requirements. The telemedicine solution employs G.711 for audio compression. This is a simple and effective compression algorithm that is used in telephony applications." (Kodandaram, 2009)

The telemedicine platform, through host the application and platform on a Linux OS "has the advantage of connecting the hardware directly to any IP (Internet Protocol) port without having to worry about porting the TCP/IP protocol stack to the embedded platform. Linux also gives us lot of flexibility in implementing application Graphical User Interface (GUI) using any of the open GUI frameworks. The platform is also designed to support online firmware/application upgrades. This feature is helpful when new medical standards are evolving, as it eliminates the need for a technician to visit the field and allows easier software maintenance. The platform handles close to 3,000 patient records. This is adequate for a community of people in a small village. The solution has been realized with low-cost memory devices and interfaces, allowing for optional higher memory size. Patient records are stored as EMRs so as to enable transfer of data to a remote server located at hospitals or data centers. Patient EMR and usage information can be uploaded into the integrated smart card device for tracking and billing purposes. Data is sent to the servers in HL7 format with additional encryption, making it HIPAA-compliant." (Kodandaram, 2009)

Kodandaram (2009) reports that many sensor devices including "blood glucometers, BP monitor sand other personal care devices are becoming Bluetooth-enabled." The MindTree telemedicine has since the addition of Bluetooth connectivity and the health device profile become a perfect solution for homecare and chronic disease management. Telemedicine is stated to have the ability to increase life expectancy, better the individual's lifestyle and optimize the use of healthcare resources. (Kodandaram, 2009, paraphrased)

The work of Roth, Carthy, and Bendek (1996) entitled: "Telemedicine in Emergency Home Care -- The Shahal Experience" reports that more than 36,000 cardiac, pulmonary and blood pressure subscribers. The system combines emergency home care and telemedicine in a patient-initiated system geared toward the prevention of cardiac and pulmonary complications."

Approximately 150,000 calls each year are received annually. Stated as the medium time from symptom onset to a call for help is 44 minutes. This system is described as unique and one that has facilitated improve home health care in terms of control and enabling patients in managing their own. It is a unique system which has been shown to facilitate improved home health-care control, enabling patients to manage their own health condition and providing them with a higher quality of life and enhanced peace of mind. (Roth, Carthy and Bendek, 1996)

Roth, Carthy and Bendek (1996) states that in the majority of telemedicine applications "a certain amount of time is consumed while multidisciplinary inputs converge in order to reply to the needs of the remotely located patients or form a link between one medical source and another." Described is the Shahal1 system which is one in which the patient plays the "primary role in setting the system in motion." Activation is stated to begin from the home of the patient and medical information is stated to be used "in realtime during any emergency thus eliminating any undue waste of time." (Roth, Carthy and Bendek, 1996) Making the system unique is the "...redirection of the traditional focus from diagnosis to realtime intervention and prevention, and Shahal's emergency care orientation..." (Roth, Carthy and Bendek, 1996) Shahal was stated to have been founded in 1987 for the purpose of providing efficient pre-hospital emergency medical care to patients who subscribe to the service. Shahal operates a monitoring center that is staffed by intensive cardiac care unit (ICCU) nurses and physicians and a fleet of mobile intensive care units (MICUs) which are all stated to be physician staffed. The MICUs are stated to be dispatched from various locations throughout Israel and to be controlled by a "single monitoring center in Tel Aviv." (Roth, Carthy and Bendek, 1996)

Following subscribing to Shahal the patients undergo a medical interview which includes their medical record as well as a "12 lead electrocardiogram (ECG) and personal details are stored in a continuously updated computer at the monitoring center." (Roth, Carthy and Bendek, 1996) Shahal subscribers carry a "patient-operated device which enables them to transmit a complete 2-lead ECG via the telephone network" and as well carry an "automatic intramuscular 300 mg lidocaine injector for self-injection if instructed to do so by the center." (Roth, Carthy and Bendek, 1996)

