Telehealth has increasingly been framed as a strategic response to rural healthcare disparities, particularly where geography, demography, and workforce shortages intersect (18). Greece exemplifies this challenge, with rural regions like Agrafa experiencing persistent deficits in general practitioners and specialists. During tourist seasons, the healthcare burden further intensifies due to population surges and increased accident or chronic care needs (19). Telemedicine is proposed as a cost-effective, scalable solution for remote triage, chronic disease management, and emergency support (20). However, implementation success varies significantly based on local infrastructure, digital literacy, and trust in technology (21). Regions with aging populations often face resistance to unfamiliar medical technologies, despite their clinical efficacy. As such, successful adoption of telehealth tools is closely tied not just to technological readiness, but to community engagement, education, and culturally appropriate rollout strategies. TytoCare represents a new class of consumer-friendly medical technology that enables remote physical examinations typically limited to in-person clinical visits. The device integrates a camera, otoscope, stethoscope, and thermometer into a compact unit that transmits data to licensed physicians via cloud platforms. This design has allowed it to be used effectively in schools, remote clinics, and homes worldwide. Critically, the platform doesn't just improve access—it also builds confidence in remote diagnostics by ensuring physicians maintain visual and diagnostic control. This hybrid model, where laypeople collect data but doctors maintain interpretive authority, helps alleviate liability and quality concerns. Devices like TytoCare can “extend the reach of doctors into communities without requiring their permanent presence,” an especially potent concept in areas like Agrafa, where medical professionals are scarce (18).

There is growing recognition that telemedicine infrastructure can catalyze wider socio-economic gains. Beyond direct healthcare benefits, digital health systems can anchor new models of regional development rooted in wellness, remote work, and lifestyle migration. As traditional tourism evolves into longer, purpose-driven stays—especially among digital nomads and remote workers—regions that offer both natural beauty and essential digital infrastructure are emerging as competitive destinations (22). Digital nomads, defined as professionals who use telecommunications technologies to work remotely while traveling or living in diverse locations, increasingly seek destinations that blend affordability, authenticity, connectivity, and safety. While Wi-Fi and coworking spaces are often seen as baseline requirements, access to dependable healthcare—especially in isolated areas—is an underrated yet critical factor in destination choice (23). The presence of telehealth services like the one proposed in Agrafa not only supports local populations but directly aligns with the expectations of this new class of mobile professionals. Moreover, national strategies across Europe—including Greece's own digital nomad visa initiatives—are designed to attract longer-term residents who contribute economically while working for companies abroad. However, for rural destinations to capitalize on this trend, they must ensure not only digital connectivity, but also medical security—an area where telemedicine serves as both a public good and a marketing tool. By offering remote diagnostics in a region historically deprived of health infrastructure, Agrafa can position itself as a “resilient retreat” for health-conscious nomads and lifestyle migrants. The synergy between eHealth and digital nomadism also aligns with the EU's broader Smart Villages agenda, which promotes digital inclusion, sustainable growth, and innovation-driven resilience in rural territories (24, 25). In this context, the proposed telehealth solution is more than a health device—it becomes part of a strategic infrastructure enabling demographic revitalization and rural rebranding. In this context, telehealth evolves beyond a care delivery mechanism and becomes part of a broader territorial strategy. It reinforces Agrafa's identity as a resilient, future-ready rural destination capable of hosting health-conscious tourists and remote workers, thereby contributing to place branding and rural regeneration agendas.

Despite accelerated telehealth adoption in recent years, sustainable implementation in rural areas requires overcoming infrastructure, policy, and patient engagement challenges (26, 27). Although the telehealth pilot in Agrafa is still in early stages, lessons from similar initiatives suggest key dimensions for evaluating its success: •

Access and equity: Reduction in travel needs, especially for vulnerable residents

This project follows a feasibility and implementation case study design to assess the early deployment and perceived impact of a telehealth solution in the remote rural region of Agrafa, Greece. The approach prioritizes practical insight into real-world implementation rather than hypothesis-driven clinical outcomes.

The evaluation focuses on four core feasibility domains: •

Acceptability: User satisfaction and willingness to engage with the platform, based on informal interviews and community reports.

