**3. Forms of e-health in Greece**

e-Health does not only provide technological and procedural solutions to the needs of healthcare, but also reliable supportive applications, which are called upon to serve man, as the object and recipient of the health services provided. The tools that are employed in the context of e-Health promoting, are more effective, more userfriendly and more widely accepted both by the health professionals and the patients themselves. In e-Health applications there are included the electronic patient record, the electronic health card, e-prescription, development of telemonitoring and teleconsultation systems, as well as e-referral and electronic refund of medical expenses [18].

### **3.1 Electronic patient record**

More specifically, the Electronic Patient Record or alternatively the Electronic Health Record comprises an individual electronic catalog, in which the medical data concerning the patient is registered and kept, so that its transference to any hospital institution or authorized doctor can be possible, aiming at a better diagnosis and limitation of medical mistakes [19, 20]. The same philosophy is served by using the electronic health card, so that an overview of its owner's health condition arises.

The electronic record includes data regarding the patient's medical history, such as their admission or readmission dates, their treatment duration, the results of laboratory and paraclinical tests conducted, the administered medicines and other treatment actions, information for the cost of the provided services, prior services offered as well as reports of acute cases, so as to constitute the patient's diagnosis basis and treatment approach, and at the same time the basis of epidemiological studies. In addition, it provides information of administrative, financial and statistical nature which is related to the respective hospital unit and the patient's demographic data (full name, VAT number, competent insurance institution, blood type), as well as quality control data [21].

The Electronic Health Record comprises an updated version of the Electronic Patient Record, as it aims at the continuous observation of its owner's health and not exclusively during their treatment period. In contrast with handwritten records, it ensures the preservation of the registered data (health data, laboratory results, medical instructions, imaging records, bio-signal records), and their endurance through time, it allows their holistic management while providing interconnection capacity via applications of data transmission. This way, it facilitates the provision of medical consultation remotely, simultaneously enabling the electronic prescription. It also contributes to the timely and correct illness diagnosis, the right observation of patients, the elimination of multiple registrations, the operational cost reduction (e.g. avoidance of pointless examinations, facilitation of payment,

distribution of resources connected to the diagnosis and treatment), and at the same time it creates a constantly developing "electronic library" which is also compatible with research purposes [22–24].

Since the data which is included in the patient's medical record, fall within the most sensitive personal information (main illness, history of present illness, allergies and medicines, medical history, family history, social history, occupational history, sexual history, addiction to use of drug, smoke and other substances), every aspect of their safety, confidentiality and protection must be ensured substantially [25, 26]. In the last few years, the Citizen Health Record has been promoted in Europe, which corresponds more thoroughly to the contemporary vision of the globalized citizen, as far his expectations from the health services are concerned. It is an improved version which fully covers the digital recording and preservation of the contents of the electronic medical record and simultaneously deals successfully with the problems that arise from its electronic nature [27].

In Greece, the creation of a National Medical Record is being promoted, in order that all the necessary information regarding a citizen's health condition (hospital treatments, medical opinions, imaging and laboratory examinations, prescriptions, etc.) will accompany them from now on [28]. The efficiency of this modern digital tool will be bidirectional. On the one hand, it will guide and facilitate the citizen in their contact with the National Health System (e.g. through the application myHealth, the appointment making will be conducted digitally, as well as the system navigation). Nonetheless, at the same time it will comprise a "portal" of access to their data for the treating doctors, so that they have the full medical history available, thus abolishing the printed records. The first step has been taken with the activation of the Individual Electronic Health Record. In the next stage, there is the provision of its further reinforcement and its gradual disengagement from the Family Doctor through legislative interventions [29]. As the General Secretary of the Ministry of Health stated, in the electronic record there will be included the patient's biochemistry and blood tests, as well as the main clinical documents of the hospitals that concern them [30].

The formation process of the Electronic Patient Record is advancing at a satisfactory pace. It is noteworthy that the non-profit Public Company under the name "Electronic Government of Social Insurance" (IDIKA P.C.), which undertook the implementation of the project, was awarded an international distinction at the awards ceremony of the World Information Technology and Services Association "WITSA Global ICT Excellence Awards 2019" that took place in the context of the World Congress on Information Technology, on October 8th, 2019 in Erevan, Armenia. The project of the Electronic Health Record (EHR) was distinguished as Merit Winner in the category "Innovative eHealth Solutions" [31].