It is reported that subscribers are encouraged to telephone the monitoring center "immediately upon recognition of any clinical symptoms, identify themselves by name or code number (i.e., telephone number), whereupon their personal medical file is displayed on a computer terminal. The nurse on-duty then engages in a questioning process while simultaneously receiving and recording the subscriber's ECG." (Roth, Carthy and Bendek, 1996) Through use of the patient's "self-described symptoms, computerized medical record history and the record of previous call the nurse does the following:

(1) dispatches an MICU to the subscriber's location,

(2) consults with a physician who is on-call at the monitoring centre, or (3) concludes the call by providing the subscriber with the appropriate advice and reassurance. (Roth, Carthy and Bendek, 1996)

The work of Dr. Piniel Mavengere entitled: "A Case for Compliant Telemedicine as a Solution for Underservice in Healthcare" states that the technological advances of the 20th century are "unprecedented [and that which] have led to dramatic developments in information and communications technologies that have the potential to revolutionize health care -- one of such developments is definitely Telemedicine." (Mavengere, nd) Telemedicine has been shown in studies and reports to be "both successful and popular with patients and health care professionals and is set to be one of the most successful developments in healthcare and medicine." (Mavengere, nd)

The word telemedicine is stated to mean "medicine at a distance" according to Mavengere however it is stated that there have been many various alternative definitions posited including: (1) distance independent medicine; and (2) two-way transmission of audio-video information or data between two or more points using electronic technology for the purpose of medical care, consultation or administration." (Mavengere, nd) Telemedicine may also be defined as "the integration of information technology and telecommunication to enhance healthcare delivery." (Mavengere, nd)

As Mavengere notes telemedicine is "...a health delivery technique, not a technology" although there is often confusion between the two terms which is stated to be reason for concern "that the introduction of telemedical techniques might be driven by the pressures of innovative technology rather than demonstrated clinical need or effectiveness." (nd) Mavengere additionally states that from every indication "telemedicine will soon become a routine practice." (nd)

Benefits stated by Mavengere provided by telemedicine include the improvement in the delivery of health care "by bringing a wider range of services such as primary care, radiology, mental health services and dermatology to underserved communities and individuals in both urban and rural areas." (nd) The second stated benefit is that telemedicine can serve to assist in attracting and retaining "health professionals in rural areas by providing ongoing training and collaboration with other health professionals." (Mavengere, nd) An issue that must be addressed is the need for properly trained professionals which will require a "pioneering approach...to bring appropriate and cost effective (but not inferior) technologies to developing countries." (Mavengere, nd) Mavengere concludes by stating that there is a "strong case for telemedicine as a solution to a number of healthcare service delivery problems across the globe." (nd)

In a March 2008 report it is related that telemetric system training has been the focus of doctors and nursing staff "from several municipalities in Greece" as well as four specialists from the Athens Medical Center. These four municipalities are reported to be members of the Inter-Municipality Health & Welfare Network OTA across Greece. Vodafone Greece organized and provided support for the training course and the report states that the medical teams "as part of their training were...given equipment used to record life signs (electrocardiograph, spirometer, oxymeter, blood pressure monitor and glucosometer) and a PDA device." (Hospital Information Technology Europe, 2008) The equipment stated to be provided to the doctors serves to enable their conduction of examinations of individuals with diseases that are chronic in nature and they specifically are enabled to "...take a cardiograph or check respiratory function if asthma is suspected at any of the regional medical offices participating in the program and transfer those examinations - using the Vodafone Greece GPRS network - to the Athens Medical Centre to a cardiology or pneumonology expert, who will examine them and send his opinion back in the same way. Consequently, regional medical offices will now be able to offer specific specialist services in addition to primary health care." (Hospital Information Technology Europe, 2008)

The Greek telemedicine system is one that is reported as being based on "mobile telecommunications technology" and one that offers "multiple benefits to all participants." (Hospital Information Technology Europe, 2008) Included in those benefits are patient benefits which enables patients in practicing preventive medicine while simultaneously abolishing "geographical limitations" and strengthening the "sense of security felt by patients...thanks to direct access to specialist doctors." (Hospital Information Technology Europe, 2008) Furthermore, Doctors in the regions stated previously in this report are enabled to manage their patients more optimally through the provision of "specialist heath care services in remote areas where there is no direct access to a central hospital and the doctors are also enabled in working and communicating with the Athens Medical Center specialists. It is reported that a year following the successful implementation of the telemedicine pilot program at five regional medical offices of the Central Macedonia 2nd Health and Welfare System, that the telemedicine program is presently being implemented in the municipalities as follows:

Aliveri (Evia);

Alyzia (Aitoloakarnania);

Alykes (Zakynthos);

Ano Pogoni (Ioannina);

Therapnes (Laconia);

Kalloni (Lesvos);

Kormista (Serres);

Lambia (Elia);

Makedonida (Imathia);

Neo-Siderohori, (Rhodopi);

Nisyros (Dodecanese);

Paliki (Cephallonia);

Pallini (Attica);

Poros (Attica);

Tilos (Dodecanese); and Hydrousa (Andros). (Hospital Information Technology Europe, 2008)

All of these locations are stated to be members of the Inter-Municipality Health & Welfare Network OTA.

The Life Connection, Ltd. Located in Athens, Greece states on its website that according to the World Health Organization Telemedicine or 'Health Telematics' is defined as "...a composite term for health-related activities, services and systems carried out over a distance by means of information and communications technologies, for the purposes of global health promotion, disease control and health care, as well as education, management and research for health." (2009) Telemedicine services are stated to include those as follows:

Direct contact of patients with a specialized doctor anytime and any place;

Increase of quality of care, decreasing the time of diagnosis;

Benefit of Advisory medical services;

Recording of patients' Medical history, for immediate use in case of emergency;

Treatment of the most important Medical examinations, as Cardiological, Microbiological etc.

Avoidance of pointless transfer of patients, thus reduction of cost;

Modernization of the work environment and continuing education of health care staff with the use of modern technology and services based on international standards. (2009)

Products that the Life Connection states are available include the AEROTEL Heartview P12.8 Plus which is shown in the following labeled Figure 1.

Figure 5

AEROTEL Heartview P12.8 Plus

The AEROTEL Heartview device is a 12/8 Lead ECG Personal Recorder/Transmitter Acoustic Digital and Wireless User-Friendly 12 or 8 lead Electrocardiogram Recorder Transmitter. It is small and easy to operate and places the patient in control and simultaneously provides the doctor with "clear, comprehensive ECG graphic recording. Operating this device requires little effort. It is stated that the patient "... simply records a 12 or 8 lead ECG by using a 3-wire patient cable and the four embedded electrodes on the back of the unit. The recorded ECG is then transmitted through the phone to the Receiving Station (TLC) for immediate diagnosis." (Life Connection, 2009)

The second product of Life Connection is the Pocketsize Transtelephonic ECG Event Recorder Innovative, Single Lead, Easy to Record Post Event ECG Recorder. This transmitter can be used any time and any place and is portable and capable of maximum mobility for the patient. This is a "state of the art device" that does not make a requirement of a cable and fits into a pocket. The patient places their thumbs on the electrodes and pushes a button to record rhythm lead. Recorded results are then transmitted to the Heartline Receiving Station (HRS) from any telephone. The AEROTEL HeartOne is show in the following labeled Figure 2.

Figure 6

AEROTEL HeartOne

The work of Tambouris, Williams, and Makropoulos (2000) entitled: "Cooperatives Health Information Networks in Europe: Experiences from Greece and Scotland" states that internet technology is transforming the general approach to communication and dissemination of information in the field of healthcare." (Tambouris, Williams and Makropoulos, 2000) The chaotic nature of the World Wide Web (WWW) and the simplistic approach adopted by search engines can make the task of finding relevant information difficult and the user can waste considerable amounts of time on the process." (Tambouris, Williams and Makropoulos, 2000) Tambouris, Williams and Makropoulos (2000) state that in Greece the focus has been on the establishment of a CHIN to act as a resource directory for health related information in Greece, and to provide health professionals with a number of telemedicine applications for remotely accessing multimedia patient records." (2000)