To collect early-stage feedback, informal interviews (n = 6) and structured questionnaires were conducted with a small but strategically selected group of local stakeholders: one hotel owner, one restaurant manager, one municipal employee, one permanent resident, one hotel employee, and one local service provider. The municipal employee was included because he serves as a year-round liaison for local services and frequently assists residents and visitors in accessing community resources. His institutional role, continuous presence, and direct interactions with vulnerable residents made him an appropriate facilitator despite not belonging to the other occupational categories represented. A general practitioner who periodically serves the village under a fixed-term municipal contract was also trained in the use of the telehealth system so that she could request remote specialist second opinions from physicians when needed. Although involved clinically, she did not form part of the six trained community facilitators. For clarity, the evaluation distinguishes three participant groups: (a) the six trained community facilitators (non-clinical, device guidance); (b) 24 residents and 6 tourists who used the system for teleconsultations; and (c) one local general practitioner, whose role was limited to seeking specialist second opinions rather than facilitating device operation. These six individuals were not only early users but also identified as key facilitators of the service. The hotel and restaurant owners were chosen due to their year-round presence in the area and their locations at critical access points for tourists. Their role was envisioned as twofold: to assist older or digitally inexperienced residents in using the telehealth unit and to inform and guide visitors and tourists regarding the availability of the service. Their digital literacy levels were sufficient to allow rapid onboarding and effective operation of the platform after basic training. Data were collected after training sessions and initial system use. Although the sample was small, it provided valuable insights into user experience, perceived benefits, and implementation barriers. The findings were summarized thematically by the project team without formal coding and should be considered preliminary. Qualitative inputs from interviews and field observations were thematically grouped into recurring categories related to usability, confidence, and operational challenges to ensure a minimum level of analytical structure (see Table 1).

These 30 cases represent end-users of the service and are analytically distinct from both the trained facilitators and the GP, whose involvement related exclusively to clinical guidance rather than system operation. A more comprehensive evaluation phase with larger samples is planned during the forthcoming 12-month monitoring cycle.

This pilot was conducted as a real-world service implementation project and not classified as human-subject research. Nonetheless, ethical safeguards were integrated throughout the process. All participants involved in interviews or feedback provision signed a consent form prior to participation, and no personally identifiable data were collected—only anonymized testimonials were used. The telehealth platform itself is both FDA-approved and fully compliant with the General Data Protection Regulation (GDPR). Before each teleconsultation, users were informed directly through the platform interface about the handling of their sensitive health data and asked to provide digital consent in accordance with GDPR principles. Additionally, an online questionnaire was provided post-session, in which users gave explicit consent for their anonymized responses to be used for service evaluation and research dissemination. All communication was encrypted, and no personal data and health records were stored locally or permanently during this feasibility phase. Furthermore, formal approval was obtained from the Municipality of Agrafa to administer the anonymous questionnaires and conduct interviews with participating residents, as part of the local service quality improvement strategy.

As part of the pilot's initial operational phase, 30 real-time teleconsultations were completed using the deployed unit in Granitsa. Of the 30 teleconsultations, 24 involved permanent residents and 6 involved tourists or short-term visitors, allowing for a clearer distinction between local healthcare needs and tourism-related cases. Table 2 provides a descriptive summary of the 30 teleconsultations conducted during the pilot, broken down by resident vs. tourist status and by clinical use-case category.

These descriptive findings correspond to the “Reach” and “Adoption” dimensions of the RE-AIM framework, illustrating early uptake among both resident and visitor populations. These involved residents and tourists who presented with minor acute symptoms or chronic follow-up needs. Connectivity was ensured via a dedicated 4G SIM card and router provided by the implementation team, which bypassed local broadband limitations and guaranteed stable communication. Table 3 summarizes the preliminary feasibility indicators of the Agrafa pilot, mapped onto the core dimensions of the RE-AIM framework to clarify early uptake, operational viability, and user experience.

Qualitative Themes from 6 Stakeholder Interviews (Thematic Analysis): 1.

Increased Confidence (RE-AIM: Adoption) – “Now I can guide anyone confidently after training” (hotel owner).

While these results are preliminary and based on early deployment, they confirm the technical and operational feasibility of the system under real-world conditions. A structured 12-month evaluation phase is planned to capture broader usage patterns and assess long-term impacts.

As part of the implementation case study approach, while quantitative data is yet to be collected, early modeling and qualitative stakeholder feedback suggest three main use cases with high projected impact:

Primary Use Cases: 1.

Chronic Disease Monitoring

Residents living with hypertension, diabetes, or chronic respiratory conditions (e.g., COPD- Chronic Obstructive Pulmonary Disease) can monitor vital parameters and receive guidance from physicians based in urban centers. This is expected to reduce unnecessary emergency department visits and enable preventive care.

An interactive, map-based dashboard displays data in real time across participating villages, using heat map visualizations to illustrate the density and distribution of telehealth interactions. Case categories—such as electronic prescription requests, chronic disease follow-up, symptom reporting, and emergency service coordination—can be filtered by variables like visit purpose, presenting symptoms, or action taken (e.g., prescription renewal, nurse dispatch).

This geographically disaggregated view provides actionable insights for local health authorities and research teams, supporting responsive service planning and contributing to the evaluation of pilot scalability. Additionally, the platform aligns with national digital health strategies and EU Smart Villages objectives by enhancing transparency and enabling data-driven policy development.

Early qualitative feedback from community members indicates a positive reception of the telehealth service. One elderly resident noted, “I feel safer and no longer worry about long trips to the city doctor—now the help is here.” A local facilitator added, “We see people who were hesitant at first, but after the first visit, they bring their neighbors along.” Such narratives underscore the importance of perceived convenience and local trust in the successful adoption of digital health interventions in rural communities. Across the qualitative material, three dominant themes emerged: (a) increased facilitator confidence, (b) device usability strengths and limitations, and (c) contextual barriers such as digital literacy among older adults.

To assess feasibility and inform scalability, the following indicators will be tracked over a 12-month period, following evaluation dimensions adapted from the WHO Digital Health Monitoring and Evaluation Framework and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance) (29, 30): •

Number of completed remote consultations per month (Reach, Effectiveness)

Long-term, this pilot may serve as a replicable model for other mountainous or island regions in Greece, potentially informing national Smart Villages strategies and EU-funded digital health programs. In keeping with the feasibility study design, this evaluation framework will guide both formative (process) and summative (outcome) insights to inform potential scale-up scenarios.

Community personnel, including municipal staff and social service coordinators, were trained through blended workshops combining device handling, scenario-based simulations, and digital health literacy modules. The training focused on ensuring guided use of the TytoCare device by older residents, emergency scenarios for tourists, and onboarding digital nomads unfamiliar with the Greek healthcare system. A user manual and support line were also developed for sustained use beyond the pilot phase. The involvement of community actors in training sessions emphasized the democratization of digital health tools and the empowerment of non-medical personnel to serve as digital health intermediaries—a key factor in reducing digital exclusion and fostering community resilience.

One of the most direct impacts of the telehealth pilot is its contribution to health equity in isolated populations. By decentralizing diagnostics and allowing for remote consultations, residents—especially elderly or mobility-limited individuals—gain timely access to clinical-grade examinations without the burden of long-distance travel. This is particularly significant for patients with chronic conditions such as hypertension, COPD, and diabetes, where continuous monitoring is essential for preventing acute episodes (31, 32). Furthermore, telehealth helps optimize regional healthcare resources. Physicians in urban centers such as Lamia or Athens can provide remote assessments, thereby increasing efficiency and allowing specialists to manage rural patient loads asynchronously. The integration of patient data into centralized health registries enhances continuity of care and facilitates early intervention protocols. In emergency contexts—e.g., winter weather disruptions, natural disasters, or road closures—telehealth provides a resilience layer, ensuring clinical triage remains possible when physical access is compromised (24). These observations reflect initial feasibility outcomes drawn from local implementation experience rather than quantitative impact data, which is currently being collected. The thematic patterns identified in the qualitative findings strengthen this interpretation by illustrating the early dynamics of user acceptance, operational practicality, and facilitator readiness. Maintaining this distinction between facilitators, end-users, and the GP is essential for accurately interpreting feasibility outcomes and understanding the specific functional expectations of each group.

Health infrastructure is an often-overlooked pillar of tourism attractiveness in remote areas. For destinations like Agrafa, known for hiking, eco-tourism, and seasonal festivals, the availability of digital diagnostics via telehealth may in the future reinforce the destination's perceived health assurance and emergency readiness, contributing to a broader 'Safe Travel' framing. Visitors with preexisting health concerns (e.g., asthma, heart disease, immunosuppression) may be more inclined to travel to rural destinations that offer on-demand medical access, even if not physically located near a hospital (33). This is aligned with recent health tourism literature, which emphasizes perceived medical preparedness as a decisive variable in rural travel choice (23). The pilot also supports Greece's digital nomad visa program, offering extended-stay professionals not only Wi-Fi and natural beauty but also modern medical infrastructure. As digital nomads often stay for weeks or months, particularly in nature-rich environments, telehealth access becomes a prerequisite for inclusion in this mobility trend (28, 34). It is important to note that these tourism- and digital-nomad–related implications remain hypothetical at this stage, as the current feasibility study did not include measurement of actual travel behavior, economic indicators, or destination competitiveness.

