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Proposal for an eHealth Based Ecosystem Serving National Healthcare

Article  in  IEEE Journal of Biomedical and Health Informatics · May 2018

DOI: 10.1109/JBHI.2018.2834230

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
1

Proposal for an eHealth Based Ecosystem

Serving National Healthcare
Eirini C. Schiza, Member, IEEE, Theodoros C. Kyprianou, Nicolai Petkov, and Christos N. Schizas,
Life Senior Member, IEEE

 by healthcare providers; it is readable and understandable by

Abstract— The European Union (EU)’s keen concern about all health providers, thus facilitating the best possible medical
citizens’ health and well-being advancement has been expressed service to the citizens. In a national healthcare ecosystem, we
at all levels. It has been understood that at present, these can only
will define the environment in which healthcare coverage is
be achieved through coordinated actions at the individual
member states’ level based on EU directives, as well as through provided to the whole population and its visitors, without any
promoting and funding R&D and expanding the use of eHealth restriction or prejudice. The term ecosystem is used
technologies. Despite the diversities and particularities among metaphorically for emphasizing that a national healthcare
member states, common values such as universal access to good system is a complex network of interconnected systems that
quality healthcare, equity and solidarity have been widely interact with each other and with conflicting interests. The
accepted across EU. That demanded the adoption of policies and
healthcare "system" can be better understood as an ecosystem
follow directives, which streamlined actions to bridge healthcare
gaps, and facilitate cross-border healthcare. This paper of interconnected stakeholders, each one charged with a
articulates a framework for deriving a national healthcare mission to improve the quality of care while lowering its cost.
system, based on interoperable Electronic Health Record (EHR) To ensure patient’s safety and quality care while realizing
with safeguarding healthcare quality, enabling quadruple helix savings, these stakeholders are building new relationships
(Public, Academia, Industry, NGOs) driven R&D and guided by often outside the four walls of the hospital. Few of the new
a patient-centered approach. A methodology to develop an
relationships, such as health provider-payer that are taking
integrated EHR at National level is proposed as a prerequisite for
eHealth and put into perspective. Recommendations are given for shape, are explained in detail in this paper [1].
the steps needed, from the managerial, legal, technical and In the following sections, we present, analyze and discuss
financial concerns in developing an open access, patient-centered the main topics related to this challenge and introduce
national healthcare system based on the context and constraints solutions with road marks guided by the related EU directives
of a country. The example of a small country to apply the and other international initiatives. We suggest how a country,
proposed methodology is demonstrated. Stakeholders, including
like Cyprus, can build its own eHealth ecosystem based on EU
citizens, healthcare professionals, academia and the industry are
mobilized, enabled, and incentivized for implementing the principles and directives. We give historical background with
methodology. Experiences are aspired to be offered as lessons the main landmarks of the EU efforts and we concentrate on
learned for other countries to adapt on their environment. the current state-of-the-art and the EU research initiatives in
which Cyprus is participating. By utilizing the technological
Index Terms— Electronic Health Record (EHR), eHealth, solutions offered by the EU-funded initiatives and claim active
Interoperability, Patient-Centered Healthcare, Public Health, role, every EU country can follow analogous paths for
National Healthcare.
realizing their healthcare ecosystems. In principle, every
country’s healthcare system should serve its purpose within
I. INTRODUCTION
their legal, technical and financial frameworks and at the same

I this paper, we address the main barriers to overcome in

N
building an integrated, interoperable National Healthcare
System covering the whole population, as well as allowing
time remain EU directives’ compliant without diverting from
the citizen-centered objective.
The concept of healthcare for all, at least for Cyprus,
access to visiting and migrating population. ‘Interoperable’ extends back to ancient times, and this fact was used as
simply means that the EHR of a citizen is remotely accessible leverage for touching people’s self-esteem and lower possible
resistance to change. For instance, the recognition that
E. C. Schiza and N. Petkov are with the Department of Intelligent Systems environmental factors can have an impact on human health
Group, Johann Bernoulli Institute for Mathematics and Computer Science, can be traced back to as far as the physician Hippocrates (460-
University of Groningen, 9712 CP Groningen, Netherlands, (e-mail: 370 B.C.) [2]. This perception, also known as all-embracing
ischiza@cs.ucy.ac.cy & n.petkov@rug.nl).
T. C. Kyprianou is with the Department of Intensive Care Medicine, healthcare, evidenced by the Idalion Bronze Tablet discovered
Nicosia General Hospital, 215 Palaios Dromos Lefkosias Lemesou, Nicosia in Cyprus [3], [4]. It refers to the reached agreement between
2029, Cyprus (e-mail: tkyprian@gmail.com). King Stasikypros and the citizens of Idalion on one hand, and
C. N. Schizas is with the Department of Computer Science, University of
Cyprus, Nicosia 2109, Cyprus (e-mail: schizas@ucy.ac.cy). He is counselor of
doctor Onasilos and his brothers on the other. The doctor
the President of the Republic of Cyprus for eHealth. agreed on an all-embracing scheme to treat those injured

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
2

during the war around 470 B.C., when the Persians and the and EU undertook the responsibility to facilitate them with
Phoenicians of Kition attempted to conquer Idalion. The King technical knowhow, knowledge sharing and experiences
and the city agreed to compensate Onasilos and his brothers gained in more advanced member states in order to be able to
with a fixed amount expressed in silver or plots of land. In leapfrog, minimize the societal and technological gaps and set
modern days, this notion is expressed as national healthcare their strategy for building their local health ecosystems
system, and the fact that the agreement was taken jointly by integrated into a pan European and beyond.
the King and the citizens, demonstrates the Greek democratic In this paper, we also aim to explain the importance of
ideals on the political system of the kingdom and the existed studying the country circumstances to achieve the EU goals of
solidarity regarding financial compensation. Furthermore, the cross-border healthcare, as simplified in Figure 1 with the
care and concern felt by the ‘city-state’ authorities towards the introduction of National Contact Points (NCPs). In Section II,
citizens, provides evidence for the existence of the most ‘Foundations of a National eHealth System’ we explain
ancient system of social welfare known to us that employed Interoperability and stress its important role in eHealth. In
citizen centered idealism [4]. Section III, ‘Method’, we justify the proposed dynamic
The EU with Directive 2011/24/EU [5] gave a definition of methodology. In Sections IV, V, VI and VII, the patient-
patient-centered approach that applies the social welfare centered approach, the Technical, Financial, and Legal
principle based on the value that patients are owners of their Frameworks are respectively discussed, and finally, in Section
own medical records. At that point, EHR (Electronic Health VIII, we discuss the proposed actions and a roadmap for
Record) was introduced as the central ingredient for achieving achieving an eHealth based Ecosystem.
patient-centered approach, an approach that has long routs
especially when it comes to solidarity driven principles. II. FOUNDATIONS OF A NATIONAL EHEALTH
Individual efforts have been made by EU countries for SYSTEM
updating existing or developing new national health systems. EHR is defined as a structured collection of constantly
The most recently completed and well-commended example is updated healthcare data associated with a citizen throughout
the one in Estonia where the EHR uniformly covers the whole one’s life. EHR management systems enable storage and
country and virtually registers all citizens’ medical history retrieval of patient’s data and facilitate physicians and other
from birth to death and based on state-developed IT healthcare providers to provide safer and more effective care
infrastructure. It was launched in December 2008, and since through embedded clinical decision support and other
January 2009 all healthcare providers have been obliged to intelligent systems. EHR can also support public health and
incorporate an agreed number of standardized medical biomedical national and international research. Additionally,
documents, electronic information notes and electronic better management, improved care coordination and chronic
medical documents to it [6]. Other countries such as Austria diseases management, cross-border medical care, handling of
and Sweden started their efforts two decades ago and their interoperability issues, reduction of medical errors and delays,
efforts continue with excellent functionality at country level.
Their diffusion with other EU countries is slow because of lag
of standards across Europe [7], [8], [9]. Individual eHealth
Strategies Country Reports and further information about
eHealth initiatives in Europe have been prepared and funded
by the European Commission, DG Information Society and
Media, ICT for Health Unit in 2009 and it is available online
[10].
The purpose for writing this article was motivated by the
claim that an all-included pan-European health system can
only be achieved through the individual nations’
implementations following the relevant EU directives rather
than implementing a general system and forcing it to the
member states. Some of the abovementioned example can be
Fig. 1. Example of the role of a National Contact Point (NCP). Each
studied by another country as exaples to be followed, but in no NCP is responsible for patient summary interchange.
way one should expect that they can be transplanted as they
are in another country. This claim embodies a very reduced operational costs, personalized prescription, and
fundamental principle of EU that takes into consideration the patient enactment and participation are expected [11], [12].
diversities, particularities, maturity and readiness of member Interoperability, an important feature of modern EHR is
states in following revolutionary reforms. Such reforms defined as the ability to reach the record from different
concerning healthcare have been discussed and dreamed for at vendors, and to interact with other computers across local or
least a decade in Europe with the motto, “citizen-centered wide-area networks regardless of their physical architecture
healthcare”. The first reading of this motto produced three and operating systems. It is feasible through hardware and
fundamental pillars: Catholic, Mutual guarantee, and Access software components that conform to open standards such as
to all. The member states were asked to accept these principles those used for internet.

2168-2194 (c) 2018 IEEE. Translations and content mining are permitted for academic research only. Personal use is also permitted, but republication/redistribution requires IEEE permission. See
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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
3

The essence of healthcare systems nowadays is to provide communication protocols and standards [16], [17].
efficient, results-driven, cost-effective services, addressing the Lag of interoperability is the key obstacle on all current
real needs and preferences of citizens/patients and the society. solutions offered and it is a crucial functionality that an EHR
Patient-centeredness was considered a radical approach not so management system should offer to healthcare. The benefits of
long ago, and the EHR is the cornerstone and precondition of interoperability extend to all actors [18]: healthcare
patient-centered eHealth [13]. professionals – for supporting decision-making procedures via
Patient-centered approach mainly relies on listening to, advanced and contemporary status of patient information and
informing and involving patients in their care in such a way evidence-based clinical guidelines; patients – delivery of care
that care is provided in a respectful and responsive to the at the point of need, more reliable and personalized care,
individual patient’s preferences, needs and values [14]. In integrated care including treatment abroad; users - lower
practice, the patient becomes the owner of their EHR, granting implementation and integration costs for interoperable
permission per need to healthcare providers. systems; healthcare businesses - the use of a common eHealth
Designing and building an EHR system, as an operational EU Interoperability Framework facilitates the expansion of a
and functional entity, is possible for IT professionals (analysts, digital single market for healthcare thus creating competition
designers and developers) in close collaboration with health which in turn reduces the development cost.
professionals as proper functioning and exploitation of the The new era of cross-border healthcare in EU is now
EHR benefits, requires semantic interoperability of medical regulated by EU directives which address also privacy and
information. This level of interoperability is absolutely needed confidentiality, personal data, and data protection issues are
for dissimilar EHR systems, business related information highly relevant when deliberating EHR [19]. These
systems, medical devices, mobile technologies, and other evolvements made patients increasingly alert regarding their
systems to improve wellness, as well as the quality, safety, benefits and claimed the right to choose their health providers
cost-effectiveness, and access to healthcare delivery [15]. It including those beyond their national borders. Telemedicine
also requires considerable effort and input from management for instance is evolving because of the rapid development of
services and end users. Excellent efforts were made by technology and because of the cross-border healthcare since
international vendors and organizations like WHO for there is collaboration between healthcare professionals across
establishing universally accepted tools and methods to be used borders. This is believed to be the single most important
for building national eHealth strategies using common revolution in healthcare since the advent of modern medicine,
vaccines, or even public health measures like sanitation and
clean water [20]. eHealth and patient-centered approach
mainly through the implementation of national and eventually
pan-European EHR systems, is demonstrated by the recently
announced Horizon 2020 work program titled ‘Health,
Demographic Change and Wellbeing’ [21].
A central aim for the design and implementation of a global
national healthcare system is to secure financial viability and
sustainability. This will prevent underestimating the cost and it
will minimize the risk for inevitably increasing the citizen’s
financial contribution for preventing the collapse of the
system. Financial viability can be sustained by introducing
another pillar to the system being High Quality of Services in
association with efficiency and reforming public hospitals into
cost centers. The gained status will allow them to become
competitive and operate in a free economy environment along
with the private hospitals and other private medical centers.
Instituting and regulating a National eHealth Authority
(NeHA): The appointment of such a body by the highest
authority being the council of ministers, will create a
regulating body with legal powers for enforcing standards in
medical, social, and financial services for securing
interoperability at local and EU levels as seen in Figure 2.
NeHA will form the next pillar of the ecosystem.
Biomedical research could also be greatly benefited by
integrating it into the national technical and legal system for
sharing patients’ data an option (from the patient and the
Fig. 2 National eHealth Authority is the Regulator of the ecosystem,
being the setting up of the country NCP for health for cross-border
healthcare professional point of view) that would enable
healthcare, the licensing, regulating and controlling the operation of collection of anonymized data (biosignals, diagnoses, notes,
institutions for storing EHRs in interoperable databanks. lab results, images, videos, etc.) and central/distributed storage

2168-2194 (c) 2018 IEEE. Translations and content mining are permitted for academic research only. Personal use is also permitted, but republication/redistribution requires IEEE permission. See
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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
4

paired with analytics toolbox [22]. The development of such analyst familiar with the system’s environment and the roles
infrastructure would ideally involve stakeholders from the of the main players of the system was appointed to head an ad-
quadruple helix (Public, Academia, Industry, NGOs) [23]. hoc NeHA. Their first task was to estimate the Capability
The ultimate scope is to progress into a new healthcare Maturity level of the system for minimizing risks and
ecosystem securely supported by six pillars, as illustrated in optimizing the competitiveness of the system’s life cycle [25],
Figure 3, serving the citizens at national and pan-European which in this case was estimated to be Level 4. This
levels and bridging private and public sectors. methodology has been chosen as our group has developed
In the process of building on the pillars mentioned above, competency in using it [26], [27]. The systems group (ad-hoc
the most challenging obstacles are those related to NeHA) has recruited when deemed necessary, stakeholders’
organizational, process and infrastructure aspects since these representatives and users community members i.e. public
are deeply rooted in the culture of societies and the way health & financial policy makers, health professionals from
people are used to do things and pass these to newer the private and public sectors, patients’ organizations, IT
generations. In Cyprus those challenges have been handled experts, public and private insurance organizations, legal and
systematically from primary school to the university level IPRs/Data protection experts etc. Those players have been
through specialized seminars and courses in University interviewed and become actively involved in the development
curricula [24]. Similar efforts are taken for educating health of the aimed eHealth ecosystem. Before interviewing,
professional through seminars. executive presentations on eHealth concepts and its benefits
were organized and public discussions were initiated and
facilitated. At least twelve such presentations were organized
and followed by structured interviews. Overall thirty
interviews were analyzed, and user requirements and opinions
were surfaced. The findings were processed and presented to
relevant groups by the senior analyst and structured or
unstructured feedback was received. Policy and decision
makers were challenged to take actions accordingly.
The legal framework was revisited several times as twenty-
four relevant laws of the country were studied and the related
articles had to be taken into consideration, crossed checked
Fig. 3. eHealth Ecosystem Pillars with relevant groups, the legal service and the commissioner
for data protection for legal compliance and verification (laws
and regulations from the national electronic repository:
III. METHOD http://www.cylaw.org). A dedicated law regulating eHealth
To reach an optimal result in designing and implementing a through a national committee for e-Health has been drafted
state-of-the-art, interoperable, affordable and sustainable and submitted for parliamentary approval as described in
national eHealth ecosystem to support healthcare reform, our detail in Section VII.
team had to find a fine balance between the ‘ideal’ and the Eventually, the pillars for a national health ecosystem have
‘realistic’, applicable to this country. In that respect, many been formed, priorities have been set, user and technical
variables have been taken into consideration: a) the country’s requirements have been finalized and a solid plan has been put
and stakeholders’ maturity level for technological, legal and forward. The national strategy for implementing an eHealth
social reforms described in Section VII; b) International ecosystem accompanied by a roadmap and an action plan
technological standards recommended by EU through received a presidential endorsement and support. Problems
directives, decisions and reports described in depth in Section arose from interoperability i.e. legal, ethical, technical, and
V; c) Emerging technologies and solutions developed by R&D financial were dealt with accordingly, as suggested in the
activities of the local scientific community in Section V – relevant sections here below in the paper.
paragraphs C&D; d) Adoption of a patient-centered approach Based on the methodology described above, the steps
necessary to support interoperability, described in Section IV; described below were followed:
e) The legal framework necessary to allow for universal Step 1: Built a model and a roadmap of the eHealth
coverage, interoperability and adoption of technological ecosystem and rendered it part of the country’s
standards described in Section VII, and f) The cost of presidential strategy;
individual tenders pertaining to different parts of the Step 2: Agreed on the minimum technological functionalities
ecosystem, the cost partition between public and private of the system;
sectors, the available budget for initial investment and running Step 3: Designed the financial model of the system and
expenses and opportunities for external funding (i.e. EU secured necessary commitments;
structural and cohesion funds) described in Section VI. Step 4: Revisited national legislation and accommodated all
The research methodology used for addressing the functionalities, duties, responsibilities, and rights of
aforementioned challenges was a classic structured systems all stakeholders into the system; and
analysis and design method (SSADM). A chief systems Step 5: Established by law the National eHealth Authority to

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
5

undertake the non-trivial task of regulating, healthcare center, her EHR will be updated accordingly.
coordinating and supervising the implementation of Access to the medical data is permitted only after the
the eHealth ecosystem and the necessary reforms. authorization and consent of the owner and in line with the
legislation for privacy and confidentiality. Data kept in the
IV. THE PATIENT-CENTERED APPROACH EHR can be used for clinical tests and for research purposes
The principal aim is to design and build a complete EHR only after the prior consent of the owner/citizen. This
system for replacing the standard paper medical records. Thus, approach is promoting the motto ‘aiming for health to
it is aimed to improve clinical decision making by storing and minimize illnesses from birth till death’. This approach is
retrieving medical data in various forms. When a patient is excellently described and illustrated in practice in a recently
under the care of more than one doctor, tracking one’s history, published book titled The Patient Will See You Now, which
including allergies, blood type, current medications, chronic must be read by every health professional, citizen, and
illnesses, past procedures, and all the relevant data that a government official [32].
patient summary may include, can be problematic when Health Affairs editor-in-chief Susan Dentzer stated, “It is
relying on paper folders [13], [17]. The remote access of EHR well established now that one can in fact improve the quality
allows multiple care providers, regardless of location, to of healthcare and reduce the costs at the same time.” Quality
simultaneously access a patient’s record from any computer of care improvement and simultaneous cost reduction
connected to the Internet. The EHR features contribute to principle can only be achieved if the citizen becomes the
lower costs, significant time savings, resulting to better quality central actor, a principle that lead to the term patient-centered
and greater efficiency [28]. care. One of the most important rudiments contributed by the
The central player in healthcare has been the doctor, who patient-centered approach is the quality assurance to the
has long been described, as ‘doctor knows best’. While the General Integrated National Health System [33]. Physicians
doctor may indeed have the knowledge and responsibility for practicing patient-centered care, by improving the quality of
care, that does not mean one knows best. In the new paradigm the doctor-patient relationship improve their patients’ clinical
dictated by the patient-centered approach, the information is outcome and satisfaction, while decreasing hospitalizations
no longer flowing from the top. Data and information are not and referrals. This approach replaces the current classical
knowledge, and for the latter, the doctor will continue to be its physician-centered system with one that revolves around the
source. Moreover, the intimacy at the heart of the best doctor- patient. Effective care is mainly defined by or in consultation
patient relationship, where a patient can reveal their secrets with patients rather than by physician-dependent tools or
and worst fears or experiences, the physician’s touch to standards [34].
promote confidence and healing cannot be compromised and
should never be lost. The aim is to strengthen this relationship V. TECHNICAL FRAMEWORK
by supporting the health professional with a sophisticated The technical framework used for implementing the system,
EHR intelligent environment and by providing continuous incorporating the existing legacy systems, and designing the
education in health informatics. additional new subsystems needed is addressed below:
EHR is used by citizens for maintaining and managing their A. EHR Summary Standards
own health data, even by enriching them through innovative
One important technical issue that needs to be addressed is
mobile applications, which serve as sensors for monitoring
the construction and implementation of the EHR in an
health indices and the course/early phases of a disease [29].
interoperable environment that can process diverse data. Every
Patients, being the central focus of healthcare delivery, gain
member must follow EU guidelines and standards. Regarding
benefit by avoiding duplicate testing, lab procedures, imaging
EHR, the deliverables of the epSOS project was adopted and
examinations because all test results are kept in one historical
turned into Directive 2011/24/EU ‘minimum/non-exhaustive
file, which is also remotely accessible. Coordination and
patient summary dataset’ applicable both to the unexpected, as
remote access among health providers can lead to better and
well as the expected healthcare contact [5], [17]. The relevant
accurate diagnoses, better overall care especially to chronic
guidelines were incorporated in the legislation as a
patients [28]. Healthcare providers and patients who share
standardized set of basic health data for the patient (e.g. name,
electronic access to health information can collaborate in
birth date, gender, etc.), medical summary consisting of the
intelligent decision-making. Patient participation is especially
most important clinical patient data (e.g. allergies, current
important in managing and treating chronic conditions such as
medical problems, medical implants, or major surgical
asthma, diabetes, and obesity [30].
procedures during the last six months), list of the current
Patient-centered approach is giving the patient another role,
medication including all prescribed medication that the patient
instead of being the problem or part of it, one is made part of
is taking and information about the Patient Summary itself.
the solution. This elucidates why the integrated EHR is the
The steps followed were the identification and inclusion of the
cornerstone for attaining this through a unique account for
different specialties, such as cardiology, gynecology, pediatric
every citizen created automatically at birth with its first
etc., as seen in Figure 4. A complete interoperable EHR for
medical data belonging to the fetus and inherited from the
the citizen is enabled in combination with an eHealth Cloud
mothers EHR at the earliest ~9 months before birth [26], [31].
infrastructure. The EHR was further enhanced by giving the
From that moment onwards, each time a citizen visits a

2168-2194 (c) 2018 IEEE. Translations and content mining are permitted for academic research only. Personal use is also permitted, but republication/redistribution requires IEEE permission. See
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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
6

option to the citizen to enter in a separate section of the EHR

any data that is considered important for the medical
professional to see when the citizen issues such a request.
B. Standardization for Storage Retrieval and Communication
In healthcare, standards provide a common language and set
of expectations that enable communication between systems.
Such standards in healthcare are HL7, ISO, CEN, ICD10,
SNOMED and other in a wide variety of ways [35].
Harmonizing different information systems requires data
translation and mapping, as well as document and messaging
standards. Integrating the Healthcare Enterprise (IHE) is an
initiative that brings together users and developers of medical Fig. 5. Interoperability Standards and Medical System.
information systems to advance data integration. Adopting
IHE, technical interoperability is secured and gives value by Guidelines and the steps followed for our implementation
coordinating the use of established standards for the specific methodology are briefly stated here: Problem Identification
clinical needs [36]. The lack of cooperation by many hospital phase - Clinicians and IT experts were asked to identify
systems fail to satisfy everyone’s effort to automate processes, problems when accessing data, problems with the
create and review medical reports [37]. The adoption of IHE administration infrastructure, and problems with their clinical
standards automated these processes and brought about a very workflow. Then stakeholders select the most suitable
efficient medical workflow. standards for each identified integration need. Integration
Profile Specification phase - Those standards are documented
in the IHE technical framework. Vendors implement the
selected integration profiles and test their systems with
software tools and at a face-to-face Connectathon [38], a
cross-vendor, live, supervised and structured testing event
where industry leaders test implementations of IHE Profiles to
advance health IT interoperability. The IHE Connectathons
take place annually in various countries across the world to
advance health IT and patient safety. Lastly, vendors publish
IHE Integration Statements to document the integration
profiles supported by their systems – which is the Integration
Statement and RFPs phase.
The most recent profiles that were developed by the IHE
regarding EHR services used the Fast Healthcare
Interoperability Resources (FHIR) standard from the HL7
Fig 4. Structure and functionality of the Electronic Health Record. organization for exchanging healthcare information
Layer 1 – Patient summary with specializations, Layer 2 – electronically [39]. FHIR solutions or Resources are a set of
interoperability privacy and security, Layer 3 – Health providers and modular components, which can be easily assembled into
medical centers. working systems for solving real world clinical and
administrative problems in a very efficient manner. FHIR
The goal of the IHE Technical Framework is to define the solutions are explicitly suitable for EHR-based data sharing
interactions among system components so that the roles of the and server communication in large institutional healthcare
actors are not assigned to specific industry products, such as providers. FHIR defines a simple framework for extending
hospital information or radiology information systems. The and adapting existing resources and this could solve many
vendors of the different system components suggest how the interoperability problems that all anticipate in their way [40].
actors’ roles are implemented [37]. Overall, the IHE technical The eHealth Lab of the University of Cyprus developed
framework helped to build a market for standards-based with success in collaboration with IHE under the FI-STAR
integration by giving incentives, education and tools for both project the IHE profiles below. FI-STAR aims to build a
providers and purchasers. vertical community for creating a sustainable ecosystem for all
IHE is not a standard; it supports the use of existing user groups in the global healthcare and adjacent markets [41].
standards in an integrated manner. It is simply an • IHE PDQ: Patient Demographics Query; where, Patient
implementation framework creating interoperability between Demographics Query provides ways for multiple distributed
medical systems. IHE provides templates that can be used as applications to query a patient information server for a list of
standardized tools to build starting points for optimizing patients, based on user-defined search criteria, and retrieves a
workflows in a uniform way, as demonstrated in Figure 5, patient’s demographic information directly into the
adopted from ‘http://wiki.ihe.net/index.php’. application.

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• IHE XDS.b: Cross-Enterprise Document Sharing; where, anemias can further benefit research due to their design and
Cross-Enterprise Document Sharing (XDS.b) IHE Integration capacity to follow a broad group of patients for long periods.
Profile facilitates the registration, distribution, and access These registries assume a critical role in improving
across health enterprises the EHR. comprehension of rare anemias by creating guidelines for
Cross-Enterprise Document Sharing is focused on providing disease treatment and management and providing information
a standards-based specification for managing the sharing of to assist the development of new treatments. This system laid
documents between any healthcare enterprises, ranging from a the foundation for a consensus, and evidence-based disease
private physician to a clinic of an acute care in-patient facility. management system, and as demonstrated in a recent
The European Commission Decision (EU) 2015/1302 of publication, eHealth-funded initiatives supported by EU can
July 2015 has decided the 27 IHE profiles describing the benefit through applied research by citizens in need and the
different layers of interoperability with a view to find medical profession [27].
interoperability solutions for exchanging or sharing medical The experiences gained above were very valuable as it taught
data [42]. In Figure 5, one can see the different IHE profiles us how a national eHealth ecosystem can be gradually built
establishing the cross-border communication between the once the technical framework and the tools become available
provider and the receiver and also for exchanging medical to the expected team of professionals. Lessons learned can
information between systems. IHE Integration Profiles speed up the efforts of other EU countries in securing
organize sets of IHE actors and transactions for addressing the interoperability and functionality.
specific needs for care of patients. These profiles offer a
D. eHealth Cloud
convenient way for vendors and users to communicate in a
standard way the functionality that is defined in the IHE It is stated that eHealth aims at “cost-effective and secure
Technical Framework without having to provide all the details use of ICT in support of health and health-related fields,
of the IHE actors and their transactions. They describe clinical including healthcare services, health surveillance, health
information and workflow needs and specify the actors and education, knowledge and research” [46]. Cloud computing is
transactions required to address them. Thus, IHE profiles can a facility or service that eliminates the need of an organization
be used for the system development and are in compliance to maintain in-house special and expensive hardware, network
with the EC decisions. infrastructures, and costly technical professionals for
supporting and operating in-house ICT systems. The Cloud
C. Technical solutions and tools developed offers diverse IT solutions and resource time-sharing as on-
As stated earlier, three open source software libraries, demand services for different organizational needs, and it
namely the EHR SE, epSOS SE and PACS SE, were enhances resources utilization and service delivery [47]. A
developed by the eHealth Lab of the University of Cyprus [43] special type of Cloud, an eHealth Cloud that can solve some
in the context of the FI-STAR platform and were designed to of the current limitations faced by healthcare ICT solutions
facilitate the deployment of innovative applications and value- was proposed [48]. An eHealth Cloud can be physically
added services in the healthcare sector [44]. Targeting towards situated in a country and regulated by local legislation, thus
the enrichment of the FI-STAR framework for use in the satisfying to an extent, security and confidentiality concerns,
healthcare domain, the EHR-EN software library addresses the which are some of the main obstacles brought forward when it
objectives to build: i) the EHR specific enabler (EHR-EN); ii) comes to adopting ICT solutions that require interoperability,
the patient summary specific enabler based on the ‘European high volume and remote access to medical data.
Patients Smart Open Services’ (epSOS) project (epSOS-EN), The apparent scalability, flexibility and availability of cloud
and iii) the Picture Archiving and Communications System services and the low cost associated, contributed to the rapid
(PACS) specific enabler based on the dcm4che open source adoption among enterprises or health related agencies in
software (PACS-EN). These three FI-STAR platform enablers recent years. Patient-centered healthcare encourages citizens
developed and used by our eHealth lab can facilitate the to be involved in their own healthcare activities, and the
deployment of similar innovative applications and value added cloud-based platform provides a technical solution and a
services in the healthcare sector and are readily available in valuable option. When data become available in the cloud, it is
public domain [41]. subject to security preconditions and can be processed by
As a pilot study, a full EHR application has been developed remote services or distributed automatically to all relevant
by the eHealth Lab of the University of Cyprus for the needs health providers. As stated by one of the authors of this paper:
of the EU project eENERCA dealing with rare congenital “Around one third of the studies show that the security and
conditions that require lifelong follow up and treatment [45], privacy gaps of healthcare data in the cloud could be solved by
[38]. The proposed eRegistry serves as an epidemiological access control encryption schemes and security protection
tool to improve the management of patient services and techniques” [49]. This suggests that it would be possible to
ultimately improve patient care [19]. For this project the switch current eHealth services to improved eHealth Cloud-
following modalities were created: Demographics, Diagnosis, based services. This was considered as the most suitable for
and Clinical Data. Patients and healthcare providers benefit our case to serve as central host of all the EHRs of the citizens
from this eRegistry, since they were provided with valuable and those visiting the country and would like to have readily
sources of information on their disease. eRegistries for rare available their EHR while visiting Cyprus. The eHealth Law

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Biomedical and Health Informatics
8

provided an entire framework for such a specialized cloud and of-pocket being about 2.5 times higher than the average figure
operated under the control of the National eHealth Authority. among all EU countries. In the Netherlands, for example, the
Evidently, an eHealth Cloud platform, with all technologies corresponding figures are 18% and 30% while the average
incorporated, offers an excellent opportunity to the healthcare out-of-pocket is below the EU average. Private health services
industry for addressing challenges such as patient care, quality in Cyprus are provided by privately owned hospitals,
and safety, healthcare costs, ICT and access costs, backup and polyclinics and clinics, independent practitioners, diagnostic
security, and collaboration and knowledge sharing among centers, and pharmacies, which are regulated, licensed, and
healthcare professionals at any geographical area. An overall inspected by the Ministry of health [52].
outcome will be the high quality services at the lowest cost for Health services in the public sector are covered by five
healthcare. The general advantages are summarized as district hospitals and one pediatric/gynecological hospital,
follows: i) Reduction of the cost of owning and maintaining three small rural hospitals and 38 health centers. The Ministry
hardware, software, and people-ware of ICT systems; ii) covers nearly 80% of the population which is entitled for free
Integration and exchange of medical records across multiple healthcare in the public sector. The rest of the population is
experts locally and worldwide; iii) Enhancement of diagnosis, receiving treatment privately, and a small proportion receives
support medical research activities, and simplification of treatment in public hospitals at a cost.
administrative operations; and iv) Improved availability, A study of the healthcare expenses in Cyprus over the last
scalability and flexibility of the health information system. twenty years has shown an exponential growth averaged to
Several issues and challenges have been addressed before about 8%, while the GDP growth remained around 4%. As a
the eHealth Cloud was considered as a good alternative result, the system was going bankrupt unless money was
approach for this healthcare service. The major concern was pumped in by the taxpayer or the quality of service was
the security and privacy issues, which were adequately compromised. Alternatively, an efficient and effective
addressed. Financial and legal concerns are addressed in the National Health Insurance System (NHIS) was proposed on
following sections. To date, the available security and privacy the bases of eHealth and citizen-centered principles, which
measures are at an acceptable level of confidence. The seemed as the only realistic way for defeating the crisis.
inclusion of strong security measures when the owner is not Just for the history, in June 2012, the Cyprus Government
available can be handled by deciding beforehand and in applied for financial assistance from the Eurogroup and the
agreement with the owner by signing a properly prepared IMF. As precondition to this, the participating institutions
consent form [49]. forced Cyprus embark on an economic adjustment program
aimed at restoring the health of the financial sector, continuing
VI. FINANCIAL FRAMEWORK the on-going process of fiscal consolidation and to implement
The present Cyprus healthcare system comprises two structural reforms that support competitiveness, balanced and
parallel sub-systems, being the public and the private. These sustainable growth [53]. One of the actions taken for restoring
systems operate separately and independently resulting in this was the gradual implementation of a National Health
inefficiencies, low communication and overall coordination of System for providing comprehensive medical care to the entire
healthcare. The funding of this system is mainly covered population, achieving universality in coverage, good quality of
directly from the pockets of the citizens, implying a lack of care, equity, solidarity, and long term financial sustainability.
justice and solidarity within the healthcare sector. Therefore, if The proposed system was an insurance-based system, which
the public and private sectors continue to operate separately, it has been designed to address the current challenge, distortions
would not hold back further wastage of resources, overlaps in and deadlocks in the healthcare sector characterized by:
services, and lack of quality of service [50], [51]. 1. Universal coverage meaning all Cypriot citizens/EU
The public sector is owned and operated by the Ministry of citizens and other legally living in Cyprus to become
health. They are responsible for ensuring access to health beneficiaries of this system.
services for all beneficiaries and were exclusively financed by 2. Comprehensive benefits package for covering a broad
the taxpayers. The Ministry of health is however responsible spectrum of healthcare services such as primary care, clinical
for the regulation, planning, licensing, and quality control for laboratory tests, emergency care etc.
the entire health sector, realities which make the role of the 3. Equal treatment where all beneficiaries have the same
Ministry highly debatable. The Ministry placed patients into rights in respect of the provision of healthcare services.
three categories based on income, chronic illnesses, and 4. Free choice to the citizen for healthcare provider.
number of children, consisting of people who receive 5. Solidarity where each citizen will contribute according to
treatment free of charge, those who pay reduced fees and those their income level.
who pay fully [50]. Not even the full charge represents the real Currently, the top priority of the Government and Ministry
cost due to the lack of proper cost estimation system in place. of health is to continue reforming healthcare and upgrade
As a result in most cases, the cost was underestimated and the public healthcare centers to autonomous, ensure healthcare is
taxpayer is called to cover the deficits. patient-centered, reliable and accessible. Next step, Health
The private sector is mostly financed by out-of-pocket Insurance Organization (HIO) which was set up under the Law
payments and this covered about 55% of the total healthcare N.89(I)/ 2001 as a public legal entity to support its mission,
budget; and from this, approximately 87% is covered by out- which is the implementation of the proposed National Health

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
9

Insurance System (NHIS) operating initially as a closed achieving an effective legal framework, each country needs to
system [54]. The HIO which is partly controlled by the study its national legislation and take into consideration the
government is the strategic buyer of health services by all EU legal framework and directives. An important issue when
public and private providers on an equal basis. The insurance implementing a new EHR system is the system’s compliance
fund of HIO is generated by the contributions of the social with the law regarding the rights of patients. Each country has
partners being the employees, the employers, and the State. its own legal system; however, all member states should
The free market began generating competition forcing the comply with the guidelines, standards and legislative
public hospitals to undergo radical operational and framework set by the EU. For example, before the accession
organizational changes. Another novelty brought by the NHIS of Cyprus to the EU a series of laws were inherited from EU,
including those relating to patients' rights and the protection of
was the reorganization of the Primary Care sector by having
the data generated and stored. Therefore, a study on the
the citizens to choose their family doctor including the
capability level of the national legislation on these issues was
pediatrician, thus relieving crowding in public hospitals. The
performed. It also took into consideration the differences and
family doctors are compensated per capita and not per visit, idiosyncrasies of the locals, and derived recommendations for
and the patient only uses the secondary or tertiary care through the amendments to be introduced as new legislations or amend
referral from the family doctor. Similarly, prescriptions for accordingly existing laws. This safeguarded a smooth
pharmacies and laboratory test can only be issued by the transition into the new order with less rejection probability.
appropriate personnel and compensated directly by the HIO. The EHR although it is based on an evolving concept
These reforms are generating a fully financially accountable oriented approach that provides improved healthcare quality,
NHIS, whose greatest success will be eventually the savings in the patient should not deny the ‘right’ of the medical
healthcare spending and its transformation to a positive-sum professional to be informed when needed and to safeguard
game, thus generating added value and extra benefits to the this. For this, it was necessary to establish an appropriate
citizen at a lower cost. legislative framework so that all the necessary procedures and
The above summary of the state of affairs and the necessary actions to be taken conformed to the law as it applied locally
reformation was made by adopting the eHealth approach in and at EU level. Such considerations include electronic
line with an interoperable, national coverage, cross-border, processing and collection of personal data of the citizen, and
and citizen centered healthcare system. A preposition for an the movement both within their state borders and cross-border.
eHealth ecosystem on these lines is presented in the discussion The British Medical Association mentions that, “the
section below. Its functionality and operability is gradually physician must maintain secrecy on all he knows”. In this
implemented and tested by the EU funded initiative CEF-TC- general principle, however, there are five exceptions, releasing
the doctor of confidentiality: when the patient gives her
eHealth CY-IA-0095 (26922256) -Deployment of Generic
consent, when it serves the interests of the patients, when the
Gross Border eHealth Services in which the Ministry of health
doctor's duty to society prevails, and for research purposes as
of Cyprus and the eHealth lab of the University of Cyprus are
approved by the Ethics Committee for Clinical Research and
participating. In this initiative another 15 EU countries are the information required for legal procedures [47].
participating. Parallel to this, the initiative CEF-TC-EESSI- New announcements of the European Parliament, such as
CY-IA-0016 (27574468) -Cyprus Electronic Exchange of the eHealth Action Plan, emphasizes how ICT can be used to
Social Security Information, funded by EU is in progress since provide better quality healthcare services throughout the
March of 2018, for supporting the full functionality of the Community. The crucial aim of this action was the creation of
country’s healthcare ecosystem to operate at EU level. a ‘Pan-European eHealth’ for recording practical measures to
be applied in various fields. The eventual goal of the program
VII. LEGAL FRAMEWORK is that by the end of the decade, eHealth to bind the habits of
A successful legal framework for healthcare management health professionals toward a citizen centered thinking. It was,
should address and regulate the following mainly conflicting however, necessary to regulate this kind of thinking by
domains: i) EHR-definition and content; ii) EHR-ownership legislation in order for the application to become effective.
and access; iii) catholic-applied to all citizens and to all Data banks are used for storing medical data. The storage of
healthcare providers; iv) solidarity-mutual guarantee; v) such data in a central location raises new questions about the
economic viability-sustainability and cost effectiveness; vi) protection of personal data, which do not arise when data is on
high quality-services in medical care; vii) autonomy-in the paper. For example, who can have access to these data? Who
framework of operation and running of the system; viii) can generate information from? How safe is the personal data?
interoperability at national and cross-border levels, and ix) the Evidently, the protection of personal data by appropriate
establishment and the operation of EHR databanks. These legislation is absolutely important. Intellectual property or
domains were studied by the systems design team and the copyright or exclusive rights of the copyright of a work should
relevant national legislation was revisited. be granted by law and be valid for a certain time and forbid
In a constantly changing technological environment, a others to use the work without the consent of the author. The
significant impediment to the successful implementation of copyright is an arbitrary right of each author and applies
eHealth is not only the technological complexity and the without the need to make application to one institution or
challenges presented, but also the lack of adequate and work to be recognized by a service [56]. The Government is
necessary legislative framework to cover this effort [55]. In responsible to support the requirements by introducing
appropriate legislation when needed.

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10

The EHR systems are subject to the risk of unauthorized Parliament for approval. The approval was secured a priori as
processing of personal health data of the patient, thus, new it was already negotiated and agreed with all involved.
safeguards to ensure the protection and privacy of personal The main expectancies of the bill were:
medical data are required. The establishment and operation of 1. The EC Regulation No 883/2004 on the coordination of
EHR systems must comply with the principles of protection of social security systems is incorporated in the bill, thus making
personal data set by the EU Directive 95/46/EC [57]. When it all the citizens of Cyprus beneficiaries for healthcare and as a
comes to health, this directive varies and many times consequence become beneficiaries at EU level. It was
prohibitive principles formulated can affect the smooth observed that until the approval of the bill, many Cypriots
operation of an organization. Maintaining confidentiality for were not beneficiaries at EU level.
patient records on paper is not enough to secure the privacy of 2. Citizens of other countries are covered by the Regulation
patient medical data when files are converted into electronic 859/2003/EC or by the Regulation 1231/2010/EC, thus
form. So far in the existing legislation there is no rule of become beneficiaries in Cyprus.
conduct on neither eHealth nor clear principles defining 3. The Council of ministers appoints the NeHA which acts as
accountability in case of technical problems of information the regulator of the associated affairs, such as the setting up of
systems related to healthcare. Therefore, the adjustment of the NCP for health for the country for cross-border healthcare.
hospital organization to technological change requires changes 4. The definition of the content of the EHR, being the patient
in the existing regulatory framework. summary, the extended summary, and the citizen’s optional
In many cases, a transitional grace period is given to avoid space for adding relevant data.
undesirable shocks at the early stages of implementation for 5. Regulation of the use of the EHR, its ownership, its content,
safeguarding a smooth transition. Through the study of the users, and their rights and obligations.
relevant legislation that exists worldwide, it became clear that 6. The obligation of healthcare providers, and operators of
the legislation in Cyprus was at a primitive stage. The legal other related services of being able to access, retrieve,
framework required radical reform and necessary political will download, and upload the parts of EHR that are relevant to the
for promoting the integration and the widespread use of EHR medical examination being performed.
and eHealth in general. The success of EHR to the greatest 7. The promotion and dissemination of modern forms of
extent depends on the human factor and to a lesser extent to electronic data exchange, education and professional training.
legislation. Acceptance is a matter of mindset and culture and The national eHealth system and the supervision of the
necessary measures through education and awareness were healthcare providers is becoming a reality upon gradual
taken as part of the whole strategy [24]. It was necessary to implementation of the above points of the law. The NeHA
bring together the stakeholders. The study in question was being an independent and autonomous entity contributes a lot
based on an analysis of the existing infrastructure so that the in the harmonization of the medical care centers nationwide.
necessary measures were adopted before any implementation. The new era in the running of public hospitals brings in
The legislative measures to be decided, was the result of an independent quality experts. Furthermore the introduction and
overall analysis that put into the equation social, political, enforcement of the law for administrative and financial
organizational and technological issues. autonomy makes all the public hospitals and medical centers
It would be worth for a country to follow the steps that competitive, operating in a free economy environment along
Cyprus took recently for revisiting the relevant laws for with the private hospitals and medical centers.
accommodating the pillars of eHealth stated earlier. Initially, a When a country reaches such a maturity level, the new
general health sector reform strategy has to be decided at the eHealth Law, which incorporates all the gained experiences,
highest political level and supported by three main pillars: 1) harmonizes the operation of eHealth at national level.
eHealth, 2) Reform and homogenize all public and private
hospitals and health centers, and 3) Promote research and VIII. DISCUSSION AND CONCLUSION
collaboration with academia with all healthcare providers. The This paper purposely has some extra theoretical background
second pillar included the reform of the legislation in and prepositions for the reader to consider and judge if
accordance with the existing Cyprus law for cross-border (L. applicable in the problem under consideration. The suggested
149(I)/2013) which led to the introduction of a new law methodology and approach for building an eHealth ecosystem
explicitly for regulating eHealth in Cyprus. A team of experts for serving national healthcare is country dependent and
studied the relevant EU Directives 95/46/EC and 2011/24/EU, subject to many parameters within the sub-system’s
and Executive Directive 2012/52/EU as well as twenty-four environment. The paper however, is not limited to a
national laws relevant to healthcare, such as the law for theoretical framework but it took all the steps forward and
pharmaceuticals, operation of clinics, medical profession developed a solution for Cyprus which is progressing evolving
practicing, establishment and protection of patients' rights, etc. and growing. This system was evaluated and tested with
and prepared the eHealth law in harmony with the cross- commercial standards before put into practice. From the legal
border care law. The new law was presented and discussed, point of view certain changes were suggested and the existing
negotiated and agreed with all interested bodies, including the legislation was revisited appropriately and new eHealth law
Cyprus Medical Association, the Federation of Patients was introduced. These reforms entertained any justifiable
Associations and Friends of Cyprus – Member of EPF concerns regarding legal, ethical, and cultural issues. The
(European Patients Forum), the Health Insurance changes come within and not imposed by the outside and as a
Organization, the Cyprus Pharmaceutical Association, and all result made their acceptance a natural reformation. The last
healthcare providers. The agreed bill was submitted to the

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11

section analyses the financial framework which based on the offer its collective experience as lessons learned for other EU
fundamental pillars catholic (all-included), and solidarity countries which are puzzled as to how to proceed towards the
compromised to a NHIS initially operating as a closed system same direction for healthcare reform and remain in line with
with a unique health insurance provider, the HIO, which is EU directives and values for the citizen.
controlled by the government and the main stakeholders.
The proposed eHealth Ecosystem for Cyprus is illustrated in ACKNOWLEDGMENT
Figure 6. The most important parts being the Central Citizen This work was partly funded by the EU projects eENERCA
Data Warehouse, which uniquely links every citizen to the FI-STAR and H2020-WIDESPREAD04-2017-Teaming Phase
Central eGovernment Portal, the country Cloud integrated 1, G.A. 763781 Integrated Precision Medicine Technologies
EHR system which is regulated by the NeHA thus satisfying (IPMT). The Ministry of health of Cyprus provided valuable
interoperability and citizen-owned EHR, confidentiality, and data for this study. Many thanks are expressed to the members
security; and the providers appropriately linked to the HIO for of the eHealth Lab of the University of Cyprus and in
financial issues and the NCP for health for cross-border health particular to its co-director Professor C.S. Pattichis.
care. It would not be difficult to accommodate into this system
any non-Cypriot citizen who chooses to obtain a user account
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http://www.ieee.org/publications_standards/publications/rights/index.html for more information.
This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
12

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This article has been accepted for publication in a future issue of this journal, but has not been fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/JBHI.2018.2834230, IEEE Journal of
Biomedical and Health Informatics
13

Eirini Schiza (M’14) was born in Nicosia, chairman at the boards of the NGOs “Intensive Care Forum”
Cyprus in 1988. She obtained a BSc in and “International Humanitarian Aid”.
Computer Science from the University of
Sussex in 2010 and MSc in Computer Nicolai Petkov received the Dr. sc.techn.
Science – Multimedia Applications and degree in Computer Engineering
Virtual Environments from the University (Informationstechnik) from the Dresden
of Sussex in 2011. She is a PhD Candidate University of Technology, Germany. Since
in the area of eHealth in the Johan 1991, he is professor of Computer Science
Bernoulli Institute for Mathematics and Computer Science of and head of the Intelligent Systems group of
the University of Groningen – The Netherlands. She is also the Johann Bernoulli Institute of
mentored by the academics of the eHealth Laboratory of the Mathematics and Computer Science of
University of Cyprus. She is expected to graduate in 2018. the University of Groningen, the
Eirini is researcher at the eHealth Laboratory and the Netherlands. From 1998 till 2009 he was the scientific director
Computational Intelligence Laboratory Lab, Department of of that institute. He is the author of two monographs and
Computer Science, University of Cyprus since 2013. She coauthor of another book, holds four patents, and has
worked as a special scientist and system developer during authored and co-authored over 150 scientific papers. His
2010 to 2012 with Unilogic Ltd, a software company in current research concerns machine learning, data analytics and
Cyprus, specializing on eHealth systems. Since 2016 she has pattern recognition with applications in health care, robotics,
been attached to the EU funded project namely eENERCA, finance, animal breeding and other areas. He is member of the
responsible for the design of an electronic health record editorial boards of several journals.
system for national healthcare centers. Her research interests
are eHealth and supporting technologies, computational Christos N. Schizas (LSM’17, SM’81)
intelligent medical applications, multimedia applications and was born in Cyprus. He received the
virtual environments. B.Sc. (Eng.) degree in electronics from
Queen Mary College, University of
Theodoros C. Kyprianou was born in London, London, U.K., in 1978, the
Limassol, Cyprus in 1967. He studied M.B.A. degree in business administra-
Medicine (1986-1992) with a state tion from the University of Indianapolis,
scholarship at Medical School, University Indianapolis, IN, USA, in 1988, and the
of Athens and the University of London Ph.D. degree in intelligent systems from Queen Mary College,
(elective student for the final year). University of London, in 1981.
Subsequently he completed clinical He is currently a Professor of computational intelligence at
fellowships in Pulmonary Medicine & Tuberculosis (1992- the University of Cyprus, Nicosia, Cyprus. He was a
1997) and Intensive Care Medicine (2000-2002) in several Postdoctoral Fellow with the University of London, and a
University Hospitals in Athens. He obtained his PhD (1997- Professor of computer information systems with the
2002) from the Department of Pulmonary & Intensive Care University of Indianapolis. Since 1991, he has been with the
Medicine, University of Athens in 2002, being external Department of Computer Science, University of Cyprus. He
research fellow for many years after. was the Vice Rector of the University during 2002–2006. His
He is the founding Head of the Department of Intensive research interests include eHealth, computational intelligence,
Care – Nicosia General Hospital (since 2006). In 2011, upon medical informatics, diagnostic and prognostic systems, and
completion of 20 years of pioneering clinical work, system modeling and identification of brain activity.
professional teaching and funded research, he assumed the Dr. Schizas received the William Lincoln Shelley Award
position of Associate Professor at St Georges' University of from the University of London for excellence in research, and
London Medical Program delivered at the Medical School, a Fulbright fellowship for collaborative research in the USA.
University of Nicosia. He has been also appointed as academic He is currently the Section Editor (eHealth) of the Technology
committee member / coordinator in the MSc -distance and Health Care, IOS Press, served as Area Editor of the IEEE
learning- program: Applied Health Informatics at the Open TRANSACTIONS OF INFORMATION TECHNOLOGY IN
University of Cyprus. He also served for a number of years as BIOMEDICINE (former J-BHI), and Member of the Editorial
deputy chair of the National Committee for bioethical Board of the Journal of Intelligent Systems. He is founder of
assessment of Biomedical and Clinical research. He was the Computational Intelligence Lab and Co-Director of the
National Coordinator and member of the editorial committee eHealth lab of the University of Cyprus. He has taken part in
for the development of the European curriculum for training in European Commission initiatives for promoting the
Intensive Care Medicine (CoBaTrICE) and is currently the Information Society and the eHealth initiatives. He is national
Chair (2014-2017) of Technology Assessment & Health expert in the EU HORIZON 2020 program SC1 committee
Informatics trans-sectional Working Group and deputy chair (Health, Demographic Change and Wellbeing). He attends as
of e-Learning Committee at the European Society of Intensive Invited Speaker the annual EU Ministerial Forum week
Care Medicine. meeting on eHealth. In April 2016 he has been appointed by
Dr. Kyprianou currently represents Cyprus as national expert the President of the Republic of Cyprus as Presidential
in the EU HORIZON 2020 program SC1 committee (Health, Counselor for eHealth and matters related to the national
Demographic Change and Wellbeing). He also serves as vice- health system reform.

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