It is reported that online services for public access are provisioned through resource directory development and that the standard approach for the CHIN project is for such a directory. It is stated that the Greek resource directory was set up "...in accordance with this approach to provide a common platform for healthcare service providers to publish their content and for internet users to search for it." (2000)

The penetration of the use of the internet in Greece is stated to be very small currently stated at only 1% in July 1999 when compared to other countries of he EU in which the average was 20% in July, 1999 but is nevertheless expected to grow to comparable levels in the future. (Tambouris, Williams and Makropoulos, 2000, paraphrased) The healthcare-related information published online is stated to be "sparse and often limited to a few pages." (Tambouris, Williams and Makropoulos, 2000)

Stated as an exception is MEDNET, described as an Athens Medical Society project which is focused primarily on information for the healthcare professional. The resource directory in Greece is stated to have been created for the purpose of providing a focus and motivation to healthcare service providers for publication of their information online and via the Internet and to do so in an "integrated fashion." (Tambouris, Williams and Makropoulos, 2000)

The Greek resource directory is comprised by the following sections: (1) information on all hospitals in Greece; (2) a detailed section on the National Health System (NHS); (3) a pilot presentation on one disease; a section on medicine; (4) A presentation covering telemedicine activities in Greece; and (5) a section on the CHIN project. (Tambouris, Williams and Makropoulos, 2000)

It is related that all of the content excepting that of the NHS is in both Greek and English with the user enabled to make the selection of the language they prefer. The information is inclusive of all contact details and links to the websites of Greek hospitals, at least those of them who do have websites. Furthermore, the hospitals that do not A Java program named CHINBuilder, developed by the Scottish group, was translated into Greek and used to assist in generating these hospital web sites.

The costs of technical assistance as well as Internet related costs are stated to be "waived for public hospitals, which is one factor that has helped in achieving the widespread use of this resource. During the last year, four hospitals (Nikaia, KAT, Tzanneio, and Onassis Cardiochirurgical Center) used this service." (Tambouris, Williams and Makropoulos, 2000) It is stated that a pilot presentation on diabetes was created for demonstration and assessment of the capacities of the World Wide Web to provide knowledge related to health to the public in Greece and toward this end "information on diabetes was compiled and presented" with a specific on providing children with educational material. The section on medicine is stated to provide a comprehensive list of related web sites in Greece and stated as an example is the provision of links to the medical department of Greek University home pages. links are provided to the home pages of all medical departments of Greek universities. In this case, one of the initial objectives of the CHIN in acting as a resource directory for legacy information sources has been realized. Connecting a hospital and healthcare center is an application that is run on a network enabling electronic record medical exchange via "leased lined to ensure the security of transferred data." (Tambouris, Williams and Makropoulos, 2000) The following illustration shows the diabetes application described in the work of Tambouris, Williams and Makropoulos.

Figure 7

The Actors and Actions in the System

It is stated that in the cross-border area that there are efforts for cooperation in relation to improvement of the quality of life and that increased cooperation particularly in the "sector of new technologies will lead to the establishment of new ways to tackle local problems affecting the regions development." (Spyrou, Varzopoulous, Bamidis, and Maglaveras, 2008) Specifically telemedicine integration in the sector of public health will support the "level of provided services of health and contributes in the quality of life of population and exchange of knowledge for health care professionals." (Spyrou, Varzopoulous, Bamidis, and Maglaveras, 2008)

The proposed service of telemedicine is stated to ensure that specialized medical services are provided to patients near their residence and thereby avoiding the need to make visits to the urban center frequently. Another benefit cited in the work of Spyrou, Varzopoulous, Bamidis, and Maglaveras (2008) is that patients are found to take a more active role in their own health care and in health care follow-up. As well, due to the availability of frequent data the doctors are able to provide better treatment. Also a benefit is that the hospital by "ensuring reliable control of the patient from a distance can decrease the hospitalization per year, decreasing the incidents that need internal hospitalization" and thereby decrease the use of resources.

