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How could the IS contribute to define a new kind of

booking organization so as to reduce the problem of
waiting lists in Public Italian Health Care?
I. del Grammastro, F.Grassi, E. Pizzicannella, G. Pistilli, G. Acri
Keywords: Health, Waiting lists, Booking service, CUP, Network,

Abstract. This paper analyzes the two main causes of long waiting lists in health care that since
many years afflict the Italian Public Health System: the excessive autonomy of ASLs and the
inefficiency of the booking service managed by the local CUP. We design a new organizational
approach (CHNM - "Hospital Centralized Network Management") based on centralization as
mechanism of coordination. It would be able to give an important contribution to the reduction
of waiting lists through the use of an effective information system as a support tool. Then we
compared the new organizational model with organizational design studies, verifying that it
would be perfectly in line with them.



The paper analyzes a still unsolved problem which makes the Public Italian Health
Care system inefficient: the waiting list problem. We want to analyze the way
checkups and examinations are booked within Italian hospitals and ASL (Azienda
Sanitaria Locale). Actually, we can’t solve the problem of hospital found shortage nor
we can expect to find out a solution to a bad and poor health care system. In this paper
we are simply trying to rebuild the model of booking at regional and local levels with
a help of technology so as to improve it through offering more efficient services. Our
paper starts with a detailed classification of different kinds of checkups and
examinations as well as the related waiting times. Then, the research paper shows the
Italian Health Care system trying to figure out its structure and points out the
differences between local and regional levels. After having highlighted a large
autonomy of Italian Health care structures which work as real companies, the paper
analyzes the currently used booking system in which CUP (Unique Booking Centre)
and RECUP (Regional Unique Booking Centre) are its main instruments. The paper
goes on with analyzing various issues related to CUP/RECUP that determine a less
efficient Health Care System and ever longer waiting time because of the lack of
communication, poor informatics system and inefficient service sharing. In the end,
the paper focuses on what we call CHNM (Centralized Hospital Network
Management); a useful tool in able to both to rebuild the system of booking within
Health Care services as well as to decrease the waiting time on the base of introducing

a database system at regional level so as to oblige all health care facilities to make the
majority of their services available to the system.


The state of the art and the waiting time problem

Waiting time is a critical issue for outpatient specialist care and diagnostic services in
Italy, and it has been tackled ever more by national plans issued in the last decade.
According to OECD Health Policy Studies: “Most regions improved patients’ access
through better information on waiting times, process re-engineering and the creation
of unified booking centers (CUP/RECUP)”. 1In addition, important prioritization
criteria have been created to manage waiting list problem, based on clinical criteria
and professional judgment23.However, the current policies, including the
implementation of the national guidelines, vary across regions, with some of them
very active and the others are often delayed.
The Italian health service is passing through a time of great structural and
organizational changes in order to enclose intra-professional and inter-professional
care. Software management and information systems are the main tool to decrease the
bureaucratic burden due to the proliferation of laws and a large variety of their
interpretations. Meanwhile, ever fewer available financial resources available, the
progressive population aging as well as the increasing bureaucratic component
make the implementation of an efficient health care system more and more difficult.
Our purpose is to identify a possibility to solve the problem of waiting list in health
sector creating an information system that could define a new kind of organization
arrangements based on collaboration among different Italian health service
environments. Thus, we are trying to identify a research path that, starting from the
health organization system in Italy, could individualize the reasons of long waiting
list, such as the inefficiency of the booking service , the excessive autonomy of the
local health authorities , and their poor coordination.
In order to understand the waiting list problem thoroughly, we can divide the
patients in :
1) Out –Patient, who receives treatment at a hospital, without being hospitalized
2) In-patient, who are hospitalized while being treated.
1OECD Helath Policy Studies : “Waiting Time Policies in the Health Sector - What
Works?”, Febbraio 2013
2Ministero della Salute: “Schema di intesa tra il Governo, le Regioni e le Province
Autonome di Trento e di Bolzano sul Piano Nazionale di governo delle liste di
attesa”, 2011
3DPCM 16.4.2002, “Linee guida sui criteri di priorità per l’accesso alle
prestazioni diagnostiche e sui tempi massimi d’attesa”.

1. The average waiting time for an X-ray ( a kind of diagnostic test) is almost more than a year. the national and regional governmental tires agreed to prioritize some major interventions on the basis of clinical criteria. 1 Waiting times The results are stunning. so as to identify the causes and implications of a so long waiting time in the Italian National Health Service (NHL). this may be caused by a large number of factors.Therefore. In the other hand. such as oncology and cardio surgery. Diagnostic tests (out patients) 2. it is useful to distinguish among three classes of services: In-patient care. Cancer surgical operation (in. from 90 days to one year. we have identified an average waiting time which shows off the waiting time expressed in days in many Italian regions45: Assistance Diagnostic tests Emergency Hospitalization Cancer surgery No cancer surgery Waiting Time >1 Year 24 h 60-90 days 90-1year TAB. At first. 4 OECD Helath Policy Studies : “Waiting Time Policies in the Health Sector What Works?”. .patients) 4. and this has brought about remarkable reductions of waiting time in some fields. Gb. waiting time for out-patients results from: 1) Weak incentives to clear waiting lists for National Health Servicefunded organization 2) Strong incentives for doctors to maintain private care as an attractive alternative 3) Weak institutional and organizational control systems We have identified four different waiting lists according to the type of service. emergency hospitalization (in -patients) 3.Grassi : “Il problema delle liste d’attesa”. According to OECD. Febbraio 2013 5Prof. No cancer surgical operation (out patients) For each type of service. Let us delve into this issue by analyzing some of its important aspects. hernia for example. and for a simple operation. Out-patient medical care and outpatient diagnostics. The waiting time for in-patient care appears less critical than the one for out-patient services.

geographically based (province) and responsible to provide health care services to residents . The Italian NHS is managed by regional governments (19 Regions and 2 Autonomous Provinces). 3. This usually concerns hospitals in Southern Italy. Private accredited providers . In this context. 2. and the regions are supposed to offer that package thanks to the resources financed by the state. IRCSS – research hospitals provide highly complex procedures – often just one specialty.2. Local Health Authorities (ASL in Italian). Below. the provisions of care at the regional level are provided by: 1. provide highly complex procedures – often research and teaching hospitals. Hospital Trusts (in Italian AO Aziende Ospedaliere).1 Italian National Health-Care System Structure . there are some of Italian public hospitals that are below standard. Italian doctors are well-trained and very passionate about their profession. the State is responsible for defining Essential Benefit Package and founding principles of the system. we propose a “Structure of the Italian National Health System” FIG. The national government sets the basic and granted health care package for citizens. providing a comfort level below the standards expected by majority of Northern Europeans and Americans . Italians doesn’t take into account private health insurance so as to cover high costs of hospitalization and surgery. Nevertheless. The Italian NHS is institutionally decentralized. Besides. even by many Italians. Italy has an affordable healthcare system and a high standard medical services. and the private hospitals are alike any other throughout the world. 4.Not for profit and for profit hospitals managed by private entities – often just one specialty .1 The structure of the Italian National Health System We had better analyzed the Italian National Healthcare System (NHS) so as to understand the issue properly. Despite reputations and considerable prejudices. as well as to help overcome the problem of the long waiting lists that are common in most of the public systems. Unlike the other Europeans.