At a structural level, the telehealth pilot is consistent with EU Smart Villages initiatives, which promote the use of digital tools to revitalize rural economies through social innovation, inclusive services, and cross-sector integration (24). This is in line with broader trends in rural innovation, where transport, digital infrastructure, and healthcare are seen as interconnected pillars of regional sustainability (35). By anchoring the pilot within local health and tourism networks, Agrafa is positioning itself as a testbed for rural digital transformation. Beyond health and tourism, the existence of such a system may catalyze additional socioeconomic benefits, including: •

Increased confidence among potential returnees or retirees who may consider relocating from urban centers.

As this pilot is positioned as a feasibility and implementation case study, policy recommendations emerging from it are preliminary but grounded in real-world deployment experience. To leverage the full potential of the telehealth pilot, several policy measures are advisable: 1.

Formalize cross-sector coordination between health authorities and tourism boards.

One of the most fundamental limitations is intermittent digital infrastructure, which affects both connectivity and device functionality. Many remote areas in Greece, including parts of Agrafa, still suffer from low broadband penetration, unstable mobile coverage, and outdated telecommunications hardware. These conditions are known to obstruct telehealth implementation in rural environments worldwide (37). Without investment in stable broadband or mobile networks, devices such as TytoCare cannot reliably function in home settings, necessitating the use of centralized community access hubs, which, while functional, reduce the convenience and scalability of truly decentralized telecare (38).

Digital literacy remains a critical barrier, particularly among older adults or residents with limited education. In studies across rural populations, low confidence in using health apps and medical devices has been shown to reduce willingness to engage in teleconsultations (39, 40). This challenge is not only technical but also psychological—patients may perceive remote consultations as impersonal or inadequate, fearing misdiagnosis or the absence of physical interaction (40). Such perceptions are deeply embedded in healthcare culture and must be addressed through targeted training and continuous digital support. Building digital trust requires more than training; it involves sustained user support, social proof within the community, and long-term engagement strategies.

Although the TytoCare device is designed for guided use by non-clinicians, effective operation still depends on the availability of trained facilitators such as municipal staff, pharmacists, or community health workers. Staffing shortages in rural areas mean that existing personnel are often overburdened and lack dedicated time for new responsibilities (41). Moreover, successful telehealth requires synchronization with clinical workflows in regional hospitals. Delays in response times from remote physicians, unclear escalation protocols, or misaligned data management can reduce both effectiveness and trust in the system (42). To ensure clinical integration, escalation protocols and data handoff mechanisms must be co-designed with receiving facilities, especially in regional hospital settings.

Telemedicine platforms process sensitive health data, raising serious concerns about patient privacy and data security. General Data Protection Regulation (GDPR) compliance is required for any health platform operating in the EU. However, in tight-knit rural communities, social visibility is high, and residents may still fear data misuse or leakage—even when legal safeguards are in place (42). Studies show that mistrust in digital security mechanisms reduces adoption, even if legal protections are in place (43). Transparent privacy policies, local-language consent forms, and encryption guarantees are necessary to overcome these barriers (44).

Telehealth systems often launch with grant-based or pilot-phase funding. However, long-term sustainability is a recurrent concern. Maintenance costs, platform licensing, training updates, and broadband subscriptions all pose recurring financial demands (45). Without integration into public health budgets or insurance reimbursement schemes, the telehealth stations may suffer from operational fatigue once the pilot ends. Recent studies have shown that lack of integration into national insurance schemes or health system reimbursement plans is a major barrier to scaling telemedicine services beyond pilot phases (46).

The pilot's initial success is influenced by context-specific enablers—proactive municipal leadership, cohesive community networks, and existing tourism infrastructure. Caution is warranted in assuming automatic transferability to other regions without similar social or institutional readiness. Therefore, the scalability of the pilot model must be evaluated with caution, considering differences in demographics, administrative capacity, and local health system engagement. Future deployments should be preceded by readiness assessments, considering community engagement, governance capacity, and technical infrastructure. Recent findings also highlight the role of user trust and perceived usability in determining telehealth uptake in rural low-resource settings (47).