It should also be pointed out that the pandemic of COVID-19 gave a new impetus to the formation process of the electronic record in Greece. In particular, in April 2020, there was enforced by the Greek Ministry of Health and the Ministry of Digital Government the Electronic COVID-19 Patients Register. In this way, the contact of patients suffering from COVID-19 with their treating doctors was simplified, especially in the sectors of tele-consultation and both intangible and remote prescription. What is more, it should be highlighted that based on the Greek and European Law, the patients' personal data are protected, as health services have at their disposal merely the information which is helpful for the handling of the pandemic [32].

#### **3.2 Electronic prescription**

Furthermore, the adoption and application of electronic programmes in the field of pharmaceutical policy, such as the medicine list and the electronic prescription,

#### *E-Health Applications for Smart and Pervasive Healthcare in Greece. What Can We Expect? DOI: http://dx.doi.org/10.5772/intechopen.95859*

contributes crucially to the rational management of the provided pharmaceutical services, ensuring the appropriate and more economical care with a simultaneous minimization of expenses [33]. The uniform electronic medicine list includes the approved available pharmaceutical preparations, their cost and the amount of their provided for compensation.

Despite the fact that this specific list mainly comprises a clinical tool, facilitating the doctors' e-prescription substantially, it also assists by its central management, the significant restriction of pharmaceutical expenditure, in combination with the promoted policy of generic medicine selection (i.e. the copies of pharmaceutical preparations), instead of the original ones which are more expensive due to the patent they possess [34, 35]. Additionally, both the electronic entries of the prescriptions on the part of the doctors with the help of personalized passwords and the obligatory prescription based on the active substance and not the commercial name of the preparation, allows the wider administration of the more economical generic medicines and the electronic monitoring of medical prescription behavior in real time [36, 37].

During the COVID-19 pandemic, it became clear that the utilization of digital technologies is the only safe way in order for the patients to gain access to the health system. Thus, in the summer of 2020, the intangible electronic medicine prescription was established by law in Greece (L. 4704/2020). Both the intangible prescription and the intangible referral are transferred now exclusively using electronic means to the Primary Healthcare System. The patients log in there and state that they wish to receive their medicine prescription electronically, either through a message (SMS) on their mobile phone or via an email to their email address. In the fulfillment of the intangible electronic prescription, the printed form of the doctor's medicine prescription is not submitted to the chemist. The chemist retrieves the intangible electronic prescription by entering in the Electronic Prescription System the prescription barcode or the patient's Social Security Registration Number (SSRN) [38].

### **3.3 National Network of telemedicine (NNTM)**

The potential that new technologies offer is expanded in the field of telemedicine, tele-monitoring and teleconsultation, as well. The utilization of telemedicine and telecare, which means the remote support or provision of health services by specialized and suitably trained health professionals to that purpose, goes a long way towards dealing in a timely manner with situations that could turn out to be a health hazard. Therefore, it is about technical knowledge transfer instead of patient transfer. Its major significance lies in the fact that it provides the possibility of remote support for patient management at the regional health facilities by general medicine practitioners.

In Greece, a mainly insular country which is divided in seven health regions, there has been materialized a National Network of Telemedicine since 2016, headquartered in the country's 2nd Regional Health Authority to which the large port of Piraeus and the Aegean islands belong. The same year, NNTM won the award of Business I.T. Excellence Gold (BITE) for its output, which is awarded in cases where technological innovation coincides with business excellence. The Network of Telemedicine is based on the Public Data Network of OTE "INTERCONNECTION" and it includes 43 telemedicine units. Those are based on 12 regional and central hospitals, as well as 30 centers of the Aegean islands, including the border islands of Astypalaia, Icaria, Kalymnos, Ios, Kasos, Kastellorizo. Lastly, there is a telemedicine unit in the center of operations of the Greek Ministry of Health [39].