Furthermore, the hospital "is able to offer medical services in wide teams of population" which previously was not possible due to geographic restrictions." (Spyrou, Varzopoulous, Bamidis, and Maglaveras, 2008) Finally, it is stated that the "forecasted cross-border action and diffusion of results of work in adjacent regions will contribute in the assimilation of technology and promotion of proceeding of telemedicine, demonstrating the effect of eHealth in primary care." (Spyrou, Varzopoulous, Bamidis, and Maglaveras, 2008)

The work of Mailhes, et al. (nd) entitled: "The U-R-Safe Telemedicine Project: Improving Health Care of the Elderly" reports the U-R Safe Project is one which has as its aims the creation of a mobile telemedicine care environment for the elderly "thus helping to mitigate the problems of health care provision observed in the Western societies caused by the aging population and the associated increasing costs." (Mailhes, et al., nd) The concept stated in the work of Mailhes et al. is the elderly individual wearing devices for medical monitoring "all connected via short-range Wireless Personal Area Network (WPAN) to a central, portable electronic unit called the Personal Base Station (PBS)." (Mailhes, et al., nd) Ultra Wide Band technology is used for the short-range connection which enables: (1) the receiving and pre-processing of measured medical data sent from the measuring devices; (2) the sending of pre-processed data to the external service via the wireless public Network (GPRS, UMTS and/or GEO satellites), when the elderly person is out of home or Via the Fixed Access Network (e.g. telephony, cable, wireless), when the elderly person is at home; (3) Communication with simple sentences with the patient and extract information, (particularly valuable in emergency situations); and (4) Establishment of direct and hands-free communication between the patient and the external service and/or a medical doctor through the public wireless network (GPRS and UMTS), when this is required. (Mailhes, et al., nd)

Stated as the different network accesses in the U-R Safe project are the following: (1) PSTN: enables transmission of information to the services center over terrestrial network in indoor mode and includes automatic dialing for transmission; (2) GSM/GPRS: enable transmission of information to the services centre over mobile network in outdoor mode. It will support IP data and SMS transmission; (3) GEO Satellite: enables transmission of information to the services centre over satellite network in indoor mode in the case where no terrestrial connection is available or in outdoor mode in the case where the patient is out of the GSM/GPRS coverage. (Mailhes, et al., nd)

The work entitled: "Sustainable Telemedicine: Paradigms for Future-Proof Healthcare" states that telemedicine services "...respond to today's health and social demands, i.e. treatment of chronic patients, support for the quality of life of elderly people living at home and they also support the patient empowerment of well-informed citizens to make healthcare choices." (Mailhes, et al., nd) It is stated in the EHTEL Briefing Paper that the vision on telemedicine services in European countries can be divided into three types: (1) Those which are an integral part of the most actual eHealth strategy where telemedicine applications are developed as part of this eHealth strategy; (2) Those mentioned in the most actual eHealth strategy, but where telemedicine applications are not or not yet developed in direct relation to this strategy; and (3) Those not mentioned in the eHealth strategy but where some few developments of telemedicine applications in practice are emerging. (Mailhes, et al., nd)

The Briefing Paper states in relation to telemedicine in Greece that the lack of "...a general organizational and legal framework is noted as a major obstacle. Such a framework is needed to clarify tasks, responsibilities, and also the reimbursement principles for telemedicine services." (Mailhes, et al., nd) Stated as the overall principles of the national strategy are those as follows: (1) Bringing the nation's health information system under the quality and safety imperative; (2) Moving from administrative complexity to evidence-based simplicity; (3) Disengaging the dynamic elements of our health legal system from the rigid body of the national laws; (4) Creating strategic partnerships; and (5) Creating the knowledge based infrastructure. (Mailhes, et al., nd) Stated as the greatest of challenges in eHealth for Greece is "dealing with the constant organizational change." (Mailhes, et al., nd)

If the telemedicine goals of Greece are to be realized then the requirements include changes in the way that partnerships, professional roles and relationships are understood as needed is "leadership, new organizational infrastructures and policy integration across all sectors of society influencing health." (Mailhes, et al., nd) Also needed is ongoing political commitment and leadership in order to "maintain the momentum, align actions and eventually, empower the many actors involved at all levels to move at fast paces individually but in a concerted manner, in order to make the change." (Mailhes, et al., nd)

Findings

The questions addressed in this present study included those of:

(1) What are the requirements of successful telemedicine health care services;

(2) What are the challenges of telemedicine in health care services?

(3) Where does Greece stand in its offering of telemedicine health care services?

Telemedicine services are stated to include the following:

(1) Direct contact of patients with a specialized doctor anytime and any place;

(2) Increase of quality of care, decreasing the time of diagnosis;

(3) Benefit of Advisory medical services;

(4) Recording of patients' Medical history, for immediate use in case of emergency;

(5) Treatment of the most important Medical examinations, as Cardiological, Microbiological etc.;

(6) Avoidance of pointless transfer of patients, thus reduction of cost; and (7) Modernization of the work environment and continuing education of health care staff with the use of modern technology and services based on international standards. (2009)

The work of Doukas, Maglogiannis and Kormentzas (2006) has informed this study that telemedicine services include patient monitoring tools. These tools have the ability to record and transmit data between the patient and the heath care provider. Toward this end web services are used as the primary mechanism for communication between the components of the major framework and the external monitoring of patients. Telemedicine enables the monitoring of patient's vital signs through sensors and a PDA device that is attached to the patient. When the status of the patient is normal there is no real-time transmission of data however when the patient's status is urgent the device transmits real-time data to the healthcare provider. Because many countries and regions throughout the world are experiencing a shortage of doctors and other health care professionals telemedicine offers a viable solution to health care provision in the future. Telemedicine encompasses many applications including teleradiology, teleophlamology and others. There are specific regulations that govern deployment of telemedicine solutions and those regulations calling for compliance are found in the Health Industry Portability and Accountability Act (HIPAA). Interoperability and standards compliance requirements relate that adoption of standards such as HL7, DICOM and HIPAA become more prevalent in developing countries and that telemedicine equipment should "allow for upgrades without additional investment. Integration and interoperability between existing hospital applications could be a challenge." (Kodandaram, 2009)

The Greek telemedicine system is one that is reported as being based on "mobile telecommunications technology" and one that offers "multiple benefits to all participants." (Hospital Information Technology Europe, 2008) Included in those benefits are patient benefits which enables patients in practicing preventive medicine while simultaneously abolishing "geographical limitations" and strengthening the "sense of security felt by patients...thanks to direct access to specialist doctors." (Hospital Information Technology Europe, 2008) Furthermore, Doctors in the regions stated previously in this report are enabled to manage their patients more optimally through the provision of "specialist heath care services in remote areas where there is no direct access to a central hospital and the doctors are also enabled in working and communicating with the Athens Medical Center specialists. It is reported that a year following the successful implementation of the telemedicine pilot program at five regional medical offices of the Central Macedonia 2nd Health and Welfare System.

Florinis (2009) states that telemedicine has been proposed in Greece as a method for overcoming the challenges in provision of health care in rural areas and the small islands. The Greek Ministry of Health is reported to have financed the installation of 12 telemedicine terminal in 1992 in Healthcare centers throughout Greece. There are stated to be three telemedicine center currently in operation however, it is stated that "there is not a clear picture of the effectiveness of such programs." (Florinis, 2009) This is stated to be in part due to there being no "clear and unique legislative context" and "telemedicine programs...face troubles with technical support" in addition to the remaining "difficulties with shortages in specialized staff." (Florinis, 2009)

Benefits that are known to derive from provisions of telemedicine in health care services include the benefits of:

(1) overcoming geographic restrictions for diagnosis by distance, improvement of quality of provided services of preventive diagnosis and medical care;

(2) reduction in the costs of resources,

(3) reduction of expenses of patients, reduction of time and costs of hospitalization. (Spyrou, Varzopoulous, Bamidis, and Maglaveras, 2008)

Other benefits have also been noted in the foregoing research study and include more optimal health care for the elderly and those located in rural areas of Greece and other parts of the world.

There have been several possible solutions reviewed in this research study all of which hold promise for brining Greece up to speed with technological application of telemedicine health care service delivery.