As it is clear from Professor Nuti’s work6. The implementation of a system of integrated healthcare services’ network gets a considerable importance.Our research is aimed at Regional and Local level. and therefore large bid / ask problems. It is characterized with an ever higher percentage of elderly people. diagnostic and therapeutic procedures with particular reference to their quality. such as clinical risk. with great regional variation. the organizational aspect of the health system depends on the regions. all these initiatives are highly dependent on the conditions and management of local health structures which take no advantage of implementation and coordination at the national level. This would be possible by implementing an integrated healthcare services network system which would enable monitoring and systematic evaluation of key parameters in real time. allocated resources. first of all. So as to tackle this problem. Most of the health facilities are not still using computerized instruments and this generates a strong discomfort at the organizational level that brings to the inefficiency of the services. allow to track patient care pathways from the first interaction with the healthcare services. used technologies and level of satisfaction perceived by the citizens. However. Of course. but our idea is to overcome this by focusing our attention on the possibility to significantly improve the state of art through only the reorganization of the structures and the processes and introducing a cheap and simple information system. It results in bad communication among the health structures as well as in inefficient National health care system due to underutilization of some structure and over utilization of some others. the new technology applications offer an excellent opportunity to establish a better balance between the need for higher quality healthcare and an appropriate use of available financial resources.2 The national e -health information strategy The socio-demographic evolution of the population.ssa Sabina Nuti :”Italian Regional Healthcare Systems. In addition. with lack of cooperation between the different structures. along with the need to balance the available resources and quality of care provided to population. under-utilization of some peripheral structures. the Italian Health System authorities have put much effort into spreading information among the citizens about waiting time as well as into re-engineering of the processes. first of all at this very moment of a profound change and evolution of the National Healthcare System (SSN). Italian Hospitals in general are considered as real companies and move on their own so as to achieve efficiency. inadequate facilities. are a stimulus to develop new ways of providing healthcare. and consequently an ever larger healthcare service needs which are necessarily more focused on local services rather than on the hospital ones so as to cope with chronic diseases. In this context. How to manage them?” 2012 . 6 Prof. 2. which would. the reduced financial resources for the health facilities represent another important aspect that gets such health facilities to be underused .

electronic transmission of prescriptions (ePrescriptions) and sickness certificates (on line transmission of sickness certificates).These actions are essential to create a fair ground for the implementation of an eHealth Information Strategy at national level. with significant priority of intervention: .833/78. The main objective of this strategy is to ensure a harmonic. we intend to concentrate our attention on the main organizational inefficiencies of the system that lead to the waiting list problem. digitalization and . This standardization of organizational models was the direct result of the desire to build a strong National Health Service. with an unified governance.availability of patient’s clinical history: integrated electronic health recorded systems (EHR) for the management of all episodes of care for every citizen on individual basis.structural and organizational redesign of healthcare services network through telemedicine. The USLs (Unità Sanitaria Locale) were mere territorial divisions of the system and they have an identical organizational structures (at least formally) within the same region and also very similar among different regions.8 The universalizing logic of law 833/78 had set up a system in which the first principle to be observed was the guarantee of a unique and uniform service throughout the country. n. "Istituzione del servizio sanitario . 517. These initiatives are mainly pertinent to the following areas. “Riordino della disciplina in materia sanitaria” 8 LEGGE nazionale” 23 dicembre 1978. through major projects at central level as well as through ongoing initiatives in almost all Italian service access: integrated health services booking systems (CUP) that allow citizens to book health care services throughout the Country. 833. so as to support patient care and governance of NHS. we can schematically compare the current model of the National Health Service. that is. that is the excessive autonomy of the ASLs and the current booking system. with increasing interoperability levels.3 The excessive autonomy of ASLs To fully understand the meaning and practical implications of the concept of selforganization of ASLs. . consistent and sustainable development of the national information systems . Now.innovation in primary care: establishment of general practitioners’ network. 2. a single institutional " container" within which to resolve the fragmentation and heterogeneity of health service inherited from the 7 DECRETO LEGISLATIVO 7 dicembre 1993. The implementation of the eHealth services is proceeding with considerable dynamism. . . n. introduced with the reform of 19937 with the structure defined by L. after having analyzed the state of the art.

the individual local structures had gradually developed and implemented services offering models and health spending managements very different: super-equipped hospitals against backward and desert hospitals. theirs development strategies. Organizational models are not predetermined and they can be configured according to the local needs. The operational independence of A. The organizational management independently identifies the organizational structure of the company as both internal organizational system ( executive staff ) as well as levels of decentralization (powers of management and control). ASLs and research institutes) the right and duty to define theirs own role. The autonomy of A. The underlying rationale for this new approach is that the ASL (according to the business principles) through the organizational autonomy and through private tools. The accounting management involves the economic and financial area.L. "Norme per la razionalizzazione del Servizio sanitario nazionale” .previous mutual societies . this innovation has led to a systematic increase in competition among health care companies within the same region with the disintegration of a single ultimate goal ( the health service to the citizen as soon as possible) in many micro 9 DECRETO LEGISLATIVO 19 giugno 1999. both through acts of acquisition and acts of divestiture and finally the technical management provides the procedures and methods of use of resources. organizational and capital autonomy. administrative. Assigning greater responsibility to the regions and establishing healthcare companies with strategic. a growing gap between the formal structure and the real organization was simultaneously forming. in fact. the power to provide for the placement of human and financial resources and the power to verify the results. theirs organizational structure rather than deny the diversity under organizational models formally homogeneous. should better respond to criteria of effectiveness and efficiency.S.S. Patrimonial area manage ASL assets. includes organizational. while the administration management has the power to adopt administrative measures that imply public authority. patrimonial and technological management.L. If this approach has undoubtedly led to a number of advantages on the side of economy management. n. Behind the apparent homogeneity of the formal organizational models. ASLs benefit of considerable autonomy in defining their organizational structure. With the changes introduced by Decree 517/93 and confirmed by Decree 229/99 9 the legislator has recognized to the individual elements of the system (regions. on the other hand. However. accounting. Hence there is the possibility that. it is recognized the need to bridge the existing gap between formal structure and real structure. 229. Within the institutional constraints fixed by the National Health Service. Then. it exists different organizational models within the same region. respecting budgetary constraints through the balance between costs and revenues. formal homogeneity but very substantial difference. has the power to determine independently the objectives of the action plan activities.

. “Gruppi e reti aziendali in sanità” . Hurley 199311) and in the national one (Cichetti. making them feel part of a single organization.. the Information Technology. constraining their choices and their behavior. “The Purchaser-Driven Reformation in Health Care:Alternative Approaches to Leveling Our Cathedrals”. both in the international arena (Pointer et al. DE LUCA A. that contrary are naturally led to autonomy. CIPOLLONI E. (2002). In this perspective. then it is difficult to imagine that only the formal adhesion to the same organization can guarantee by itself the pursuit of common goals. (2005) “L’analisi dei network organizzativi nei sistemi sanitari: il caso della rete di emergenza della Regione Lazio”. 11 HURLEY R. structures and professions involved in the care pathway... These considerations suggest a focus on the model of the network welfare. institutions. has issued a 10 POINTER D. 200212. 199410. Thus. The debate on the contribution that the adoption of network models could provide to the health services .. Egea . Genova 10-11 novembre 2005 13 LEGA F. Frontiers of Health Services Management. RUGGERI M. In the absence of operational mechanisms and in the absence of an organizational culture that integrate the different structures. ALEXANDER J. Frontiers of Health Services Management. ZUCKERMAN H. “Loosening the Gordian Knot of Governance in Integrated Health Care Delivery Systems”. (1994). MASCIA D. advanced structure. Milano. in terms of effectiveness and efficiency is substantial. that supports the communication processes and that sustain decisions of individuals who carry out interdependent tasks can be a very useful tool. Atti del Convegno Nazionale dell’Associazione Italiana di Economia Sanitaria. Lega . PAPINI P. In 2009 the Ministry of Health. 12 CICHETTI A. 2.. as a complex organization in which a plurality of mutually independent and autonomous entities work in a coordinated way. (1993). it appears the need to identify new organizational solutions designed to meet the growing exigency of integration between the different jurisdictions.particular objectives pursued by each local health authority ( efficiency in terms of cost. 200213). offering integrated services and overcoming the existing boundaries fixed by the organizational structure. the Ministry of Health made the first national survey on waiting times for outpatient and in-patient services14.. The end result is the weakness of overall governance and the complexity to develop an integrated system.4 The current booking service In 2001. specialization).

CUP is the service that guarantees you a specialist visit and diagnostic analyses’ booking. coverage. so as to facilitate booking.document15 to help the regional hospitals organize their services.. To book or cancel outpatient within health services.salute. As the local ASL is independent. In most of the cases. “Priorità cliniche in sanità”.it/imgs/ c) multiple booking problems due to the lack of communication among various local CUPs. 2006 . an organizational tool called CUP (Unified Center of Booking) is expected to bring about coordinated health service supply at local level as well as about making bookings easier to patients. Roma 16 Mariotti G. the existing CUP often operate on their own and through different channels e) no early ticket payment f) no automatic cancellation mechanisms g) many resources are wasted on calling patients to ask them to confirm the booking a few days before the visit All these problems create a very inefficient booking service contributing to the formation of long waiting time. there are more absent patients than the present ones. In particular. b) drop-out events16: citizens sometimes don't go to the already booked appointment. “Sistema CUP: Linee guida nazionali”. 14 http://www. the situation in terms of availability. Most of the CUP at the local level have important problems due to: a) Lack of centralized digital platform: bookings can only be made through the call center or ASL counter. in fact.pdf 15 Ministero della Salute. Franco Angeli. The proliferation of CUP systems at local level is particularly remarkable along with a significant diversification in terms of technological and infrastructural solutions they commonly use. 27 Ottobre 2009. citizens can either call the CUP call center or go to the CUP counter personally. and characteristics of the CUP is extremely heterogeneous. Every local ASL has its own CUP. An integrated network doesn’t exist.

On the other hand. “The RECUP was created to make life easier for citizens .2 the regional level.forumpa. the ASL must share many of their agendas with RECUP/SOVRACUP. capable of covering all the available places for operations and visits. which have to meet all the demands of health services. to let them avoid unnecessary and often problematic shifts and long queuing in front of the counters”. All this is at the citizens’ expenses as the RECUP/SOVRACUP is not able to offer them any available term. Anyone who does not provide his own agendas creates difficulties to other ASL. A CUP management in the ASL involves 17 http://archive. It tries to provide the concept of sharing among the local levels. there is a large competition among the various local booking centers(CUP) and regional booking centers ( RE –CUP).htm .17 The main problem regarding this particular kind of regional booking service is that so as to make it working properly. almost allservice the regions have adopted RECUP/SOVRACUP The current booking system (Regional Unified center of reservation) that could allow patients to make booking in their region in various local and others hospitals don’t do booking book at all.At FIG. the fact that ASL or other hospitals provide total availability of their performances confirm that the system could work and would be able to offer a good service with everybody’s collaboration. trying to introduce a mechanism of coordination. Thus. director of Re-Cup call center service. All this at the citizens’ expenses as the RECUP/SOVRACUP is not able to offer them any available term. But some hospitals have transferred to RE-CUP only 2 per cent of their agendas. According to Gianni Fontana (cooperative social Capodarco). deciding to manage the remaining 98 per cent by themselves.

SALUTE E SOCIETÀ.4 Regions / Autonomous Provinces claim to have ongoing projects or a CUP sub-regional/sub-provincial coverage . maybe. Regarding the deployment of regional / provincial CUP coverage at national level. in most cases .9 Regions / Autonomous Provinces describe to have neither implemented a system of booking at regional nor ongoing projects in this area. Trabucco A. “Integrazione dei sistemi Cup: aspetti tecnologici e aspetti organizzativi”. FIG. some leaders keep in their mind the needs of their company much more rather than the regional system needs. . 2009 . the CUP system does not have an adequate coverage in terms of performance actually booked services and performances.8 Regions / Autonomous Provinces have a CUP regional / provincial system.. the Manager . the conditions are the following 18: . the Information and in addition there is the Head of Service . Even where CUP regional / provincial system exist.various directions : the Health . So.3 Regions that have adopt RECUP (or SOVRACUP) system Regarding the booking system a taking into account the operability or CUP and RECUP (or SOVRACUP) we can redesign the "Structure of the Italian National Health System" as following: 18 Micocci S.

the CUPand exists in some regions at local level and in others. -Not pooled with cup -For almost non digital access -Competition with cup . The results in both cases are too poor. Thus.4 Regional/Local level As we have Linkage been ablebetween to see soCUP/RECUP far. the only way -Lack of communication among CUPS -Competition with RECUP -Competition among CUPS -Overload Booking -No anticipated ticket payment -No automatic cancellation mechanism -No Preliminary analysis -Multiple booking -Too independence . we can speak about co-presence of CUP at local and RECUP at regional level.FIG. for the purposes of our assessment we have identified the general requirements and divided them between local and regional level.Insufficient Technologies -Difficulties in data access LOCAL LEVEL -No digital access COMMON -Inhomogeneous system -Call center. REGIONAL LEVEL -Difficulty to make available the performance on the part of health care facilities.

This is a fundamental point that allows to overcome the problem of information sharing. able to support a single process aimed at a single objective: the waiting time reduction. This new organizational approach requires a centralized system implementation in all the local CUP within a region. Each CUP must be connected through a centralized online software that offers continuous updating and the ongoing coordination of data automatically. 2 General Requirements 3 The Centralized Hospital Network Management The general requirements may be considered as our input and our starting point to identify the role that information systems can play in a so uneven and disorganized system. so to leave the 20% for the emergency. This new network is made up of elements. So. but when combined they can create an innovative system ex novo. In this way. not necessarily associated with each other. it is necessary to strengthen the network of existing CUP via the coordination carried out by IT. the most effective solution is centralization. Our goal is to define what we call CHNM (Centralized Hospital Network Management) as a result of our work.The establishment of a national award for the health facilities that share higher percentage of their service. If this condition will be satisfied there would be a quantum leap in the level of service offering . that could be considered as a RECUP reorganization. Combining centralization to an efficient network. In fact. In the meanwhile. the main characteristics of Centralized Hospital Network Management are: -The provision of a standardized computerized booking software system on which each ASL can upload all their performance and agendas . capable of producing excellent results in terms of reducing waiting lists. The two key words of the CHNM are “Centralized” and “Network”. In fact. For this purpose it is necessary to authenticate the user and make him recognizable by the software for each undertaken task. which is too slow and awkward. we believe that in such a context characterized by a huge amount of data. Organizational design studies teach that with increasing complexity and amount of information to be managed. .TAB. In this way the already existed competition between CUP . we would like to define a new organizational structure based on the local and regional level integration that could meet the global need of all the involved through a suitable information system. the system will be able to assign a single health service to a single user by preventing from multiple booking. It is necessary to abandon the call center system. the booking system management and waiting lists management will be much more effective and flexible. For example the Lazio Region has issued an internal circular which lets the Health and hospital to provide an indication of the Recup at least 70 percent of the services offered by each agenda. The intent is to create a CUP Unified database. a possible solution for a suitable system is centralization. The input must come from the institutions and they have to make the health facilities provide at least the 80% of their available services .

and in this context they are considered as if they were a single level. and if infected how to take care of themselves and prevent from 19http://doctor. first of all. breaking through the barriers between the regional level and the local one. The booking will be managed by the CHNM database and it will be the only way to book. in this context. a channel of health information system.html . the patients should be made more responsible by the immediate ticket payment. . it is necessary to introduce a tool for health education to prevent from the disease and a tool as e-visits or telemedicine as preliminary analysis. the idea of prevention can be realised only when people are informed how to protect themselves.5 CHNM operative level In order to solve the problem of inefficiency due to unnecessary visits. According to what has emerged from the analysis of Doctor NDTV19. .In order to solve the problem of multiple booking and drop-out cases. In this view the CHNM plays a key role in preventing from overbooking and multiple booking problems.So.ndtv. This could be a solution so as to limit the absenteeism. the concept: “prevention is better than cure”. The information system contribution is important as it is _Insurance. -The creation of a complete interface between the CUP and the information system software as well as a connection between the two database systems . FIG.and RECUP would be converted in a positive view: in order to offer more services to the patients. thus we get a network system that sees the CHNM center to which all CUP business is connected. to make a quite homogenous and standardizes organizational system of booking. The intent is to create a mechanism that would enable the patients to make just one single booking for a certain kind of visit.

named “Telemedicine for the Benefit of Patients. several actions involving both European Union and Member States are described. we are talking about communication among people and among different provinces. In order to analyze home care services in a systematic way. The working group is currently working on defining a strategic framework in which to place telemedicine services. in fact. thanks to telemedicine and e-visit: a) Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at distance. It is also used to save lives in critical care and emergency situations. the types of telemedicine projects and service investigated towards eCare Observatory have been expanded from homecare to all telemedicine services. Lombardy Region. subjected to subsequent renewals. care supply. Within the “Consiglio Superiore di Sanità” (Advisory body of the Italian Ministry of health) on February 24th 2011. Marche. The systematic and continuous updating of such information by the Regions within the eCare Observatory allows not only to have detailed information about the level of implementation of telemedicine in the Country. The Ministry of health is directly taking part in several initiatives in this area. the patient could make a preliminary analysis in order to figure out whether they are able or not to make a reservation as well as to to avoid unnecessary visits. as well as . It brings about distance barriers eliminating and also improves the access to medical services that often would not be really available in distant rural communities. models. in 2007. Healthcare System and Society”. and in agreement with the Coordination of the Health Committee of the Conference of Regions and Autonomous Provinces. it is the matter of the concept of a preliminary analysis. Thus. Veneto and Sicily Regions and . In particular. aiming at promoting a greater integration of telemedicine services in clinical practice. With the aim of making a detailed picture of telemedicine services available in the Country. concerning the establishment and execution of the National Observatory for evaluation and monitoring of eCare services. Campania. but also to monitor and measure the results achieved in the different Regions over the time.Secondly. The following Regions take part in the Observatory: Tuscany. European Commission attributes particular relevance to telemedicine. and to widespread the best practices arising from organizational. clinical. Liguria. actually those provided towards telemedicine. in the EU Communication (COM-2008-689) of November 4th 2008.spreading the infection. a working group aimed at drafting national Guidelines for supporting the systematic use of telemedicine in SSN was set up. technological and/or economic point of view. removing major barriers to its full and effective implementation. from 2011. Through the CHNM platform. processes and pathways for integration of . In such a context the best tool to play this role is an Information System. from 2009. . the Ministry of health stipulated an agreement with Emilia Romagna Region. being also able to provide the information required at EU level towards the above mentioned EU Communication.

taxonomies.telemedicine services in clinical practice. This phase turns out to be a filter so as only reservations with an higher degree priority will access to the booking. The user before proceeding to the booking would have the possibility to verify ex-ante the appropriateness of the health provision. common classifications.6 Centralized Hospital Network Management At this point we can sum up our general components. “Online care or an e-visit is a way of obtaining medical care for problems which do not require a physical examination and which do not require treatment beyond a prescription available online or diagnostic tests beyond blood tests”. b) c) According to Haya Rubin (Internal Medicine). Online visits can be conducted using a video-camera but the term is also used for visits carried out over the telephone when the history is online. as well as all the aspects related to legal and regulatory profiles along with economic and sustainability issues concerning telemedicine services. Regional Health sector standardization Standardized computerized reservation Mechanisms for only one reservation More responsible patients . Telemedicine would become part of the CHNM as the first step of the reservation process. and the doctor documents the visit online. Hence. which have been identified as possible solutions to our problem. it is possible to illustrate the Centralized Hospital Network Management as follow: FIG.

Drop-out events .One automatic booking mechanism through a unique centralized booking system -Digital online platform . the only way -No anticipated ticket payment -No automatic cancellation mechanism -No Preliminary analysis -Overload Booking .Centralized service . Now we can compare the General Components and General Requirements: GENERAL REQUIREMENTS -Difficulties in making available the performance in a part of health care facilities. online platform) and organizational ones (standardization. both technological (sms and e-mail sending. software. centralization. procedures through ex ante agreement -Standardized and computerized booking system -Immediate ticket Payment -Mechanism for only one reservation -e-visit/telemedicine/prevention .Regional and local = same level .Coordination mechanisms as rules. 80% agendas provision). 3 General Components The Centralized Hospital Network Management results from the combination of all these elements.Automatic E-mail/SMS sent by CHNM system some days before he appointment to remind the patients -Immediate Ticket Payment .Little homogenous system -Not pooled with CUP -Lack of communications among CUPs -Competition with CUP/RECUP -Competition among CUPs -Too much independence -Call center . -Non digital access .Multiple bookings -Difficulties in data accessing GENERAL COMPONENTS -Provide at least 80% of services -National awards/feedback health facilities -Digital online platform -Standardization of regional Health sector -Standardized computerized booking system -Unified CUP database .system CUP database software Provide at least 80% of services National awards/feedback health facilities Service centralization Immediate ticket payment Centralization of reservations e-visit/telemedicine/prevention Digital online platform TAB.

Grandori speaks of foundations claiming that they are characterized by a system in which the parties have divergent preferences within a large range of issues. but. each ASL is characterized by a relative autonomy but they all together constitute the regional health system and they are in some way dependent on it. Organization Studies. with increasing complexity and number of actors. the work by Anna Grandori examines the information complexity and the different interests of the parties. it is possible to agree ex ante over a set of procedures and resources. Galbraith shares this opinion and shows in his work the coordinating mechanisms that organizations should adopt in conditions of increasing complexity and uncertainty21. Talking about a stable organization with low uncertainty. it is possible to frame the Centralized Hospital Network Management as a system characterized by “pooled interdependence”. Specifically.Grandori evaluates and examines various types of interdependencies among different organizations (through the use of variables such as the direction of resource flows.4 An organizational point of view "An Organizational assessment of Interfirm Coordination Modes"20 by Anna Grandori turns out to be an important framework through which to analyze the network system we have proposed. defining the bureaucratic model. in this paper we intend to refer to the configuration of “foundation” and more specifically of the “bureaucratic model”. In this work A. the more effective coordination is the one of information codification and communication through written documents side by side with a set of rules. thereby configuring the minimal basic way in which two or more units are linked because of their belonging to the same organization”. anyway. 21Gailbraith J. Grandori suggests that even in the absence of conflicting interests. 1977 . outlining numerous network configurations. "An Organizational Assessment of Interfirm Coordination Modes". that is a system in which each part (in our case health facilities with their CUP) “renders a discrete contribution to the whole and each is supported by the whole. Due to the similarities with our proposed system. 6/8. explaining that sometimes it is necessary to centralize the decisions making processes as well as procedures. Organizational Effectiveness Center and School. Moreover. but 20 A. We have already described the problem that affects ASL that is the competitiveness among them which creates many problems to the health services management. the relationship between the ASL represent a "foundation". “Organization Design”. Besides. Adopting this eminent research tool. Thus. the interests of various ASLs can be defined as different from each other but in a second analysis it is possible to find a mechanism by which they can set up an agreement with the pressure of the Region. Grandori. 1997. explaining on various mechanisms which can regulate them effectively. In these terms. the interest of the parties and the information complexity). procedures and information systems.

CHNM allows to streamline bookings . but others are very good and have the same medical clinics in demand. But what are the advantages for the administration? At first. Therefore. Thus. could be one of hypothesis to take into measuring and analyzing of the data related to requests because some facilities request 2 days waiting time and some others 90 ? With this system it is possible to record the public preferences concerning certain structures rather than the others . Instead.CHNM is an organizational information network system that could coordinate the booking issue within health services not only at regional but also at national level. With this project work we intend to create an effective network between the regional and the local levels and at the same time to propose a centralized booking service that has access to all information services of the local health facilities. without having to queue at the counter. through authentication the system not only avoids the possibility to book at many different ASL (causing the well-known problems of multiple booking) but it is also able to remember the appointment to the user with a simple SMS some day before the appointment so as to eliminate the drop-out events. Surely. Another advantage is the possibility of day-to. integrated information system and that our proposal perfectly reflects previous research studies. Given the increasing affordability and accessibility of air travel that no longer makes unthinkable the possibility of having a medical examination at hundreds of kilometers away without inconveniences. . cancellations and shifts . And this causes both a big waste to public health and less available performances/services for those who really need them. So as to analyze the preferences means to understand them. booking at branches or call centers CUP a person is very likely to increase the number of busy places. The analysis of data related to booking is also useful for system studying in order to calibrate the issue. The advantages of the proposed service regarding the citizens are obvious: with a simple iphone/tablet the patient can access to the e-service and book more visits and more diagnostic tests. optimizing the supply of such services. It is well known that the demands of many diagnostic tests are unnecessary or redundant . we can state that the network we have proposed .characterized with high complexity. Moreover. . some structures need to be improved . 5 Conclusion In conclusion we identify how IS could bring about identifying a new organization arrangement in order to reduce the waiting list problem in the Italian health system. and then to act accordingly. Galbraith describes centralization as one of the best coordinating mechanisms to take. in these terms. as a coordinating mechanism is able to centralize the booking management and supply health services at the regional level just with the help of one single. This results in shedding the precious places which are unnecessarily busy. it is only the matter of making a targeted communication campaign so as to inform citizens about the same quality of other surgeries.

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