The National Telemedicine Center is bound to be expanded to 22 additional islands of the Northern and South Aegean, covering the healthcare needs of 52 islands on the whole, with 71 telemedicine units and 90 patient monitoring systems at home [40]. This way, there is provided an equal access of the island regions patients to the services of the National Health System. At the same time, the pointless transfers and evacuations by air are limited, simultaneously relieving the hospitals Out-patient Clinics.

Every telemedicine unit consists of a specially configured chamber, a camera, a screen and appropriate medical instruments that broadcast the indications of examinations live at hospitals of Athens and Piraeus. In this effort towards not only the provision of specialized health services, but also the guidance and education of the regional health professional in the Aegean islands which are isolated from the major urban centers, 270 health professionals participate, among whom 67 doctors-consultants from 27 different specialties (Psychiatry, Child-Psychiatry, Pediatrics, Surgery, Pediatric Surgery, Breast Surgery, Orthopedics, Pathology, Bio-pathology, Pathologic Oncology, Cardiology, Dermatology, Medical Imaging, Dentistry, Pulmonology, Obstetrics-Gynecology, Chest Surgery, Plastic Surgery, Nuclear Medicine, Ophthalmology, Rheumatology, Gastroenterology, Endocrinology, Nephrology, Urology, Critical Care Specialist, Emergency Unit Specialist) [39]. The examinations categories which are mainly requested are child-psychiatric, endocrinologic, diabeteologic, psychiatric and oncologic [40]. In a country such as Greece, which has over 90 islands, the telemedicine network is estimated to serve the needs of more than 320,000 permanent residents and a fairly large number of visitors each year [41].

According to the information available, there were held more than 4,500 appointments of specialized health services provision in regular and emergency incidents in Aegean islands of the Greek-Turkish border through the NNTM. At the same time, actions of prevention and promotion of oral hygiene were conducted to children aged 6–12 in Chios (Pyrgi, Kalamoti), in Oinousses and Icaria's Fournoi, as well as an action of prevention aimed at children and adolescents of the border island of Ios about mental health issues. Furthermore, continuous education of the health professionals who staff the insular health units is carried out, the main bodies being the University General Hospital "Atticon" and the General Nikaia Hospital "Agios Panteleemon". It is interesting that over 300 educational seminars have been materialized to date. Alongside, in the education context of the general population, junior high and high school students of Lesbos island (Antissa) were educated on Basic Life Support (BLS) and the use of an automatic external defibrillator.

Moreover, the telemedicine network is used for administrative support, with frequent video-conferences (approximately 70,000 teleconferences were carried out up to November 2020) for the further familiarization with the use of the system and primarily for the change of philosophy of the employees in the sector of health and the adoption of the operation of NNTM οn everyday practice. What is especially important is the free-of-charge provision of tele-interpreting for the facilitation of hospital institutions and Health Centers in the handling of incidents where there is no common communication language between the patient and the health professionals. As far as the future goals of NNTM are concerned, they include the integration of emergency incidents in the hospital shifts, in order to achieve a 24-hour coverage of the Aegean islands, at least concerning cardiologic and pediatric incidents.

#### **3.4 Patient tele-monitoring**

An advancement of telemedicine is the provision of health services at home, which supports tele-monitoring and tele-management of patients in their own premises. The health professionals, who provide care remotely, can diagnose X-rays, receive a medical history from patients, assess laboratory findings and suggest

#### *E-Health Applications for Smart and Pervasive Healthcare in Greece. What Can We Expect? DOI: http://dx.doi.org/10.5772/intechopen.95859*

courses of treatment. Electronic recording devices are used, which send the data to the treating doctor, and then he/she on his/her part, having all the necessary documentation, consults the patient-user comprehensively. The system under discussion addresses mostly patients with heart disease, pulmonary disease, hypertension and diabetes, who require long-term monitoring. Nevertheless, there is also the possibility to utilize it in the monitoring of patients having different treatment needs, such as post-operative or psychiatric patients [42].

Greece has also demonstrated significant progress in the sector of patient telemonitoring in the last few years. More specifically, the following programmes are being carried out:
